Incorporating Minimally Invasive Techniques into your Office Treatment Protocols. Daniel H Ward DDS. May 19, 2017

Transcription

1 Incorporating Minimally Invasive Techniques into your Office Treatment Protocols Daniel H Ward DDS May 19,

2 Health and appearance conscious Appearance The Public has concerns about: Metals Patients are more knowledgeable than ever We must listen more to our patients 2

3 We must provide alternatives for our patients but the right alternatives Minimally Invasive Dentistry CAMBRA Conservative approach Ideal treatment is no treatment necessary Remove only diseased portion of tooth Preserve healthy tooth structure for future restorative needs stands for CARIES MANAGEMENT BY RISK ASSESSMENT Tooth Decay Caries Tooth decay is the destruction of tooth enamel. It occurs when foods containing carbohydrates (sugars and starches) such as milk, pop, raisins, cakes or candy are frequently left on the teeth. Bacteria that live in the mouth thrive on these foods, producing acids as a result. Over a period of time, these acids destroy tooth enamel, resulting in tooth decay. Caries is a point in a persons life at which the process of demineralization of tooth structure by acid from bacteria in the tooth biofilm overwhelms the patient s ability to remineralize tooth structure. ADA Website 3

4 Caries-Important Points Caries-Important Points Caries is a bacterial infection caused by specific acidogenic bacteria in tooth biofilm. These bacteria are indigenous to humans. There are known cariogenic bacteria present in saliva. Most commonly cited are Strep mutans, Strep sobrinus, Lactobacillus, and Actinomyces. These bacteria are acidogenic (acid producing) and aciduric (survive in an acidic environment). They produce lactic, acetic, formic and propionic acids. Caries is a transmissible infection. Studies have shown that certain strains of Strep mutans are transmitted from mother to child. Early colonization, even before the teeth erupt, can occur in infants by transmission from mothers and caregivers. Transmission from child to child and adult to adult of Strep mutans have been reported. Children who have been colonized earlier have been shown to have more decay later. Featherstone J. The Caries Balance. Dimensions Dent Hyg. 2004;2(2): Berkowitz RJ. Acquisition and transmission of mutans streptococci. J Calif Dent Assoc. 2003;3: Caries-Important Points Demin/Remin Caries is a multifactorial process of tooth demineralization and remineralization which, until cavitation, is reversible. This progression is determined by the balance between pathological factors and protective factors. Pathological factors include acid-producing bacteria, fermentable carbohydrates, and reduced salivary function. Protective factors include salivary components, fluoride together with calcium and phosphate to remineralize the lesion, and antibacterial therapy. Components of Saliva Phosphate Calcium Oral ph Acid Equilibrium TOOTH Calcium phosphate Featherstone JDB. The caries balance: contributing factors and early e detection. J Calif Denta Assoc. 2003;31: Demineralization Remineralization Demineralization Caries Detection vs Diagnosis Calcium Phosphate Detection identifies signs (cavitations) and symptoms Diagnosis identifies the disease (bacterial infection, biofilm disease) TOOTH Demineralization Remineralization 4

5 Caries Activity Caries Risk Traditional Surgical Model Medical Model Paradigm shift Surgical Model-Wait until cavitation occurs and surgically remove Medical Model-Attempt to influence patient to change oral environment to prevent caries 2002 FDI POLICY STATEMENT The FDI World Dental Federation supports the principles of minimal intervention dentistry in the management of dental caries. The Principles are: 5

6 1. Modification of the Oral Flora to Favor Health Dental caries is an infectious disease, and the primary focus should therefore be on control of the infection, plaque control and reduced carbohydrate intake. Bacteria Poor Oral Hygiene Dexterity Flossing Frustration Older adults may have a difficult time Bacteria-Removal Removes biofilm Bacteria-Removal Compensates for poor technique Sonicare Diet Loss of Taste results in increased sugar intake 2. Patient Education and Informed Participation The etiology of dental caries should be explained to the patient, together with the means of prevention through dietary and oral hygiene measures. 6

7 Acidity Critical ph Enamel exposed to a ph less that 5.5 will begin to demineralize Acidity of Common Drinks Bottled Water: 155 liters per capita Fruit Juice: 42.8 liters per capita Soft Drink : 216 liters per capita 5 Source: Global Market Information Database, published by Euromonitor 2002 Determining the Cariogenic Bacteria Load CariScreen Caries Susceptibility Testing Meter Rub swab over tooth surface Bioluminescenceme measures ATP levels which are elevated by cariogenic bacteria Xerostomia Associated Diseases Cancer Diabetes Sjögren s Syndrone Prevalence of Xerostomia Prevalence of Xerostomia In a published study of 3,313 patients, 21.3% of men & 27.3% of women exhibited dry mouth In another study approximately 1 in 4 adult patients complained of dry mouth symptoms Nedersfors T, Isaksson R, Mornstad H et al. Prevelance of perceived symptoms of dry mouth in an adult Swedish population-relation to age, sex and pharmacotherapy. Community Dent Oral Epidemiol. 1997;25: Orellana MF, Lagravere MO, Boychuk DG et al. Prevelance of xerostomia in population-based samples: A Systematic Review. J Public Health Dent. 2006;

8 Prevalence of Xerostomia Xerostomia-Questions to Ask Another study states that dry mouth impacts 30% of the elderly. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc.2002;50: ;50: Do you have any difficulty swallowing? Does your mouth feel dry when eating a meal? Do you sip liquids to help in swallowing dry food? Does the amount of saliva in your mouth seem to be little, too much, or do you notice? Xerostomia-Clinical Appearance Xerostomia-Effects Rampant Decay Tooth Loss Periodontal Disease Difficulty Speaking Candidiasis Quantify S. mutans & Lactobacilli levels-measure buffering capacity Determining Saliva Volume, ph, and Buffering Capacity CRT Bacteria and CRT Buffer-Ivoclar Saliva Check-GC 8

9 Test One-Hydration 1. Roll back bottom lip 2. Dab dry with gauze 3. Timer starts 4. Look for bubbles of saliva forming at outlets from the minor saliva glands 5. At 60 seconds check with a tissue Measures unstimulated saliva from minor salivary glands Test Two-Viscosity 1. Observe the consistency of saliva (watery, bubbly, frothy, stringy??) Measures quality of saliva-serous vs mucous(poor buffer) Test Three-pH Test Four-Quantity 1. Expectorate some resting saliva into the plastic cup. 2. Test the ph using the ph strips 1. Chew the unflavoured gum for 5 minutes, collecting the stimulated saliva in the measuring cup 2. Discard the gum once finished 3. Record amount of saliva collected Volume of Saliva <3.5 ml ml >5.0 ml Value very low low normal Measures ph of stimulated saliva Measures stimulated saliva from major salivary glands Test Five-Buffering Record and analyze results 1. Using the pipette dispense 1 drop of saliva on each of the 3 squares ensuring the entire surface is covered by saliva 2. Invert buffer strip so excess saliva is absorbed into the underlying tissue 3. Read results after 5 mins. Green = 4 points Blue = 2 points Red = Combined total Buffering ability very low low 0 points Normal/hi gh Measures bicarbonate level of stimulated saliva 9

10 Determining Presence of Strep Mutans Xerostomia-Aid Products Saliva Check Mutans Biotene Xerostomia-Aid Products Environment Chemotherapeutics Long Lasting, Slow Release Cellulose based Contains ACP, Essential Oils, Xylitol Bicarbonate neutralizes ph Dissolves biofilm Freshens Breathe Salese lozenges Remineralization of Non-Cavitated Lesions of Enamel & Dentin ACP-CPP CPP Remineralization Saliva plays a critical role in the demineralization/remineralization cycle, and its quantity and quality should therefore be assessed. There is strong evidence that white spot lesions of enamel and non-cavitated lesions of dentin can be arrested or reversed. Such lesions should therefore be managed initially by remineralization techniques. The extent of the lesion should be objectively recorded such that any progression can be identified at recall. Acid Demineralization TOOTH Remineralization (hydroxyapatite) 10

11 ACP-CPP CPP (amorphous calcium phosphate- casein phosphopeptides) Amorphous calcium phosphates stabilized by casein phosphopeptides Molecule serves as a delivery vehicle for Calcium and Phosphate at the tooth surface in a slow release amorphous form ACP-CPP CPP Increases phosphate and calcium in plaque Derived from milk products-highly concentrated Lactose Intolerance OK If allergic to milk NO CPP Effects CPP coating allows attachment to biofilm and stabilizes ACP In presence of acid Calcium and Phosphate ions are released ACP CPP-ACP Action of ACP-CPP CPP (amorphous calcium phosphate- casein phosphopeptides) Prevents enamel demineralization Promotes remineralization of non-caviated enamel subsurface lesions Seals off dentinal tubules reducing sensitivity MI Paste MI Paste vs MI Paste Plus Provides bio-available calcium and phosphate to the oral cavity Aides remineralization Reduces localized hypersensitivity when used after scaling or tooth whitening Remains on tooth surface 3 hours Use MI Paste After tooth whitening For pregnant mothers For children 6 & under During or after ortho Desensitization Poor Oral Hygiene Extra protection for teeth 11

12 MI Paste Plus MI Paste vs MI Paste Plus Addition of 0.2% NaF 900 ppm NaF (toothpaste =1100 ppm) If F - concentration too high-caf deposited on surface preventing absorption 150 micron penetration Use MI Paste Plus White spot lesions Desensitization During or after ortho Medical compromised pts Xerostomia High Acid Environment High Caries Risk pts Extra Protection MI Paste Application MI Paste Uses Apply after toothbrushing No food or drink for 30 minutes May apply with trays for 3-5 minutes Open dentinal tubules Occluded dentinal tubules Temperature sensitivity Dentinal hypersensitivity After tooth-whitening During or after ortho Xerostomia Excess soft drink consumption During pregnancy Saliva substitute MI Protocols for Adults Apply MI Paste: After toothpaste and fluoride application Before bleaching/scaling and days after Ongoing throughout day and night MI Paste works well in SGH (salivary gland hypofunction)pts-use all day/night Home use in trays at night Recaldent gum all day long For longest time possible Jane Chalmers BDSc MS PhD University of Iowa MI Varnish 5% Na F (22,600 ppm) 2% ACP-CPP Releases Ca, PO 4,F Excellent retention Desensitization Does not clump Extra protection for teeth 12

13 MI Varnish Application MI Varnish Mechanisms Place after prophy but not mandatory Dry teeth before applying Do not brush or floss for 4 hours Avoid hard, hot, sticky foods and alcohol containing products for 4 hours Do not use fluoride for 24 hours No water so it does not precipitate Ca allowing for longer retention Greater amount of fluoride in saliva Highest amount of fluoride uptake is in demineralized areas Fluoride effects are present 1-7 days 4. Minimal operative intervention of cavitated lesions An operative ( surgical ) approach should only be used when specifically indicated, e.g., when cavitation is such that the lesion cannot be arrested, or when there are aesthetic or functional requirements. Operative intervention should focus on the preservation of natural tooth structure and be limited to the removal of friable enamel and infected dentin. This can be done with hand, rotary, sonic, ultrasonic, air abrasive or laser instruments, depending on the circumstances. Each prepared cavity is therefore unique, and is primarily dependent on the extent of infected dentin rather than on a predetermined cavity design. Preparation of minimal cavities enables their restoration with adhesive materials such as glass-ionomer cement and/or resin composite. Some studies suggest that glass-ionomer cement may aid in the remineralization of demineralized, firm, non-infected dentin; however, further clinical studies are needed. Composite The most USED and ABUSED Material in Dentistry Amalgam Preparation Composite Preparation Convenience Form MID 13

14 Minimally Invasive Dentistry Conservative Tooth Preparation 169L VF Lifetime of tooth often determined by first dentist intervention Fissurotomy bur How do you restore? G-aenial Universal Flo Homogeneous spherical particles G-aenial U Flo Mean particle size 200 nm Conventional Nano-hybrid Particle size range nm Low Viscosity Flowable Composite High Viscosity (Low Flow) Flowable Composite G-aenial Universal Flo Homogeneous spherical particles Good wear resistance High flexural strength (167 MPa) Filled 50% by volume Good polishability Beautifil Flow 00 Unique glass ionomer filler particles Releases fluoride and other ions Neutralizes ph-antibacterial Good polishability Visibly blends in well Blends in well High Viscosity (Low Flow) Flowable Composite S-PRG (Surface pre-treated Glass Ionomer) High Viscosity (Low Flow) Flowable Composite 14

15 S PRG Fillers Reduced Plaque Accumulation BEAUTIFIL Containing S-PRG filler plaque Conventional Restorative Material Not containing S-PRG filler Less plaque Full-grown plaque Intra-oral plaque formation 24 hours W/O Brushing CALSET Thermal Assisted Light Polymerization Compule Tray Warmer W A R M E R Dispenser Gun Tray ADVANTAGES Thermal Assisted Light Polymerization Improved flowability of composites CALSET Thermal Assisted Light Polymerization Improved marginal adaptation Improved rate of polymer conversion Improved surface hardness/durability/polishing. Decreased curing time and increased depth of cure Increased sculptability and ease in shaping anatomy Stansbury JW. Use of near-ir to monitor the influence of external heating on dental composite photopolymerization. Dent Mat 2004; 20(8). Comax Dispenser Dispenser Gun Tray Completed Tooth Restorations 5. Repair of Defective Restorations Removal of restorations results in an inevitable increase in cavity size as a consequence of removal of sound tooth structure. Depending on the clinical judgment of the dentist, repair could be considered as an alternative to replacement in some circumstances. Low Viscosity Flowable Composite & Warmed Composite 15

16 Minimally Invasive Dentistry? Minimally Invasive Dentistry? Dentistry begets Dentistry The more dentistry you do for a patient, the more dentistry they will eventually need. Treatment performed at age 18 Smile Evaluation Black Triangles Opaque Crowns Dark Roots visible Recurrent decay Long Central Incisors Inadequate buccal corridor display Steep Curve of Spee Color Smile Template Provisionalization Final Impressions & Lab Communication Teeth Preparedunprepared 2 nd molars Fabricate desired shape in provisionals Allow patient to wear, evaluate and accept Once approved take final impressions-send model of provisionals Send photos of desired color shade tab, stump shades and provisionals 16

17 Final Impressions & Lab Communication Minimally Invasive Dentistry Tryin and seat crowns Notice lower anterior teeth 15 Year Old Minimally Invasive Dentistry Multiple Step Layering Techniques 70% RED Proportion Buildup dentin replacement Add Buildup translucent special remaining with effects form with shade opaque to incisal simulate hybrid similar darker or to desired hybrid imperfections microfill typically within final color with A3-A3.5 tooth structure hybrid (typically A1-A2) Add dentin shade Aura Dentin 6 Miris Add General Purpose Shade Aura MC 3 TPH Spectra Add Characterization Optrasculpt Add Facial Surface Aura Enamel Important-Junction G-aenial GT must be invisible Beautifil II Esthelite Sigma Quick 17

18 Finish and polish restoration Restore adjacent tooth Shape, finish and polish restorations Pre-Operative Restore opposite teeth Finished Restorations Hydrodynamic Theory Hydrodynamic Theory Fluid flow within dentinal tubules causes PAIN Brannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12: Opened, unsealed dentinal tubules causes PAIN Dentin Dentin Bonding 70% inorganic carbonate hydroxyapatite calcium phosphate 30% organic (collagen) and water Dentinal tubules microns in diameter Most Bonding occurs between dentinal tubules Hydrophilic 18

19 Oh NO, not another bonding lecture! What are MMP s and what agents can affect their effects? What is the effect of the width of the hybrid layer and dentin bond strengths? What new Self-Etching Primer Dentin Bonding Agent has bond strengths to unetched enamel greater than 40 MPa? Oh NO, not another bonding lecture! Is there a relationship between postoperative sensitivity and dentin bond strengths? What are the characteristics of alcohol, acetone and water based solvents of dentin bonding agents? What are Universal Dentin Bonding Agents? Etched Dentin Etched Dentin Demineralize surface Expose collagen fibers Remove smear layer Increase porosity of intertubular dentin Open up dentinal tubules Increase surface area Bonding agent should not leave the dentinal tubules open Method #1-Reducing Post-Op Sensitivity Total Etch Technique Placement of Etchant Total Etch Technique Fill and Occlude open dentinal tubules 19

20 Rinsing of Etchant Moist Dentin Placement of Resin Primer Apply multiple coats Overwet Phenomenon Placement of Resin Primer Overdrying Collapsed collagen fibrils Moist Moist Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3): Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3): Overdrying Proper Moisture Un-collapsed collagen fibrils Collapsed collagen fibrils SEM Perdigao 20

21 Moisture Variability Bonding Agent Solvents Acetone Alcohol Water Evaporating the solvent with dry air Air only syringe Warm air dryer Variability Air/water syringe Air/water syringe Sensitivity Bond Strength Effect of Dentin Depth on Bond Strengths Adhesive System Superficial Dentin Deep Dentin Single Bond 22.1 (+/-2.8) 14.2 (+/-7.0) Optibond Solo 18.9 (+/-4.1) 18.4 (+/-4.8) Mean shear bond strength in MPa Clearfil Liner Bond 21.0 (+/-7.4) 17.6 (+/-5.9) Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6): GLUMA Occludes tubules Anti-bacterial 21

22 Total Etch Technique Summary Most technique sensitive Requires proper attention to detail Use in ideal sized preparations Occlusions Total Etch Technique Materials-4 th Generation Total Etch Technique Materials-5 th Generation Acetone solvent Alcohol solvent Acetone solvent Alcohol solvent Bonding agent should not leave the dentinal tubules open Self-Etching Primer Method #2-Reducing Post-Op Sensitivity Self Etch Technique Never leave the dentinal tubules open O O Methacrylate-group Hydrophobic end connects to polymer-network CH 2 CH 2 O Spacer-chain link between functional groups O COOH COOH Acid-groups Hydrophilic end etches tooth structure (self limiting) 22

23 Self Etching Primer Acidifying Primer accompanies etch Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion Acid reaction is self-limiting Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2): Self-Etch Technique Challenges Decreased bond strength to un-etched enamel Marginal gap formation with un-etched enamel Bond incompatibility to self-cure and dual-cure resins More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time Self etching Primer 37% H 3 PO 4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface 23

24 Effect of Enamel Etching-Marginal Gaps SEM analysis found no marginal gap formation of enamel etched w phosphoric acid prior to application of a self-etching 6 th generation bonding agent (Clearfill SE) following thermocycling SEM analysis reported marginal gap formation of enamel not etched w phosphoric acid prior to application of a self-etching 6th generation bonding agent (Clearfill SE) following thermocycling Effect of Enamel Etching-Marginal Gaps Solution: Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents. Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37: Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37: Bond Incompatibility with Self and Dual Cured Resins When the ph of a dentin bonding agent is too low (more acidic), tertiary amines (necessary for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins. Bond Incompatibility with Self and Dual Cured Resins Solution: Use of a higher ph (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization. ph=3.2 Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5: Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5: Bond Incompatibility with Self and Dual Cured Resins Solution: Use a dual-cure activator Hydrolytic Degradation The cured layer of 1-step self-etching adhesives is hydrophilic and a permeable membrane. Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:

25 Hydrolytic Degradation Hydrolytic Degradation Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of crosslinkage. MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nanolayering may explain the high stability of MDP-based bonding. Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9: Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9: Self Etch Technique Unprepared enamel surface 6 th generation DBA that effectively etches enamel Etched with 37% Phosphoric Acid OptiBond XTR 6 th Generation DBA OptiBond XTR Popular 6th Generation DBA Popular 7th Generation DBA Swift E, et al. J Esthet Restor Dent. 2011;23(6): Self Etch Technique OptiBond XTR Self Etch Technique OptiBond XTR 2 component self-etch 15% filled by volume Hydrophilic acidic self-etching primer with enhanced etching capabilities Hydrophobic adhesive to maximize material compatibility, increase strength and promote bond durability 25

26 Self Etch Technique OptiBond XTR Primer contain acetone, alcohol and water solvents Low film thickness (5 micron) Bonds to gold, non-precious metal, zirconia, porcelain Direct and indirect restorative procedures Seventh Generation DBA Beautibond Dual acidic monomers Low film thickness (5 micron) Radiopaque Easy to use-single application 10 sec Long Term Dentin Bond Stability MMP-Matrix Metalloproteases MMPs are naturally occurring proteases involved in dentin formation and trapped during odontogenesis Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers Low ph causes dentin to release these inherent MMPs which attack exposed collagen fibrils Long Term Dentin Bond Stability Cysteine Proteases (Cathepsins) Lysosomal enzymes that become activated in lysosomes by a low ph Secreted by osteoclasts in bone resorption Regulated by chondroitin Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinasemediated collagen degradation. Eur J Oral Sci 2011;119: Terasariol Il, Geraldeli S.,,Minciotti Cl., et al., Cysteine catepsins in human dentin pulp complex. J Dent Res 2011; 90: MMP-Matrix Metalloproteases In-vivo 12 m w/pbnt (Acetone) w/chx in 12 m Immediate (MPa) 14 mo (MPa) Control 29.3 (9.2) Control 19.0 (5.2) CHX 32.7 (7.6) CHX 32.2 (7.2) Carrilho et al., JDR 2007; 86; 529 Brackett et al.,operative Dentistry; 2009;34(4): Long Term Dentin Bond Stability Potential MMP Inhibitors Chlorhexidine (CHX) Benzalkonium Chloride MDPB ((12-methacryloxydodecalpyridinium bromide) Galardin (mimics MMP-binds Zn atom) (inhibits tumor growth and metastasis) Epigallocatechin-3-gallate (green tea polyphenol) Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:

27 Long Term Dentin Bond Stability Disinfect to prevent MMPs Long Term Dentin Bond Stability Disinfect to prevent MMPs OR Use Etchant containing 1% Benzalkonium Chloride TE-Apply SE-Apply 2% 2 Chlorhexidine coats 2% after Chlorhexidine acid etching prior for 30 to sec application of primer MDPB (12-methacryloxydodecalpyridinium bromide) Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7): Dentin Bonding Challenges Dentin Bonding Solutions SE 1-step adhesives are too hydrophilic and permeable even after polymerization The best way to minimize these weaknesses is to apply a neutral-ph, hydrophobic adhesive resin layer in a separate step Acidic components cause incompatibility with selfcured composites. 3-step, etch-and-rinse adhesives remain the gold standard in terms of adhesive durability. De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2): De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2): Selective Etch Technique Apply etch to enamel only for 15 seconds Wash thoroughly Place self-etching primer Selective Etch Technique High Viscosity allows precise placement Contains BAC Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:

28 Universal Dentin Bonding Bond strength same to total vs self etch Dentin Bond Strength Total, Self or Selective Etch Universal Bonding Materials Self etch Selective etch Total etch Self-Etch Total Etch Moist Total Etch Wet Total, Self or Selective Etch Universal Bonding Materials Total-etch, self-etch or selective-etch technique Can be used for direct and indirect restorations Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate. Compatible with light-cured, self-cured and dual-cured composite and luting cements. Total, Self or Selective Etch All-Bond Universal Total-etch, self-etch or selective-etch Single bottle for direct and indirect restorations High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate. Compatible with light-cured, self-cured and dual-cured composite and luting cements since ph is 3.2 Becomes hydrophobic upon setting Total Etch vs. Self Etch Shear bond strength of Universal Adhesives on Tooth Structures MPa* Total, Self or Selective Etch MDP Universal Bonding Materials *Manufacturer supplied data 28

29 Total, Self or Selective Etch Universal Bonding Materials Bonding agent should not leave the dentinal tubules open Method #3-Reducing Post-Op Sensitivity GI Sandwich Technique- Never open the dentinal tubules Resin-Modified Glass Ionomer Resin-Modified Glass Ionomer Never open dentinal tubules Less post-operative sensitivity Fluoride release Long-term consistent bond to dentin RMGI Base RMGI Liner Reprepare No dentin conditioner needed due to self-etch primer component Dentin conditioner preferred to achieve optional dentin bond 29

30 Pre-Operative Fuji II LC Resin Modified Glass Ionomer Base Completed Preparation Kalore TOP TEN REASONS: GI isn t used under every restoration 10. It s not necessary 9. It takes more time 8. It costs more money 7. I don t understand which product to use 6. Not necessary with today s Hundredth generation bonding agents TOP TEN REASONS: GI isn t used under every restoration 5. I don t know how to use 4. Not as strong: I bond everything-holding tooth together and making it stronger 3. It doesn t bond as well to dentin as resin 2. Fluoride release is transient 1. Old fashioned: used before better bonding agents were available Social Media Communication Cell Phone Text Messaging Appt Reminder/Late Cancel 30

31 Custom Messaging Appt Reminder/Confirmation Custom Messaging Appt Reminder/Confirmation Custom Newsletters Holiday Promotions Custom Newsletters Promotions Custom Newsletters Regular Newsletters Custom Messaging Birthday Wishes 31

32 Custom Patient Surveys Automated Post-Appointment Custom Patient Surveys Automated Post-Appointment Custom Patient Surveys Automated Post-Appointment Online Patient Reviews Monitor Online Reviews Online Patient Portal Automated Post-Appointment Pay Bills Online Online Dashboard Summary 32

33 Management Research-Maps Research Locale Demographics Maps Mobile Devices New Mobile Apps Distribute Testimonials Online Healthgrades Increase internet marketing March 1, 2016 Healthgrades Increase internet marketing If you cannot see it you cannot treat it! Orascoptic Designs for Vision Surgitel December 1,

34 If you cannot see it you cannot treat it! If you cannot see it you cannot treat it! Ultra-Light Optics Nano Freedom DentLight Flecta Mirror Digital Dental Photography US Population is Aging Xerostomia Difficulty maintaining oral hygiene Root exposures Some unable to tolerate long appointments Difficulty coming to office Fixed Income A Day at the Office US Population is Aging Don t t miss appointments Appreciative Pay bill Often need more treatment Refer new patients Say Thank You! One-Visit Technique Immediate placement natural tooth fiber-reinforced reinforced bonded pontic 60+ Patients are Wonderful 34

35 Perio abcess Sub-gingival distal decay Carefully extract tooth Suture Cut off root of extracted tooth Remove decay and restore with glass ionomer Cut lingual slot when trying in Place groove inline with 2 adjacent teeth Scale and root plane adjacent teeth Tryin and prepare slots Shape root area to support tissue 3 months later 3 months later Prepare Ever Stick fibers Place tooth Etch and bond 35

36 Before Oral Environment Challenges- Xerostomia Happy patient says that I just straightened his crooked tooth Multiple Medications Oral Environment Challenges- Xerostomia Oral Environment Challenges- Xerostomia 40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect Chalmers J. Personal Communication In a published study of 131 different prescribed medications the most common side effect cited was xerostomia. Smith RG, Burtner AP. Oral side-effects effects of the most frequently prescribed drugs. Spec Care Dent. 1994;14: Oral Environment Challenges- Xerostomia Oral Environment Challenges- Carbohydrates Incidence increases with # of drugs taken 50% of patients taking 4 or more medications had Dry Mouth Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g 36

37 Oral Environment Challenges- Antacids Oral Environment Challenges- Bottled Water Ingredients:Calcium carbonate, adipic acid, corn starch, crospovidone, dextrose, flavors, malodextrin, sucrose, talc, colors. Fluoride-less water Fluoridated water Oral Environment Challenges- Illegal Drugs Need Therapeutic Restorations Meth mouth or chronic marijuana use Xerostomia patients High carbohydrate users Non-fluoridated water users Drug abusers Composite Challenges Glass Ionomer Post-operative sensitivity Low post-op sensitivity Recurrent decay Fluoride Release Achieving proper moisture Moisture variability Polymerization shrinkage No shrinkage Increased time-layering Bulk placement Technique sensitivity Simple-more forgiving Look, we all know that Glass Ionomers are weak! Which wears more resin modified glass ionomers or pure glass ionomers? According to research what is the average 10 year survival rate of posterior single surface glass ionomers? 37

38 Look, we all know that Glass Ionomers are weak! Glass Ionomer Base/Restorative Which form(s) of glass ionomer can be used as an RUC under bonded crowns? Under conventionally cemented crowns? Will placement of large glass ionomers always result in less total tooth and restored surface than placement of composites? Fuji IX Self Cure Glass Ionomer SDI Self Cure Glass Ionomer Glass Ionomer Characteristics More highly filled-reduced wear Self-curing in minutes No polymerization (setting) shrinkage stress Expansion/contraction similar to tooth High fluoride release Bioactive Glass Ionomer Uses Multiple cervical carious lesions Pediatric Patients Sealants Class V restorations Sandwich Technique Crown buildups Long term interim restorations Cements Glass Ionomer Restorations Glass Ionomer Restorations High caries rate individuals Remove decay and place matrices 38

39 Glass Ionomer Restorations Glass Ionomer Restorations Treat dentin with PAA Place, shape and wait 2:30 Glass Ionomer Restorations Glass Ionomer Restorations Shape with diamonds w/ water Dry and place Surface Sealant No phosphoric acid Glass Ionomer Restorations Glass Ionomer Restorations High caries rate individuals Spoon out decay and refine prep 39

40 Glass Ionomer Restorations Glass Ionomer Restorations Place and rinse Poly-acrylic acid Mix Gi and quickly place and push out Glass Ionomer Restorations Glass Ionomer Restorations Allow to set 2:30 Hold down gingiva and shape Glass Ionomer Restorations Glass Ionomer Restorations Dry and place surface sealant High caries rate individuals 40

41 Glass Ionomer Restorations Glass Ionomer Restorations Pediatric Patients Pediatric Patients Glass Ionomer Restorations Glass Ionomer Restorations Class V root caries Class V root caries Glass Ionomer Restorations Glass Ionomer Restorations Repair around crown margins Repair around crown margins 41

42 Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration Glass Ionomer Sealants Glass Ionomer Sealants Treat with phosphoric acid Place Surface Sealant over glass ionomer and light cure Decalcified areas in partially erupted tooth Activate, mix and place glass ionomer 42

43 Glass Ionomer Sealants Stop if you feel you will expose pulp 5 Year Recall Gain access to decay using a high speed Glass Ionomer Sealants Use slow speed and then spoon excavator Closed Sandwich Technique Condition enamel only with phosphoric acid Rinse thoroughly Condition dentin with poly-acrylic acid for 10 seconds and wash SEM of dentin treated with PCA Closed Sandwich Technique CARDOSO et al. J Dent 2010 Place Glass Ionomer base Zhang Y, Burrow MF, Palamara JEA, Thomas CDL. Bonding to Glass Ionomer Cements using Resin-based Adhesives. Op Dent 2011;36: Wait 2:30 Re-prep if necessary after set Apply Seventh Generation Bonding Agent Closed Sandwich Technique Place Composite & Cure Condition dentin w PCA Finish and polish (Sonic Fill) Acid etch enamel Preparation w cervical margin in dentin Closed Sandwich Technique Open Sandwich Technique 43

44 Place glass ionomer base Place RMGI bonding agent and cure *recommended by Dr Graeme Milicich Open Sandwich Technique Shape with diamonds and fine carbides Build up tooth with composite Open Sandwich Technique Glass Ionomer Internal Cracks RMGI Mesial View Finished occlusal view Composite Open Sandwich Technique Restoration Under Crown Deep decay w affected dentin Deep decay w affected dentin Restoration Under Crown Restoration Under Crown 44

45 Deep decay w affected dentin Deep decay w affected dentin Restoration Under Crown Restoration Under Crown Do Not Use in Anterior Teeth to replace Large Defects Restoration Under Crown RUC with crack But How long do they last? Single Surface Restorations* (*based on placement of older GI formulations) Placement 2 years 10 years But How long do they last? Multiple Surface Restorations* (*based on placement of older GI formulations) Placement 2 years 10 years Survival Rate 92.7% success 65.2% success Survival Rate (n=62) 86.8% success 30.6% success Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2): Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):

46 But How long do they last? Five Year Restorations How long do they last? 8-12 years- single surface 5-8 years- multiple surface The larger the restoration, the shorter its lifetime Long term interim restoration Then what? Re-prepare surface and place posterior composite restoration Prepare tooth for a crown Glass Ionomer/Filled Resin Sealant Easy, Quick, Universal Designed as a system that included surface sealant Becomes stronger in time Long term interim restoration Equia Surface Sealant Surface Sealant Fills in microcracks and porosity Provides a high gloss, smooth surface Increase wear resistance and allows material to mature Light Cured-Do not etch before applying Sealant retains moisture w/in restoration allowing better maturation and hardness before surface is exposed to forces 46

47 Restoration w large crack Restoration w large crack Large restoration with internal fractures Dentist-Multiple Radiographic Caries Posterior Glass Ionomer Equia Forte RIVA Self Cure HV Before and After 47

48 Posterior Glass Ionomer Posterior Glass Ionomer 47 year old female Been in the practice over 30 years Regular re-care appointments Significant changes in health history No restorations in 8 years Radiographs revealed multiple interproimal radiolucencies not present 12 months previous Required 16 restorations Need caries resistant restorations Sudden Onset Caries Preparations Posterior Glass Ionomer Posterior Glass Ionomer Preparations Posterior GI Restorations Resin-Modified Glass Ionomers Acid/base and polymerization reaction Ionic and micromechanical bonding Dual-curing Fluoride release Bioactive Resin-Modified Glass Ionomer Characteristics Acid/base and polymerization reactions Dual cured-faster Shortens time needed to control moisture More esthetic and translucent Fluoride release Higher tensile, bond strength and wear 48

49 Resin-Modified Glass Ionomer Uses Liner or Base Class V Restorations Restoration Under Crown Temporary prior to crown Sandwich technique Cements Resin-Modified Glass Ionomers-Advantages Better retention 37 pairs of caries-free unprepared abfraction lesions were treated with resin modified and resin composite restorations (single bottle total etch dba). Retention of the composite restorations at six months was below the minimum specified in the ADA Acceptance Program for Dentin and Enamel Adhesives. At two years retention was 96% for the resin-modified glass ionomer and 81% for the resin composite. The resin composite restorations generally had a better appearance, with a 100% alpha rating in color match, versus 85% for the resin-modified glass ionomer. Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada BE. Two-year clinical performance of Class V resin-modified glass-lonomer and resin composite restorations. Oper Dent. 2003;28: Resin-Modified Glass Ionomer Base/Restorative Capsule Resin-Modified Glass Ionomer Base/Restorative Paste-Paste Fuji II LC RIVA LC Ketac Nano Fuji Filling LC Resin-Modified Glass Ionomer Gingival recession & root caries 1 st molar and bicuspid Remove decay place retention Class V Restoration

50 Resin-Modified Glass Ionomer Resin-Modified Glass Ionomer Gingival recession & root caries 1 st molar and bicuspids Remove decay place retention Condition with PA Pre treatwith dentin conditioner (Polyacrylic acid) Material Placed and Light Cured Place excess material Light Cure Resin-Modified Glass Ionomer Material Placed and Light Cured Place excess material Light Cure 297 Final Restorations Shape restorations Hold back gingiva and shape with fine diamond Etch with phosphoric acid, wash and dry Place surface sealant and light cure Restoration Under Crown Quick Temporary prior to Crown Temporary placed 5 years ago 50

51 Riva Bond LC Sandwich Technique Resin-modified Bonding Agent Triturated Reduces polymerization shrinkage stress Novel concept Glass Ionomer Resin-Modified Glass Ionomer Glass Ionomer Preferred Uses Exposed to occlusion Able to control moisture Not acid etching No shrinkage stress Highest fluoride release Out of occlusion Need quickness Need to acid etch Need to bond translucence/esthetic Core-Cemented posterior crowns Entire Class I or II (Long Term Interim) Class V-high caries All deciduous posteriors Sandwich technique-co Cure Resin-Modified Glass Ionomer Preferred Uses Bioactive Core-all crowns Base Class I or II-re-prepared sandwich Class V-more esthetic Quickly placed short-term interim restorations Exchange ions to and from biological structure Regenerative/remineralization Promote healing Release Calcium, Fluoride, Phosphate Maintains alkaline ph Antimicrobial Having an effect upon a living organism, tissue, or cell. Biologically active. 51

52 Ceramir GI Initial setting and early strength Fluoride release Calcium Aluminate Long term-increased strength and retention Apatite formation Sealing at marginal interface Sustained long term properties w/o degrading Higher ph (not acidic)-virtually no sensitivity Ceramir Forms apatite crystals (a group of phosphate minerals, usually referring to hydroxyapatite, fluorapatite and chlorapatite, named for high concentrations of OH, F, Cl or ions, respectively, in the crystal. The formula of the admixture of the four most common end members is written as Ca 10 (PO 4 ) 6 (OH,F,Cl) 2, and the crystal unit cell formulae of the individual minerals are written as Ca 10 (PO 4 ) 6 (OH) 2, Ca 10 (PO 4 ) 6 (F) 2 and Ca 10 (PO 4 ) 6 (Cl) 2.) Ceramir Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Gibbsite Mixed zone Chemically formed apatite Gibbsite (Calcite) Ceramir Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin Tooth apatite Katoite Ceramir Physical Properties Creates Apatite when in contact with phosphates No shrinkage Hydrophilic system with Alkaline ph Thermal properties similar to tooth structure Low film thickness -15 microns 160 Mpa compressive strength Anti-bacterial-inhibits caries Gets stronger over time Acid resistant Bonds well to metal, porcelain, ceramics, zirconium Ceramir Self Adhesive Resin Cement Resin-Modified Glass Ionomer Glass Ionomer Calcium Aluminate RMGI Calcium Silicate Jeffries SR, Fuller AE, Boston DE. Preliminary Evidence that Bioactive Cements Occlude Artificial Marginal Gaps. J Esthet Restor Dent

53 Ceramir Ceramir Ceramir Ceramir Bioactive Bioactive TheraCem Activa Liner/Base Restorative Material Releases fluoride and calcium Releases fluoride and calcium 53

54 Activa Activa ppm Releases Calcium as ph lowers Releases Phosphates as ph lowers Versatile Material Activa Versatile Material Activa Liner/Base Restorative Material Liner Indirect Pulp Cap Direct restorative Crown Repair Core Buildup Advanced Engineering for People Biomimetic Replacing damaged structure with material that will mimic the function of the original Biomimetics is the term used to describe the substances, equipment, mechanisms and systems which humans imitate natural systems and designs. Bulk Fill Composites Allow many posterior restorations to be built up in 1 segment Descriptions Stick the stuff in the hole and cure Evolutionary Monolithic Physical Advantages Deeper depth of cure Less Polymerization Shrinkage Less Polymerization Shrinkage Stress Reduced likelihood of air voids between layers 54

55 Bulk Fill Composites Modes of Action Improved initiators Greater translucency allows better light transmission Delayed gel state formation Increased elasticity Materials Flowable Conventional Advantages Quicker, easier Less chance of enamel and cusp fractures Increased likelihood of adequate resin polymerization Bulk Fill Flowable Composites Low Shrinkage Stress Surefill SDR Voco Xtra Beautifil Bulk Flowable Venus Bulk Fill Surefill SDR Reduced polymerization shrinkage stress Bulk fill to 4mm Increased sensitivity to light Great placement with metal tips Self-leveling A1, A2, A3 Universal shades Polymerization Shrinkage Stress (MPa) Bulk Fill Posterior Composites Low Shrinkage Stress Sonic Energy Assisted Light Polymerization Voco Xtra Fill Beautifil Bulk Flow Aura Bulk Fill Tetric Evo-Ceram Bulk Fill Sonic Fill Sonic Fill 55

56 ADVANTAGES Sonic Energy Assisted Light Polymerization Sonic Energy Assisted Light Polymerization Improved flowability of composites Improved marginal adaptation 5mm depth of cure Increased sculptability and ease in shaping anatomy Composite designed specifically for use Sonic Fill Sonic Energy Assisted Light Polymerization Composite Direct Placement Challenges Interproximal Contacts Sonic Fill Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60: Interproximal Contacts Original Attempted Solutions Interproximal Contacts Sectional Matrix Challenges Microband Focu-tip Trimax Not enough pressure to separate teeth Fly off Wedge in the way 56

57 Tofflemire vs. Sectional Matrices Tofflemire System Thin contact at the marginal ridge Non anatomical Food trap below contact Increased likelihood of: fracture, recurrent caries and periodontal disease. Sectional Matrices Broad contacts at the proper height of contour Anatomically shaped contacts Tight Contacts Proper contacts that floss properly and promote gingival health Interproximal Contact Retainers Interproximal Contact Also Available as: Universal V3 Ring Narrow V3 Ring Universal Ring Narrow Ring TrioDent/Palodent Palodent Plus Bendable tab Interproximal Contact Bands Holes allow grip with Pin-Tweezers Interproximal Contact Bands Bicuspid Marginal Ridge Contour Side holes for easy removal Molar Pin Tweezers TrioDent/Palodent Plus Sub-gingival Molar TrioDent/Palodent Plus 57

58 Interproximal Contact Anatomical Wedges Wave Wedges Pin Tweezers TrioDent/Palodent Plus Prepare enamel Challenge: Adjacent margins Class II Composite Restorations Place contoured band, wedge & V-Ring Sonicfill Selective etching Wash thoroughly Apply bonding agent Remove wedge peel band back Cure IP Remove band & cure Fill box 2/3 s full Compress w 1P Cure Finish buildup Cure Re-contour diamond/finishing carbides Finishing strips Selective etching Place V-Ring on adjacent tooth Burnish desired contact area ContacEZ Place Universal bonding agent Light Cure 58

59 Adjust occlusion Peel back band Cure from both sides at gingiva Place Composite as before Light Cure Finish and polish In Today s Economy Thank You! Stay current on the latest technologies Communicate effectively with patients Offer choices dward@columbus.rr.com 59