Less is More-Incorporating Minimally Invasive Techniques into your Office Treatment Protocols By Daniel H Ward DDS 1080 Polaris Pkwy Ste 130 Columbus OH 43240 dward@columbus.rr.com September 27, 2015
Minimally Invasive Dentistry Dentistry begets Dentistry Conservative approach Remove only diseased portion of tooth Preserve healthy tooth structure for future restorative needs CAMBRA-CAries Management By Risk Assessment Definitions Caries activity- describes the status of the caries process (demin/remin) on an individual tooth surface. Caries risk- describes the status of the whole patient. It can be defined as the likelihood of the patient getting a new cavitation. Caries is a bacterial infection caused by specific acidogenic bacteria in tooth biofilm. These bacteria are indigenous to humans. There are 30-40 known cariogenic bacteria present in saliva. 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. 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. Surgical Model Model-Wait until cavitation occurs and surgically remove Medical Model-Attempt to influence patient to change oral environment to prevent caries Caries Risk-Negative Factors (BAD) Bacteria poor oral hygiene, biofilm loaded with acidogenic bacteria Acid Critical ph is less than 5.5 Diet Carbohydrate consumption Caries Risk-Positive Factors (SAFE) Saliva 1ml/minute stimulated salivary flow Awareness Educated and motivated patient Fluoride Daily exposure Environment Neutral ph with adequate calcium and phosphate ions
Fluoride Incorporates fluoride into hydroxyapatite resulting in fluorapatite Inhibits bacterial metabolism after diffusing into the bacteria as hydrogen fluoride when plaque is acidified Inhibits demineralization at the surface during acid challenges Enhances remineralization by forming a low-solubility acid-resistant veneer at the surface Result is critical ph is lowered to 4.5 ACP-CPP Amorphous Calcium Phosphate-active ingredient Casein Phosphopeptide-carrier molecule Derived from milk products Localized at tooth surface by binding to plaque and bacteria In presence of acid Calcium and Phosphate ions are released Do not use if true milk allergy, lactose intolerant OK Mode of Action Release of Calcium and Phosphate ions prevents mineralization and promotes re-mineralization Can re-mineralize subsurface lesions if no cavitation Seals dentinal tubules reducing sensitivity ACP-CPP Products MI Paste 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 MI Paste Plain Uses Dentinal sensitivity Temperature sensitivity After tooth whitening For pregnant mothers For children 6 & under During or after ortho Desensitization Poor Oral Hygiene Saliva substitute MI Paste Plus Addition of 0.2% NaF to MI Paste 900 ppm NaF (toothpaste =1100 ppm)
If F - concentration too high-caf deposited on surface preventing absorption 150 micron penetration MI Paste Plus Uses White spot lesions Desensitization During or after ortho Medical compromised pts Xerostomia High Acid Environment High Caries Risk pts Extra Protection General Application of MI Paste Apply after toothbrushing No food or drink for 30 minutes May apply with trays for 3-5 minutes MI Varnish 5% Na F (22,600 ppm) 2% Na F (22,600 ppm) Releases Ca, PO4,F 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 Composite Direct Placement Challenges Thoroughly remove the decay only o First restoration is important to remain conservative o Use 169L, 330, fissurotomy, 201.3VF burs o Use slow speed round burs o High viscosity flowables (Gaenial Flo-BeautiFil Flo 00) o Calset composite warmer Expose the ends of the enamel rods o Flare the occlusal and interproximal o 201.3VF 285.5VF Post-operative Sensitivity o Hydrodynamic theory o Open dentinal tubules o Bacterial Invasion o Overheating o Leakage o Polymerization shrinkage stress o Occlusion
Bonding Agents o Total Etch-best to enamel, technique sensitive o Solvents Acetone Alcohol Water o Effect of dentin depth on bond strengths o Moisture variability o MMP s (Matrix Metallo-Proteases), Cysteine Proteases (Cathepsins) Chlorhexidine Total etch-apply after etching for 30 sec-do not wash off Self etch- apply 2 coats before applying primers Benzalkonium Chloride MDPB o Fourth Generation dentin bonding agents All Bond 2 All Bond 3 (Ace TE) o Fifth Generation dentin bonding agents One Step-bonds to self cure composite Prime & Bond NT I Bond total etch Optibond Solo plus o Self Etch-less technique & post op sensitivity-poor enamel etch? All Bond SE- bonds to self cure composite Optibond XTR-good enamel etch BeautiBond-two different acidic components Clearfill SE Protect-contains MDPB o Selective Etch G Bond o "Universal" bonding agents All Bond Universal-1 bottle-cure if placing indirect restoration Scotchbond Universal Conservative modes of treatment Immediate bonded natural tooth pontic bridges Temporary crowns bonded to tooth In-office direct/indirect inlay/onlays In-office indirect inlay/onlays Glass Ionomer Restorative Materials Advantages of Glass Ionomer Materials Fluoride release/re-uptake Slight moisture is advantageous Bulk placement Anti-bacterial properties Reduced post-operative sensitivity Self-curing in 2.5-5 minutes
Elimination of polymerization shrinkage stress Expansion/contraction similar to tooth High fluoride release Bioactive Setting Reaction of Glass Ionomer Materials Acid/base Reaction Ionic bond to calcium of tooth structure Self-curing Glass Ionomer Restorative Material ( Equia (Fuji IX), RIVA SC) Multiple carious lesions Class V restorations Repair around crown margins Crown buildups Open Sandwich technique Closed Sandwich technique High Fluoride Materials Sealants Long term interim restorations Affect of resin coating How long do they last? Advantages of Resin-modified Glass Ionomer Materials Fluoride release/re-uptake Reduced post-operative sensitivity Less technique sensitivity Dual curing-quicker Anti-bacterial properties Setting Reaction of Resin-modified Glass Ionomer Materials Fluoro-alumino silicate glass (powder) Poly-acrylic acid (liquid) HEMA Acid/base reaction and Polymerization reaction Ionic bonding and micromechanical bonding Resin-modified Glass Ionomer Restorative Material (Fuji II LC, RIVA LC) Definitive restoration Paste/paste dual curing Deciduous teeth Class V dentin and enamel margins Best color of all GI based materials Ease of Use Dual curing Emergency Temporaries prior to crown preparation appointment Restorations under crowns Sandwich technique under composite restorations
Other Resin-modified Glass Ionomer Materials Ceramir o Hybrid cement (RMGI & calcium aluminate) o Forms apatite crystals o Fills in small marginal gaps o Extremely low sensitivity-due to high ph o Low film thickness o Ideal for zirconia-not affected by phosphate contamination Effective Patient Communication Digital Dental Radiography Digital Dental Photography o Diagnostic o Patient Communication o Laboratory Communication o Communication with Specialists o Communication with Insurance Co o Medical/Legal o Self Evaluation o Lectures, Publications, Accreditation Digital Dental Cameras o Modified-Consumer Fixed Lens Canon G-16 o Dental Specialty Shofu Eye Special C-II o Single Lens Reflex (SLR) Canon Rebel T5i camera body Canon 100 mm macro EF lens Canon MR-14-EX ring flash o Camera Settings ISO 200 Flash Sync speed 1/200 second Aperture Priority (Av setting) Over exposure override +0.5-1.5 f stops Full face (1:10 but 1:15 digital) at f 8 or 11 Full smile (1:2 but 1:3 digital) at f 22 or 32 Closeup (1:1 but 1:1.5 digital) at f 32 Manual focus o WiFi o Photoshop Elements o Avoid Smile Libraries o Proportional Smile Design RED Proportion-70% for average length teeth 78% W/H Ratio Tall Teeth-Small RED Proportion-dominant centrals Short Teeth-Larger RED Proportion
Smile Reminder o Cell phone text messaging o E mail messaging o E mail Newsletters o E mail Patient Surveys o Online Patient Reviews-monitor major servers o Online patient payments o Practice management tools (demographics, financials) Other Interesting Products Ivoclar 1-P Composite placement instrument Onset by OnPharma Thera Cal-Bisco Giomers with S-PRG filler particles made of glass ionomer o Fluoride release o Low plaque accumulation o Beautifill II o BeautiSealant New Filler Technology Non-bis-GMA resins Bulk Fill Composites o Low Shrinkage Stress Composites Delay the gel point Flexible filler particles o Greater Depth of Cure Increase translucency Different initiators o Sure Fill SDR-low shrinkage stress flowable base o Sonic Fill-low shrinkage stress bulk fill posterior composite Optra Sculpt-easy to manipulate facial composite material Triodent/V-3/V-4 Sectional Matrices Latest Generation All-Ceramic Crowns E-Max (lithium disilicate) o Best to bond especially if crown is thinner than 1mm o Beauticem-self etching resin cement-single step o Biscem- self etching resin cement-single step o Duo-Link Universal with Universal Primer-separate bond and resin cement-strongest o e Cement-kit with Duo Link and Choice II-contains everything to bond E-Max Zirconia o Ceramir-excellent with adequate crown length-easy to use o Fuji Plus RMGI cement o Bond with Duo-Link with Universal Primer o Important to deal with phosphate contaminations Ivoclean Z-Prime-use for -zirconia, metal, fiber posts Use Ceramir