reminirelzation photos
DESCRIPTION
Dental reminirelizationTRANSCRIPT
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Healing Dental Caries:Healing Dental Caries:The Minimal Intervention The Minimal Intervention
ApproachApproach
Edmond R. Hewlett. D.D.S.Edmond R. Hewlett. D.D.S.
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Maintenance & SustainabililtyMaintenance & Sustainabililty……of esthetic treatmentsof esthetic treatments
……of of oral healthoral health
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Young, et al. J Calif Dent AssocOct. 2007
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Young, et al. J Calif Dent AssocOct. 2007
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Caries: The New ParadigmCaries: The New Paradigm
MEDICAL MEDICAL management of management of cariescaries
Treatment of Treatment of dental caries as a dental caries as a diseasedisease
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Caries: TerminologyCaries: Terminology
““Caries” – from the Latin for ‘rot’ or Caries” – from the Latin for ‘rot’ or ‘rotten’‘rotten’
DENTAL CARIES is a DENTAL CARIES is a diseasedisease• PEOPLE have cariesPEOPLE have caries• TEETH have TEETH have carious lesionscarious lesions
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Caries: TerminologyCaries: Terminology
““Caries” – from the Latin for ‘rot’ or Caries” – from the Latin for ‘rot’ or ‘rotten’‘rotten’
DENTAL CARIES is a DENTAL CARIES is a diseasedisease• A rotten tooth = a A rotten tooth = a cariouscarious tooth tooth• An area of rot = a An area of rot = a carious lesioncarious lesion
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Caries: A Brief HistoryCaries: A Brief History
Ancient societiesAncient societies• little/no enamel little/no enamel
cariescaries• some root cariessome root caries• associated with associated with
gum recession/bone gum recession/bone lossloss
• progressed slowlyprogressed slowly
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Caries: A Brief HistoryCaries: A Brief History
Ancient societiesAncient societies• little/no enamel little/no enamel
cariescaries• some root cariessome root caries• associated with associated with
gum recession/bone gum recession/bone lossloss
• progressed slowlyprogressed slowly
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Caries: A Brief HistoryCaries: A Brief History
The Caries EpidemicThe Caries Epidemic• Europe and U.S. in 1700’sEurope and U.S. in 1700’s• REFINED SUCROSE!REFINED SUCROSE!• RAPIDRAPID progression progression• Began in tooth Began in tooth ENAMELENAMEL• Cause was a mysteryCause was a mystery
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Caries: A Brief HistoryCaries: A Brief History
The Caries EpidemicThe Caries Epidemic• Cause was a mystery!Cause was a mystery!
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Caries: A Brief HistoryCaries: A Brief History
Treatment of CariesTreatment of Caries• 3 historical phases3 historical phases
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Caries: A Brief HistoryCaries: A Brief History
Phase 1 (1700’s-early 1900’s)Phase 1 (1700’s-early 1900’s)• Caries = Caries = GANGRENEGANGRENE of the teeth of the teeth
Diagnosis = PainDiagnosis = Pain Treatment: Treatment:
• amputation (extraction)amputation (extraction)• local debridementlocal debridement• fillings?fillings?
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Caries: A Brief HistoryCaries: A Brief History
Phase 2 (early 1900’s-1970’s)Phase 2 (early 1900’s-1970’s)• Refined filling technologyRefined filling technology• Fillings preferred over extractionsFillings preferred over extractions• Cavity shapes driven by filling material Cavity shapes driven by filling material
propertiesproperties INVASIVEINVASIVE
G.V. Black
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Caries: A Brief HistoryCaries: A Brief History
Phase 2 (early 1900’s-1970’s)Phase 2 (early 1900’s-1970’s)• Refined filling technologyRefined filling technology• Fillings preferred over extractionsFillings preferred over extractions• Cavity shapes driven by filling material Cavity shapes driven by filling material
propertiesproperties INVASIVEINVASIVE
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Caries: A Brief HistoryCaries: A Brief History
Phase 2 (early 1900’s-1970’s)Phase 2 (early 1900’s-1970’s) Diagnosis = Diagnosis = DETECTIONDETECTION
• the earlier, the betterthe earlier, the better• visual, sharp explorer, radiographvisual, sharp explorer, radiograph
EtiologyEtiology• acid-producing bacteriaacid-producing bacteria
PreventionPrevention• plaque removal and dietplaque removal and diet
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Caries: A Brief HistoryCaries: A Brief History
Phase 2 (early 1900’s-1970’s)Phase 2 (early 1900’s-1970’s) Standard of Care = RESTORATIONStandard of Care = RESTORATION
Phase 3: The Present…Phase 3: The Present…
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Caries: Our Present UnderstandingCaries: Our Present Understanding
Caries is NOT gangreneCaries is NOT gangrene Caries is a complex DISEASECaries is a complex DISEASE
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Caries: Our Present UnderstandingCaries: Our Present Understanding
1.1. Caries is a bacterial diseaseCaries is a bacterial disease• S. mutans, lactobacilli, A. viscosusS. mutans, lactobacilli, A. viscosus• S. sobrinusS. sobrinus• acidogenic, acid tolerantacidogenic, acid tolerant
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Bacteria in dentinal tubules
Liquefaction of dentin caused by fusion of bacterial accumulations
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Caries: Our Present UnderstandingCaries: Our Present Understanding
2.2. Caries is dependant on dietary Caries is dependant on dietary sucrosesucrose
• affects thickness and chemistry of affects thickness and chemistry of plaqueplaque
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Caries: Our Present UnderstandingCaries: Our Present Understanding
3.3. Caries is driven by the frequency of Caries is driven by the frequency of eatingeating
• demindeminremin balanceremin balance
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Caries: Our Present UnderstandingCaries: Our Present Understanding
4.4. Caries is modified by fluorideCaries is modified by fluoride• harder tooth structureharder tooth structure• inhibits acid production by bacteriainhibits acid production by bacteria
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Caries: Our Present UnderstandingCaries: Our Present Understanding
4.4. Caries is modified by fluoride, Caries is modified by fluoride, calcium, and phosphatecalcium, and phosphate
• harder tooth structureharder tooth structure• inhibits acid production by bacteriainhibits acid production by bacteria
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Caries: Our Present UnderstandingCaries: Our Present Understanding
5.5. Caries is modified by salivaCaries is modified by saliva• bufferingbuffering• demindeminremin balanceremin balance• low flow = HIGH risk!low flow = HIGH risk!
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Caries Management byCaries Management byRisk AssessmentRisk Assessment
(CAMBRA)(CAMBRA)
EducatorsEducatorsScientistsScientists
AdministratorsAdministratorsOrganized DentistryOrganized Dentistry
Third-PartiesThird-Parties
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February, 2003
March, 2003
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October, 2007
November, 2007
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
The Caries Imbalance
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Demineralization & Remineralization
(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
1.1. Caries is a bacterial diseaseCaries is a bacterial disease Change the microfloraChange the microflora
topical chlorhexidine and topical fluoride topical chlorhexidine and topical fluoride
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
2.2. Caries is dependant on dietary Caries is dependant on dietary sucrosesucrose
Reduce dietary sucroseReduce dietary sucrose
Add XylitolAdd Xylitol
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XylitolXylitol
Acts directly on bacteriaActs directly on bacteria Sugar Sugar alcoholalcohol Gets substituted for fructose in Gets substituted for fructose in
bacterial metabolism cyclebacterial metabolism cycle• No acid productionNo acid production• Acidogenic bacteria dieAcidogenic bacteria die• Environmental shift favoring non-Environmental shift favoring non-
pathogenic bacteriapathogenic bacteria• New biofilm is not as harmfulNew biofilm is not as harmful
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XylitolXylitol
Works synergistically with other Works synergistically with other remin therapiesremin therapies
Caries in young children – whole Caries in young children – whole family should use xylitol to combat family should use xylitol to combat the INFECTIONthe INFECTION
6-10 g/day (6-10 servings of gum)6-10 g/day (6-10 servings of gum)
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
3.3. Caries is driven by the frequency of Caries is driven by the frequency of eatingeating Decrease the frequency of eatingDecrease the frequency of eating
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
4.4. Caries is modified by fluoride, Caries is modified by fluoride, calcium, and phosphatecalcium, and phosphate
Add fluoride, calcium, & phosphateAdd fluoride, calcium, & phosphate
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
5.5. Caries is modified by salivaCaries is modified by saliva Increase salivary flow Increase salivary flow
• mechanical stimulation/vigorous chewing mechanical stimulation/vigorous chewing • changing drugs which reduce flowchanging drugs which reduce flow
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
Assessment Assessment Determine Risk Status Determine Risk Status• LowLow• MediumMedium• HighHigh• ExtremeExtreme
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
Clinical Protocol Clinical Protocol ((specific for risk statusspecific for risk status))• Frequency of radiographsFrequency of radiographs• Frequency of caries recall examsFrequency of caries recall exams• Saliva test (flow rate, bacterial culture)Saliva test (flow rate, bacterial culture)• Antimicrobials (chlorhexidine, xylitol)Antimicrobials (chlorhexidine, xylitol)• Behavior ModificationsBehavior Modifications• Fluoride (OTC, Rx, varnish)Fluoride (OTC, Rx, varnish)• Calcium/PhosphateCalcium/Phosphate• SealantsSealants• RestorationsRestorations
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Caries Management by Caries Management by Risk AssessmentRisk Assessment
MonitorMonitor• Are the non-invasive interventions Are the non-invasive interventions
working?working?• Adjust risk status and clinical protocol Adjust risk status and clinical protocol
accordinglyaccordingly
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Caries Risk Assessment
Form
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Disease Indicators
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Risk Factors
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Protective Factors
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Saliva DeficiencySaliva Deficiency
CausesCauses
Medication Side EffectsMedication Side Effects StressStress DehydrationDehydration Salivary Gland Salivary Gland
DysfunctionDysfunction DiseaseDisease Hormonal ImbalanceHormonal Imbalance SmokingSmoking
SignsSigns
Difficulty Eating or Difficulty Eating or SwallowingSwallowing
Tongue Sticking to the Tongue Sticking to the Roof of your Roof of your Mouth/Cheeks Sticking Mouth/Cheeks Sticking to Teethto Teeth
Changes in TasteChanges in Taste Inadequate Denture Inadequate Denture
RetentionRetention Increased Rate of DecayIncreased Rate of Decay Soft Tissue traumaSoft Tissue trauma
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Saliva TestingSaliva Testing
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Saliva TestingSaliva Testing
Saliva-CheckSaliva-Check® ® (GC America)(GC America) 10 minute test10 minute test
• Salivary ProductionSalivary Production• Salivary ConsistencySalivary Consistency• Resting Saliva pHResting Saliva pH• Stimulated Saliva FlowStimulated Saliva Flow• Stimulated Saliva pHStimulated Saliva pH• Saliva Buffering Capacity Saliva Buffering Capacity
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Saliva CheckSaliva Check® ® (GC America) (GC America) When?When?
New Patient Diagnostic ToolNew Patient Diagnostic Tool treatment planningtreatment planning Prior to extensive treatmentPrior to extensive treatment determine cause of problems determine cause of problems
focus future managementfocus future management
• Prior to Ortho proceduresPrior to Ortho procedures• Risk assessmentRisk assessment• Monitor patients Monitor patients
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Saliva TestingSaliva Testing
CRTCRT®®buffer (Ivoclar)buffer (Ivoclar) 5 minute test5 minute test
• Buffering capacity onlyBuffering capacity only
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XerostomiaXerostomiaTreatment:Treatment: increased water intake increased water intake
(spray bottles)(spray bottles) change medicationschange medications saliva substitutessaliva substitutes
• BioteneBiotene®® and Oral Balance and Oral Balance®®
Lubricating gel intraorallyLubricating gel intraorally• KY JellyKY Jelly• GC Dry Mouth Gel GC Dry Mouth Gel
Vaseline or Lansinoh cream on lips Vaseline or Lansinoh cream on lips
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XerostomiaXerostomiaTreatment:Treatment:
toothpastes without additives toothpastes without additives (e.g., Biotene(e.g., Biotene®®))
DO NOT USE lemon & glycerine DO NOT USE lemon & glycerine swabs/toothettes (turns to swabs/toothettes (turns to alchohol)alchohol)
DO NOT USE alcohol containing DO NOT USE alcohol containing mouthwashesmouthwashes
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XerostomiaXerostomiaTreatment:Treatment:
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ACP ProductsACP Products
Enamel Care (Arm & Hammer)Enamel Care (Arm & Hammer) Enamel Pro (Premier)Enamel Pro (Premier) Nite White ACP (Discus)Nite White ACP (Discus) Aegis products (Bosworth)Aegis products (Bosworth)
• P&F sealant, C&B cement, ortho P&F sealant, C&B cement, ortho adhesiveadhesive
Best for pts. w/mild remin probs and Best for pts. w/mild remin probs and high motivationhigh motivation
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Amorphous Calcium Phosphate Amorphous Calcium Phosphate stabilized by stabilized by
Casein PhosphopeptidesCasein Phosphopeptides
CPP-ACPCPP-ACP
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CPP-ACPCPP-ACP
1946 -1946 - anticariogenic properties of milk anticariogenic properties of milk were due to casein, calcium and were due to casein, calcium and phosphatephosphate
1981, Australia –1981, Australia – Prof Eric Reynolds et al. Prof Eric Reynolds et al. at University of Melbourne: at University of Melbourne:
milk, milk concentrates, powders and milk, milk concentrates, powders and cheeses have anticariogenic activity in cheeses have anticariogenic activity in animals and in situ caries modelsanimals and in situ caries models
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CPP-ACPCPP-ACP 1980s-90s1980s-90s Casein PhosphopeptidesCasein Phosphopeptides ( (CPPCPP) are ) are
responsible for the tooth-protective responsible for the tooth-protective activity activity
CPP can bind calcium and phosphate and CPP can bind calcium and phosphate and keep them in a soluble, keep them in a soluble, amorphousamorphous state state
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CPP-ACPCPP-ACP
AAmorphous morphous CCalcium alcium PPhosphatehosphate
Free & available to be incorporated into the Free & available to be incorporated into the tooth structuretooth structure
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CPP-ACPCPP-ACPCPP provides CPP provides SUBSTANTIVITYSUBSTANTIVITY to ACP to ACP
ACP is available forACP is available forover over 3 to 4 HOURS3 to 4 HOURS
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CPP-ACP in plaque
CPP-ACPCPP-ACP
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1980s-90s:1980s-90s:•normally, calcium + phosphate = insoluble normally, calcium + phosphate = insoluble calcium phosphate crystals (Enamelon)calcium phosphate crystals (Enamelon)
•in the presence of in the presence of CPP, CPP, calcium and calcium and phosphate stay in a form that can actually phosphate stay in a form that can actually penetrate into the tooth enamel, work penetrate into the tooth enamel, work synergistically with fluoride and repair synergistically with fluoride and repair demineralized areasdemineralized areas
CPP-ACPCPP-ACP
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CPP-ACPCPP-ACP1990s:•patents on CPP-ACP and licensed exclusively to Recaldent P/L first sold in Japan, Australia, Europe and later in USA (Bonlac Bioscience International PTY LTD - Pfizer)
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CPP-ACPsCPP-ACPs1990s-2000s – Australia and Japan GC licensed for distribution of Tooth Mousse™ via dental practices (prescription not needed in Australia)
2004 – USA MI Paste™ (GC) distribution via dental practices
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MI Paste ApplicationMI Paste Application
Apply pea-size amount on fingerApply pea-size amount on finger
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MI Paste IndicationsMI Paste Indications
High caries riskHigh caries risk
Infants & ChildrenInfants & Children
Expectant MothersExpectant Mothers
OrthodonticsOrthodontics
Prof.. L W
alsh
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MI Paste IndicationsMI Paste Indications
Whitening Whitening sensitivitysensitivity
Root exposureRoot exposure
Chemotherapy, Chemotherapy, radiationradiation
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MI PasteMI Paste PlusPlus -- with Fluoridewith Fluoride
•CPP-ACP: 10%CPP-ACP: 10%•NaF: 900 ppm*NaF: 900 ppm*•ph: 7.2ph: 7.2
(OTC toothpaste: 1000 ppm*)(OTC toothpaste: 1000 ppm*)
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WHY ADD FLUORIDE?WHY ADD FLUORIDE?
CPP-ACP Plus Fluoride CPP-ACP Plus Fluoride exhibits superior anti-caries exhibits superior anti-caries effect than Fluoride aloneeffect than Fluoride alone
Designed for Patients at high Designed for Patients at high risk for dental caries and risk for dental caries and dental erosiondental erosion
MI Paste PlusTM 5:3:1...5/Calcium - 3/Phosphate – 1/Fluoride
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Prof L Walsh, GC Asia
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Prof L Walsh, GC Asia
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Prof L Walsh, GC Asia
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Prof L Walsh, GC Asia
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Incipient caries, Incipient caries, no cavitationno cavitation 6 weeks MI Paste 2 x daily 6 weeks MI Paste 2 x daily
Sept 2005 Nov 2005
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Glass Ionomer SealantGlass Ionomer Sealant
Ultimate protection for newly- and partially-erupted molars!
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Resin Sealants vs. GI SealantsResin Sealants vs. GI Sealants
+ Durability & Seal+ Durability & Seal
- Partial Eruption- Partial Eruption
- Tech. Sensitive- Tech. Sensitive
- Static- Static
- No available Fl, Ca - No available Fl, Ca or Phosphateor Phosphate
- Inhibits Enamel - Inhibits Enamel MaturationMaturation
- Durability- Durability
+ Partial Eruption+ Partial Eruption
+ Moisture-Friendly+ Moisture-Friendly
+ Dynamic+ Dynamic
+ Fl, Ca & Phosphate + Fl, Ca & Phosphate are availableare available
+ Enhances Enamel + Enhances Enamel MaturationMaturation
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Minimally-Invasive Smile Minimally-Invasive Smile EnhancementEnhancement
Management of Management of
White Spot LesionsWhite Spot Lesions
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Image Courtesy of Dr. Steve Steinberg
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White Spot Carious LesionsWhite Spot Carious Lesions
BEFORE AFTER
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White Spot Carious LesionsWhite Spot Carious Lesions
BEFORE AFTER
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Mild FluorosisMild Fluorosis
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Moderate FluorosisModerate Fluorosis
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Severe FluorosisSevere Fluorosis
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Enamel HypomineralizationEnamel Hypomineralization
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Enamel HypomineralizationEnamel Hypomineralization
BEFORE AFTER
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Enamel HypomineralizationEnamel Hypomineralization
BEFORE AFTER
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White Spot LesionsWhite Spot Lesions
Arrested lesion:Arrested lesion:• Check salivaCheck saliva
• Remove sealed skinRemove sealed skin Acid etch for 60 secAcid etch for 60 sec Scrub with pumice and rubber cupScrub with pumice and rubber cup Repeat until no more shiny surfaceRepeat until no more shiny surface Apply MI PasteApply MI Paste
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“Oral Health Improving for Most Americans, But Tooth Decay Among Preschool Children on the Rise”
-CDC news release April 30, 2007
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To learn more…To learn more…
……visit the websites:visit the websites:• CDA FoundationCDA Foundation• WCMIDWCMID• BioteneBiotene• GC AmericaGC America• RecaldentRecaldent
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Thank You!Thank You!