Microinvasive Dentistry: Clinical Strategies and Tools John J Graeber
Note: Page numbers in bold or italic refer to tables or figures, respectively.
Acid etching dentin 110, 110
Acteon 55
Actinomyces species 91
Activa (Pulpdent Corp) 149, 149
A-delta pain fibers 188
Affected dentin 143
Air abrasion 99
and acid conditioning of tooth structure 102
advantages 103104, 108110, 109
bond strengths, increase in 109
clinical applications 103104
contraindications to use of 103, 110, 117118
devices 118
history and scientific principles 99100, 107108
indications for use of, in microdentistry 110
interproximal lesions and 114115, 115
interproximal restoration and 115116
methods of soft tissue protection from 111
no harm to enamel and dentin by 109
operator objections to use of 118
other uses of 116118, 117
particle delivery system 101102
pit and fissure caries treatment 110112
precautionary measures 110, 111
reappearance of new devices 101
remineralization of affected dentin by 116, 117
resurfacing composite resin restorations 116
root surface lesions and 116, 116
safety considerations and precautions 103
scientific research on 102
steps in technique for 112116, 113115
technique 107118
types of particles 102
variables affecting 102
Air-abrasive cavity preparation devices 104, 104
Airdent 100, 107
Aluminum oxide 101, 102, 109, 111
Anorexia 20
Autofluorescence of enamel 55
Bioactive glass 178
Bioactive glass powder 102
Bioactive materials 144146
Bioactive product
Activa (Pulpdent Corp) 149, 149
Ceramir Crown and Bridge Cement (Doxa AB) 148, 148149
Gibbs–Donnan equilibrium 147
NovaMin (Sylc) 147, 147148
TheraCal LC (Bisco) 148, 148
Bioglass materials 145
Biomineralization process 146147
Bonding technique 122
bonding to dentin 124125
mechanism of resin/enamel 124
Bruxism 20, 21
Bulimia 20
Bulk-fill composites 173
Calcium sodium phosphosilicate 102
Calculus and plaque/biofilm 79
Canary patient report 48
Canary Scale 47
Canary System 45
advantages 51
in clinical practice 4548, 49, 50, 5051
disadvantages 51
energy conversion technology 45
procedure 4648
users of 48
Caries detection technologies 35. See also Canary System; Near-infrared (NIR) transillumination; SoproLife
approaches 46, 4647
CariVu 36, 3637, 4142, 42, 43
DIAGNOcam 36, 36, 42
methods 3637, 3738
use of VDDS and TWAIN interface 36
Caries detector dye 103
Caries lesions
acid solutions for removal of surface layer 11
classification of 11
clinical staging of 11
determination of treatment 11
radiographic evidence of 11
surgical treatment of 11
Caries Management by Risk Assessment (CAMBRA) protocol 22
Caries prevention
anticaries preparations 8
bacterial control 6
diet 6
fluoridation of drinking water 3, 67
fluoride supplements 78
tooth brushing techniques 6
using silver diamine fluoride 8, 8
using topical fluoride preparations 7
Caries risk assessment 1922
bacterial load 22, 23
questionnaire 1922, 2021
screening of cariogenic bacteria and future decay 2223
Casein phosphopeptides-amorphous calcium phosphate (CPP-ACP) 177
Case study
class III caries 129
class IV lower incisor 131
class IV maxillary incisor 130
class V lesion 132
demineralization lesion 127
molar caries 128
Cavitation of enamel 11
Ceramir Crown and Bridge Cement (Doxa AB) 148, 148149
Chromophore 119
CO2 laser, 9300 nm
for caries removal and tooth preparation 137
class I restorative procedures 138, 139
disadvantages, conventional handpiece 137
laser beam size and spot size 136, 137
laser delivery system 136
laser plume 139
occlusal pits and fissures 138, 138
progress 135136
sealant preparation 137138
Composite resin restorations 116
Demineralization 12, 2022, 35, 51
Dental caries 83
caries removal 138, 138
class II cavity preparations 139, 140
class III, IV, V, VI cavity 139, 140
contaminated tooth preparations 8990, 90
crown preparation with small knitted cord 72
detection and treatment 72, 72
diversity of bacteria identified within 9094, 9194
endodontic therapy 74, 74
glass ionomer restoratives 9698, 97
inactivating invisible microbes 8487, 86, 87
infected and affected layer in 8789, 88, 89
laser plume 139
methods for harvest of microbes present in vivo 84, 85, 86
microbes in 83
old alloys and repairing the tooth 141
posterior pediatric crowns 140, 141
silver diamine fluoride application 9496, 9596
support and training 74
tooth disinfection 85, 87
Dental decay 3, 4
Dental explorer 77, 77
Dental mirrors 7778
Dentin 143
defined 143
overview 143144
secreting cells 143
types 143
Detection dyes 77
DIAGNOdent value 61
Digital Imaging Fiber Optic Transillumination (DIFOTI) 3536, 36
Dust issue 108
Ecological plaque hypothesis 92
Electrically-accelerated and Enhanced Remineralization (EAER) 178179
Enamel, abiotic 180
Enamel matrix derivative (EMD) 179
Enamel regeneration
developmental program 171
enamel replacements 172173
limitations of strategies 172173, 173
Enamel replacement
abiotic enamel 180
infiltration resin technique 179
natural enamel proteins as scaffolds 179
synthetic enamel-analogs as scaffolds 179180
Energy density measurement 120
Erbium laser handpieces
with tips 122, 123
without tips 122, 123
Etching 1112, 1415
Facial trauma 187193, 191193
complications 187
Fiber optic transilluminator (FOTI) 35
Fissure stain removal 62
Fluorescence 46
Fluoridation 3, 67
Fluoride mineral
exposure history 4, 5
sources 3, 7
therapeutic uses 34
Fluoride varnish 8
Fluorosis 3, 8
Fractured teeth 31, 33
Frequent polishing 92, 94
Gag reflex 193, 194
Gaussian beam geometry 122, 122
Gauze squares 103
Gibbs–Donnan equilibrium 147
Gingival collars 115, 1115
Gingival recession 3
Glass ionomer cements (GICs) 173
with chlorhexidine hexametaphosphate (CHX-HMP) 176
flowable bulk-fill materials 173
HA inomers 175
self-adhesive resin composites 174
surface remineralization agents 175
Gluma Desensitizer treatment 89, 90
Halogen operating light 78
HealOzone 153, 153
Helium gas 111112
Hydrochloric acid 12, 14, 15
Icon (resin infiltrant) 1112, 1617
Illumination, adequate 78, 7879
Infected dentin 143
Infiltration resin technique 179
International Caries Classification and Management System (ICCMS) 11
International Caries Detection and Assessment System (ICDAS) coding system, for decay 23, 2324
Interproximal caries 11
resin infiltration for 12
Interproximal coronal caries 79, 79
Interproximal restoration 114115, 115
Intraoral video cameras (IOVC)
benefits 29, 3233
best practices 3031, 3031
in case presentation 32
commercially available units 33
consultation room setup 32
development of 2930
disadvantages 3233
equipment 32, 32
images 30–31
models 29, 2930
procedure 3032
role in patient education 32
KaVo-Kerr DIAGNOdent 6263
advantages 64
disadvantages 64
failed amalgam margin 64, 64
measurement of the lesion 63, 63
‘moment’ and ‘peak’ ports 63, 63
Kinetic cavity preparation (KCT) 101
Laser-assisted remineralization 178
Laser delivery system 136
Laser devices 119
Light-based devices
CariVu 79, 79
Light-based technology 185
Light emitting diodes (LED) 78
Low level laser therapy (LLLT) 190
Material seal 96
advantages 67
components of 68, 70
crown preparation with small knitted cord 71
history 67
labeled parts of 67
levels of magnification 69, 70
magnification changer 70
mounting configurations 70
Minimal invasive conservative protocol 156
Mouth rinses 56
Nano-silver fluoride 177
Near-infrared (NIR) transillumination. See also Caries detection technologies
band width 38
benefits 3844
for caries detection 35
case example 41, 4142
disadvantages 44
images 3739, 40, 4143
Nuisance dust 102
Oral cavity abrasive polishing agent 102
Orthodontic separator 1314, 1314
Ozone therapy 153
ability to kill microorganisms 154
antibacterial efficacy 156
deciduous carious lesions treatment 155156
effects on dental hard substances 157158
effects on microbes 157
future 158
mechanism 154
safety and healing 153154
smooth surface enamel caries lesions 155
Paper triangular disks (Dry-Angles) 112, 113
Peak power 121
Pen Model DIAGNOdent 6162, 62
Photoablation 119, 120
Photoacoustic 119
Photoacoustic effect 119
Photoactivated disinfection 186
Photobiomodulation (PBM) 185
applications 185
lesions and remineralization of decalcifications 187, 188
mechanisms 185
with photoactivated disinfection 187, 189
replacement of sealant restorations 186187, 187
Photochemical reactions
type 1 186
type 2 186
Photothermal radiometry and luminescence (PTR-LUM) 45
Pit and fissure caries treatment 110112
Preconditioning 193195
Pulpitis 195
Pulse duration 120
Pulse repetition rate 121
Quantitative light-induced fluorescence (QLF) 23, 67
Recaldent (phosphopeptide-amorphous calcium phosphate (CPP-ACP)) 7
Remineralization 7, 47, 51, 116, 117
of brown spot lesions 4850, 50
products 7
Resin infiltration 11
commercially available 12
effectiveness of 13
for demineralized smooth surface lesions 17, 17
for interproximal lesions 12
for white spot lesions 17, 17
initial steps 12
principle of 12
procedure 1316, 1316
Restorative prescription
aspiration of odontoblasts 162
composite resin 167
disinfection of the dentinal structures 163, 163
heat and friction 162, 162
iatrogentic damage 164
lubricant contamination 162
Mud Flaps 164
no harm to patients 164
noise and vibration 163164
pulpal injury 162
smear layer 162163
use of amalgam 166167, 167
Root surface lesions 116, 116
Rotary instruments 108, 109
Rubber dam 103, 110
Salivary contamination, of infiltration process 12
Sandwich technique 97
Schick CDR 59
Screening of cariogenic bacteria and future decay
ATP screening 22
bacterial culture 23
CAMBRA process of determining risk profile 22
of gum line notching 22, 23
pH check 23
Sealant restorations, photoactivated disinfection and replacement 187, 187
Shallow root carious lesions 155
Silver diamine fluoride (SDF) 9496, 9596
SoproLife 55, 5556
applications 57
blue florescence mode 56, 56, 58
operating portion of 56
white or daylight mode 56
working head of 56
Subgingival lesion, partially 116, 116
Subjectivity of tests 80
SYCL powder 116, 117
TheraCal LC (Bisco) 148, 148
Therapeutic bandage 9697
Thermal effect 119
Tooth desensitization, formulation for 89
Tooth disinfection 85, 87
with fluoride 4
RDA value 2425
Transillumination of teeth 35, 46 See also Near-infrared (NIR) transillumination
Trauma 187
Tricalcium phosphate 178
Triethylene glycol dimethacrylate (TEGDMA) infiltrants 12
Trimetaphosphate 178
VDDS interface 36
Whisperjet 2000 107
White spot lesion 47
Xerostomia 20, 21
Chapter Notes

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Microinvasive Dentistry Clinical Strategies and Tools
Microinvasive Dentistry Clinical Strategies and Tools
John J Graeber DMD MAGD MALD FICD Past President Certified Dental Laser Educator Academy of Laser Dentistry Attending Morristown Memorial Hospital Private Practice New Jersey, USA
© 2021 Jaypee Brothers Medical Publishers
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Tooth decay remains the most prevalent disease on earth. As Health Professionals, our goal is primarily to help heal our patients in need. This requires that we DO NO HARM.
In my opinion, we do harm when we do not avail ourselves of the most up-to-date devices and methods, which aid in the earliest possible diagnosis and intervene with the least invasive treatment, preventive or otherwise.
Microinvasive Dentistry is a series of manuscripts, which address prevention, management, early diagnosis, and treatment of caries – the most prevalent disease of mankind.
This book begins with a review of preventive techniques and current best practices with fluoride. The earliest signs of tooth decay can be treated with penetrating resins, sealants, and fluoride preparations when utilized early in the disease process.
Earlier diagnosis presents us with an opportunity to provide a better service, but only when we have the tools necessary for objective measurement and/or monitoring of the decay process. Several chapters of this book explain, in practical detail, devices, which far exceed the accuracy of the oldest dental instruments – the explorer and the dental bitewing X-ray.
The latest microbiological findings about caries are published here for the first time – shattering traditional concepts, not only in the discovery of novel causative species but also questioning current concepts of the anti-caries value of restorative materials. The potential of regeneration of dental materials is discussed by world-class researchers and clinicians.
Where caries has extended into the dental tissue, new methods of caries excavation and cavity preparation are explained and demonstrated in great detail by leading edge clinicians, based on years of real-life experience. The advantages of air-abrasives and all-tissue laser devices have been shown over the decades to be far safer on human teeth than the high-speed drills, which have been in common usage for the past 70 or so years. The time has arrived when we should be retiring the GV Black concepts designed for metallic restorations.
So, I invite you to read and study this book on Microinvasive Dentistry and challenge you to become part of the New Age in Dentistry.
John J Graeber
March 2020
Contributors Acknowledgments
I would like to extend my appreciation to Steffan Clements who provided the impetus for putting this book together. Despite my reluctance to commit to the project, his encouragement and guidance has made it an interesting experience for a practitioner. This project took on added significance for someone in the twilight of his career, and getting the opportunity of giving back to a profession which has given me so much more than ever expected.
Of course, my family and wife, Karen made the greatest sacrifice of all-giving up family time with me, somehow we made it through, but many thanks to her and our children and grandchildren.
No work of this breadth could be produced by just one individual. Fortunately, my professional career has taken me both far and wide – far in the aspect of being invited all over the world to share my knowledge and experience in the practice of Laser Dentistry, and wide in the aspect of being in the frequent company of so many talented dentists and health professionals especially in these past 30 years.
I am eternally grateful to the many contributors to this book. Their contributions to better dentistry are awesome.
I also must inform you that many of the contributors are my fellow members of the Academy of Laser Dentistry. As a founding member and Past President, I am so grateful for the insight and foresight of so many members who not only inspired this text but contributed to the formation of many of its ideals and aspirations.
John J Graeber
The future is now
John J Graeber
In the past few decades, the delivery of routine restorative care in dentistry has undergone transformative changes. New materials, techniques, and minimalist philosophy have outpaced general acceptance.
The dental explorer, mirror and high-speed handpiece remain as the standards of care. If so much change for the better in materials has taken place, why have most practitioners held onto outmoded techniques of diagnosis and treatment? Why is speed of delivery so important to the average practitioner? If less invasive techniques have been shown to produce less destruction to tooth structure, why haven't they been implemented?
Perhaps there is truth to the adage: dentists have been overly trained and poorly educated! Is it so difficult to change the way every dentist has been trained? If we subscribe to the Ethical standard of “DO NO HARM” why do we find it so hard to understand that tried and true methods may no longer be the right thing to do?
Over the past 25–30 years, there have been technological and clinical developments in dentistry, which have not become fully integrated on the delivery of routine restorative care.
Part of the cause of this is the reluctance of Dental Schools and General Practice Residency Programs to introduce many of these new technologies to their students. Rightly asked, “Why Not?”
In defense of these programs, it might be argued that the teaching staff has not been exposed to these technologies either and how could students be possibly taught by those who not yet learned themselves. Another reason is that many of these technologies are costly, and institutions are already under fire with budgetary constraints. But unfortunately, the idea of a “slower” diagnostic process, or slower treatment modalities have no obvious compelling economic benefit to the practitioner.
If we still subscribe ethically to the “do no harm” principle, then the information and evidence is there to support the idea of utilizing the most accurate techniques in diagnosis as well as treatment modalities.
In nearly 50 years of practicing dentistry, I long ago moved away from many of the principals and techniques taught in my undergraduate program. Many of those techniques and principles I questioned even then, and later came to realize that certain techniques were merely taught so as to have the entire class able to pass both required proficiencies and board exam requirements. Continuing education experiences (nearly 4,000 hours and 2 Masterships) over my career began to reshape my techniques and knowledge base. The plethora of new materials and technologies introduced during my professional career also has heavily increased my questioning of how and why. To date, there has been too little written concerning these developments. Many long-standing principles of practice have been challenged under the “medical model” scenario or the move to evidence-based care.
Beyond the cost and ethical dilemmas, what about serving the patient better? All dentists lament the fact that only about half of the population seek care on an annual basis. Why? Every dentist also has heard the two most frequent barriers to care: The “Shot” and the “Drill”. Would there be an increase of patients seeking care if both of the main objections to care were eliminated? (other than obvious economic barriers)
Most practicing dentists surveyed, indicate a lack of familiarization with the more accurate diagnostic and treatment options available to them. This seems so true despite the constant flow of device advertisements in the dental literature.
The purpose we hope to fulfill with the publishing of this textbook is to familiarize General Restorative Dentists with the updated information about these devices and how to practically incorporate them into practice. If adopted, as some dentists have already, that the incorporation of the devices in this book will increase their ability to make earlier diagnoses, make more evidence-based decisions and better educate their patients in their disease management. A bonus would be to do less iatrogenic damage to the dentition, with methods that are far more acceptable to the average patient. The net benefit to the population is earlier treatment, more scientific management and far more patients seeking this type of care. This can have a major impact on the “busy-ness” issue for many offices and clinics. There is little controversy that the smaller the restoration, the longer the tooth will most likely survive for a lifetime.
Even though dentistry is mainly concerned with three chronic diseases: tooth decay, periodontal disease and occlusal disorders, any approach to diagnosis and treatment must be rooted in sound preventive principles. So this text will begin with an updating chapter on fluorides and preventive methods. Fluoride supplementation has become one of the foundations of prevention. While we can make teeth less susceptible to the decay process, bacterial control is essential. The approach must be tailored to each individual and adjusted throughout life's oral changes and challenges. While children are taught to brush the “tops of teeth” when should practitioners introduce the technique of sulcular brushing? When is it advisable to move patient from flossing to interproximal brushing? Isn't diet monitoring necessary throughout the various stages of life? How precisely do we track patient medication and their side effects in the oral cavity? When do we introduce occlusal monitoring into the examinations process? At every stage of life, different strategies must be employed to match changing oral conditions.
When should sealants be placed? What are the best practices for sealant preparation? Clear sealants versus opaque. Fluoride release materials versus plain unfilled resin? How do you accurately determine if a sealant is indicated or a restoration? What happens if caries is present and teeth are sealed over decay? Are they worth doing at all?
Is there a way to cause melting of the sides of a fissure and coalesce the walls as a “natural” sealant? Which device could be used for this technique? Within this text, you may find the answers.
Contemporary caries management
The concept of a structured assessment of risk for caries should assist the diagnostician in weighing the treatment options. A simple carious lesion can be monitored, minimally treated non-invasively or restored aggressively depending on the risk factors for an individual patient. The goal is to perform the least necessary treatment after having thoroughly assessed each patient's risk for serious treatment consequences. Each of the risk factors need to be weighed carefully by the diagnosing dentist and an individualized treatment plan created and is explained to the patient.
Decalcification management
The process of decalcification is generally considered the precursor of the decay process and bacterial infection. If early intervention is to be incorporated into practice, a course of non-invasive re-mineralization needs to be included in the treatment options. This can be a combination of chemical intervention, penetrating resin-based, or sealant therapy. Each strategy needs to be matched to the needs of the individual patient if we are to be successful before invasive treatment becomes necessary.
Death of the bitewing X-ray?
The bitewing X-rays, both anterior and posterior have been a reliable test for interproximal decay once teeth have attained contact. There are devices currently available that offer more diagnostic information without the use of ionizing radiation. A controversial subject with pros and cons.
Transillumination with white light has been utilized for many decades. This technique has inherent limitations due to the weakness of white light to transmit through tissue deeply.
New devices currently available utilize near-infrared light that is invisible to the naked eye. However, one property of near-infrared is potentially deeper penetration into both hard and soft tissue than white light. One such device transmits this infrared light through gingival and osseous tissue and then through the roots of teeth and into the crown. A miniature infrared camera (similar to a night vision device) records this phenomenon in real-time and display an X-ray like image on a computer monitor. Besides being much more sensitive than an X-ray, the images can be saved to the patient's record. One reason that it is more accurate is that the beam travels up the root and into the crown of the tooth contrary to the penetration of an X-ray. This change in angulation of the “beam” in conjunction with visualizing a bitewing X-ray will have an almost 3D appearance. Other advantages of this type system is being able to better visualize the extent of decay in both the enamel and the dentin; the exact location of the lesion in a buccolingual dimension is also easily determined; seeing cracks in both the restorations and the enamel; imaging decay under a composite restoration or lingual or buccal to an existing metallic restoration. This is usually completely blocked in an X-ray image.
No inference should be drawn that bitewing X-rays do have value in finding other types of pathology such as alveolar bone levels and calcification density.
New diagnostic devices
The restorative dentist has always relied on the dental explorer as his primary decay-detecting device. While it should remain as the device of choice for detecting marginal defects of restorations, it fails the test as a diagnostic tool for virgin decay. Studies have shown almost a 50% failure rate in decay detection of pits and fissures. The medical model demands objective testing to support accurate diagnoses. The old methods have failed us miserably.
There have been introduced a number of simple diagnostic devices which utilize various wavelengths of light. They have been demonstrated to more accurately pinpoint the extent of carious progression into both decay and dentin. More sophisticated devices can analyze lesions for decalcification. Others measure the column of bacteria in a pit or groove base utilizing the principle of laser fluorescence.
The digital age of miniaturization and high definition has enhanced what we can see in real time. Intraoral video cameras have come a long way since their first introduction in the 1980s. Not only is this methodology important to the diagnosing dentist but it is also a very essential element in the education of patients. While these cameras are justifiable in the hygienist's hands, it is also essential that the diagnosing dentist record and present these images to the patient for their understanding and treatment acceptance.
Other cameras utilize specific wavelengths of light to highlight bacterial concentrations, plaque accumulation, etc. One such camera system (SoproLife) allows for differentiation of normal structure from carious both pre- and intraoperatively. Use of this system could make the messy dyes commonly used for decay visualization unnecessary.
Fortunately, magnification used in dentistry has advanced significantly in the past few decades. The standard of care now recognizes the diagnosis and treatment needs to be carried out under magnification. Virtually all training programs involve training with face mounted magnification. Suffice it to say that this has greatly assisted all dentists toward a higher quality of care. So what is the next step?
The operating microscope has gained favor with the endodontic and surgical specialties. How long will it take the average dentist to adapt to this higher standard of magnification?
Microbiology of the carious lesion
While it has long been established that tooth decay is primarily a bacterial infection, it has only been a recent discovery and identification of the multiple microorganisms involved in the caries infection. Once thought of as a single causative bacterium, Streptococcus mutans, there are many more causative and facilitative organisms. This disease has many causes, and there are no current therapies which can all eliminate microorganisms completely from a tooth. No restorative techniques currently can completely seal out their return!
A clearer understanding is needed foir practitioners for this disease to become eradicated or at least better treated.
Drill elimination!
The high-speed handpiece is entering its 8th decade of use! In this day and age, is there finally an alternative to the destructive nature of this device? Decades of research has shown now that every high speed handpiece causes fracturing of tooth structure when used intracoronally! This occurs due to the friction, heat and eccentricity of these devices at speeds 100,000 RPM and higher. If the high-speed handpiece were submitted to the FDA today, would approval be given? If approval were required, and not just grandfathered, would they be approved for use? What are the alternatives to use them?
More than 70 years ago, an air abrasive device was introduced to the profession. While reports at the time indicated general acceptance by both practitioners and patients, the technique did not facilitate retention of the restorative materials – amalgam and/or gold. Both of these materials require mechanical retention with undercuts.
The nature of air abrasives does not create mechanical undercuts sufficient to mechanically retain most materials. A re-introduction of the devices met with good acceptance in the 1990s for bonded restorations. The manufacturers failure to control the airborne particles has led to abandonment by most practicing restorative dentists. Newer techniques of particle management require another look by practitioners. The adherence of materials to an air abraded surface is significantly improved, and highly recommended.
Cut teeth with light? Painlessly?
More than 20 years have passed since certain wavelengths of laser light have been used to prepare carious lesions for restoration. Early models of these devices were underpowered, and overpriced for the average practitioner. As a result, only about 10% of practices adopted them. Much has changed: cost has been reduced, speed of cutting has approached that of high-speed handpieces, and software has improved the performance of hard tissue lasers. They are virtually silent; they definitely can prepare most cavities without perceptible pain and leave a very bondable and clean surface for bonded direct placed restoratives. There are now more wavelengths available for use.
Once prepared and restored, can a tooth heal? It has been observed that new reparative dentin can be seen on post-treatment radiographs. There seems to be little correlation to the traditional restorative materials. The chapter on dentinal regeneration offers some suggestions as to how to attain this reparative dentinal result more predictably. New materials introduced into the market have the potential to cause complete and predictable remineralization on remaining dentinal structure.
Enamel, on the other hand is non-living structure. It is crystalline in structure, with protein sandwiched in between the crystal prisms. In attempting to re-create it, researchers have tried any number of techniques. Unfortunately, formative ameloblast cells are lost as teeth erupt into the oral environment. This has somewhat hampered research. Chemical, electrical means and lasers low-level have been used in the regeneration trials. More work is indicated in the quest to develop more natural restorations.
Could enamel be re-grown in situ? Is this the future of restorative dentistry? This has already been done in the laboratory, but can it be done intraorally? Please see the Chapter 19 to find out how stem cells stimulated by photobiomodulation may hold the key to completely replacing lost enamel.
Although beyond the scope of this text, there is ongoing work on the use of stem cells to re-populate the pulpal space with functioning tissue. This has the potential to markedly change endodontics.
Preparation sterilization?
One of GV Black's principles 100 years ago was to “toilet the cavity” prior to placement of a restoration. Great idea, with what? Many materials have been offered as the best practice for cavity cleansing prior to restorative steps. Do they work? New evidence suggests that very few are effective as anti-infective agents. Some favor Ozone treatment (not yet FDA approved due to environmental concerns) others suggest glutaraldehyde preparations and many other chemicals have been suggested. Certainly removal of the cause of the problem remains a goal not yet fully realized.
Therapeutic lasers: A place in restorative dentistry?
Besides surgical lasers, which can cut both hard and soft oral tissues, there are class of lasers which are non-surgical and impact cellular structures and functions without any effect on normal cells. They are approved for pain control and reduction of inflammation. These devices have been employed by Chiropractors and Physical Therapy Specialists for decades. They are currently employed in dental practices in pain reduction for TMD disorders, reduction of post-treatment inflammation and expediting orthodontic movement. Other potential uses include reduction of pre- and post-treatment inflammation, pulpal analgesia, and promotion of nerve regeneration.
This type of treatment is now known as Photobiomodulation.
Buyer beware!
The suggestions in this textbook could be taken as overwhelming! It would be wise to consider making one change in your practice at a time. I strongly recommend picking one technology that you feel could make the most difference in how you treat patients. Here are some practical guidelines on how to incorporate new technologies into practice.
The purpose of this book is to bring new information to general practitioners all over the world. It is also meant to serve as a WAKE UP CALL to all who cling to the outmoded principles and techniques of the past.
Today's technological explosion has had a major impact on the practice of medicine. To a far less extent, this explosion has been much less on the practice of dentistry. Some of the reasoning is the isolated nature of dental practice, and some is the economic burden on the individual practitioner. Dentistry does not command the fee levels that medicine and hospital care command. Reduced fee programs have a negative effect on new equipment purchases.
Where the tried and true methods have proven less than adequate or prevent patients from accessing care, they should be replaced.
No one practitioner could or should employ every technology or methodology mentioned in this textbook. If every practice implemented just one of the technological changes in diagnosis or treatment, the impact on patient care could be demonstrably better.