#28 – Understanding Minimally Invasive Dentistry | Dental Practice Coaching

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#28 – Understanding Minimally Invasive Dentistry

Most of us grew up believing they should get their teeth cleaned twice a year. People are surprised to learn that this honored interval wasn’t developed by dentists. Here’s the story:

In the 1930’s the most popular radio show was “Amos and Andy.” The show was sponsored by Ipana toothpaste and they finished every show “Brush your teeth twice a day, see your dentist twice a year”. In the prefluoride 1930’s when decay was rampant and most people were constantly getting decay, seeing a dentist twice a year allowed the dentist to do fillings quickly enough to at least not lose teeth due to huge cavities.

Today, this 30″s approach to continual repair makes no sense. Using our new concepts of Minimally Invasive Dentistry, you will take over responsibility for your own health. In fact, today we know that you brush your teeth not to clean them, but to:
1. Disrupt the plaque
2. Deliver chemotherapeutic agents

The healthier you are, the fewer services you need from us. This has several advantages for you:
1. Save money
2. Less drilling
3. Your natural teeth will last a life time

A 2003 study by Data Analysis center based on 77 million claims submitted to the Delta Dental insurance company shows that a filling placed in a permanent tooth for a 10 year old child will end up costing this person on average over $2,000 by the time she/he is 79 years old and $1,000 by the age of 40! There are several reasons for this huge cost.

The Tooth Death Spiral

1. The filling needs to be replaced as it wears out
a. Tooth colored fillings in 7-10 years
b. Silver fillings in 10-15 years

2. Each time a filling is replaced, more of the surrounding tooth is lost and the tooth becomes weaker. As a result the new filling won’t last as long.

3. Eventually this large filling can:
a. Allow the tooth to break, requiring a crown
b. Lead to an abscessed tooth requiring a root canal

4. Finally, if the break down continues the tooth can be lost requiring major treatment
a. Implant
b. Fixed bridge
c. Removable appliance

To control the decay you must understand how decay works.
1. Decay is an infectious, communicable bacterial infection caused by only 2 types of bacteria that produce acid that dissolves tooth structure.
2. Before decay creates a hole (cavity) in the tooth, it can be healed. In fact, teeth are constantly being attacked by acid and healing themselves many times each day.

The bacteria in the plaque around the tooth eat the available sugar and make acid. The acid begins to dissolve the calcium and phosphorous out of the tooth, leaving a white area of initial decay. In the past, we thought decay was a continuous process. The longer we waited to cut out the decay, the worse it got. Now we know how to reverse this process. However, if the decay is not reversed, the acid weakened area of the tooth will collapse, creating a cavity which must be restored.

There are 4 steps to controlling decay risk:
1. Acid producing bacterial control
2. Reduce your risk level
3. Remineralize (heal) decayed areas that have not yet created a hole in the tooth. When the pH is above 5.5, the calcium and phosphorus ions in saliva begin remineralization.
4. Follow up and maintenance.

In the last century, patients worried about getting cavities. Today, in the 21st century, we treat decay as a process – and a cavity is the last step in the process.

So treating decay has moved from the 19th century model – see it, cut it out, to the 3 step 21st century model.
1. See the decay
2. Determine if it can be healed or not
3. Determine if more areas of decay might occur

Diagnosing Decay Activity (see brochure)

MOST IMPORTANT! DO NOT PUSH AN EXPLORING POINT INTO AN OCCLUSAL GROOVE WITH ANY FORCE. You will very likely create a cavity that now cannot be remineralized. The diagnodent is a tooth’s best friend.

In 2005 you will begin to see a new term in dentistry – Caries Management By Risk Assessment (CAMBRA). Teeth mineralize and demineralize at least 2-3 times everyday due to:
1. rise/fall in pH in the mouth
2. calcium and phosphate level in the saliva
3. fluoride available on the tooth surface

In fact, a tooth that has had an acid attack and then healed itself is stronger than a tooth that hasn’t been attacked.

Decay activity is elevated by:
1. Color/texture (in order of severity) of the tooth
a. White shiny, smooth, hard – inactive lesion (no intervention needed)
b. Brown/black areas
c. White to black areas that are chalky- Chalky, rough to the explorer = active lesion that probably can be healed (no intervention needed)

2. Diagnodent (laser diagnostic tool) that is 3x more accurate than exploring point due to the hour glass shape of occlusal fissures
a. Technique
 air abraide occlusal surface-debris gives false positive
 readings 0-25 most accurate, 26+ less accurate
 Best use overtime-if not sure, wait 6 months and retest
 Can’t be used near sealants or restorations

b. Readings
1. 0-15 no problem
2. 16-35 may not need restoration – look for other factors (if ok, record and check again at the next cleaning)
ii. Other cavities and missing teeth
iii. Number of filled, decayed teeth
iv. Diet/sugar (more than 2x/day)
v. Interventions (fluoride, chlorhexidrine, Duraflour) currently used

3. 35+ usually restore
4. To confirm a diagnodent reading, a small test hole can be cut in the occlusal and a new diagnodent reading can be made. If the number decreases to below 25 stop and seal the tooth.

3. Dye
a. Is a non-specific protein dye that stains collagen in dentin and can give false positives
b. Good to detect occlusal decay

4. X-rays
c. Occlusal-must progress 3mm below surface to see
d. Proximal- easier to see and remineralize
1. only restore if it shows progression into dentin
2. enamel can be remineralized not dentin

5. explorer
a. picks up 27% of decayed area
b. creates a cavity if pushed into demineralized enamel that could have been remineralized
c. many false positives sticking into non-decay deep grooves

6. DIFOTI (Digital Fiber Optic Trans Illumination)
a. Good for
1. fractures
2. confirm diagnodent
b. Problems
1. hard to diagnose degree of decay based on gray scale
2. not easy to learn
3. not enough clinical trials to determine accuracy

7. QLF (Quantitative Light Fluoresence)
a. Determine depth of decay using light fluorescence
b. Orange/ dark fluorescence means decay

8. cariostat-swab in mouth, incubate, shows bacterial cariers risk

9. Healozone (Kavo)- oxygenates decalcified are, reduces number bacteria, leaves discoloration, awkward to use, no long term studies

Characteristics That Affect Decay

1. Saliva (increased saliva raises pH, adds Ca, K, and H to teeth, flushes carbohydrates)
a. Quantity
ii. Unstimulated – invert lower lip, dry with 2×2, should see saliva in 60 seconds.
iii. Simulated – chew gum, spit into cup, 4ml + in 5 minutes (.7ml/minute)
b. Quality
iv. Consistency – watery, not ropey
v. pH 5.5+ buffers acid (the higher the number the more basic the better)
vi. level of strep mutans and lactonacilli
c. Diagnosis – evert lower lip, dry with gauze, should take 30 seconds to see more saliva beads
2. Cariogenic bacteria (those that create acid) – mainly lactobacilli and s. mutans – will be tested in the future.
3. Fermentable carbohydrates (sucrose, glucose, fructose, starch) support bacteria – diet diary
4. No fillings needed in more than 2 years
5. Home oral hygiene
6. Cavitation or x-rays showing decay penetrating the enamel. These areas need to be restored
7. Sugar drinks/snacks more than 3 times/day

Currently, 50% of the fillings done in general dental practice are due to reoccurring decay. In controlled clinically studies it’s 2-3%. The huge difference is because most dentists don’t bother to show the client how to heal the decay and prevent the further tooth destruction around the restoration.

Treatment

Today, we will use the medical model to try to heal the infection. In the medical model symptoms lead to a diagnosis than a treatment regimen is established to heal the infection. When all remedies fail, surgery is discussed.
1. Fluoridated water
2. Fluoridated toothpaste/mouth rinse
3. Fluoride varnish
4. Chlorhexidrine
5. Xylitol
6. ACP

In dentistry we jump from diagnosis to surgery.

By 1869, dentists began detecting decay by changes in the color and hardness of teeth. By the 1950’s, we focused on preventing decay.

Today, if that decay occurs we will try to prevent cavitation. This process is described by Douglas Terry, DDS, in “Detecting and Diagnosing Caries”. The 21st Century brought an understanding of the carious process and revolutionized its prevention and treatment. According to current research and technology, dental caries is identified as an infectious multifactorial bacterial disease dominated by streptococuus mutans and generally followed by an increase in Lactobacilli. A carious lesion is initiated by the demineralization of the inorganic component of the tooth, which is accompanied by disintegration of the organic portion from acids generated by the attached dental plaque. The viability of the bacteria is regulated by the frequency of refined carbohydrates intake and the failure in controlling plaque accumulation on the tooth, which allows the bacteria to remain and flourish.

The carious dentin lesion is characterized by two distinct layers with different ultramicroscopic structures and chemical compositions. The external layer is heavily infected by micro-organisms. This outer “infected dentin” layers has collagen fibers loosened by an irreversible breakdown of the intermolecular cross-links that consist of denatured and unstructured enamel and dentin debris.

Underneath the infected layers, the inner carious dentin layer (or “affected dentin” layer) consists of a zone of demineralized dentin containing solid collagen fibers with an undisturbed molecular structure. The original dentin tubules are present and supported by a collagen matrix. Although this layer is comparatively free of microorganisms, it is often demineralized by the acids generated from bacteria in the infected layer. Removal of the first layer of infected carious dentin eliminates the viable microorganisms and the destructive demineralization process, thus preserving the remaining dentil tissues. Understanding the carious process allows for proper diagnosis and treatment of the disease and provides maximum protection of sound issue.

Today we use CAMBRA (Cavies Management by Risk Assessment) to decide how aggressive we will be in attacking a clients decay. There are 2 phases
1. Assess client’s cavies risk
2. Treatment intervention

There are the 21st century steps we will take in our intervention

A. Restorations
1. Minimal treatment sequence
a. Enamel chip – Bond with composite
b. Enamel dentin chip – bond with composite
c. Enamel/dentin chip with exposure – pulp cap, then bond with composite
d. Decay on margin of filling
1. cut out and repair
2. use sealant on open margins
3. polish away small area
e. Veneer
i. save as much tooth as possible
ii. use 3.5 mm depth gauge
f. Crown
g. Build up to support crown
h. Endo/post/core/crown
i. Implant
j. Bridge
k. Partial denture

2. Restore cavitated areas with materials containing fluoride whenever possible
a. Severe decay/dry mouth – keep margins of crown below the gum line
b. Certainty of decay progression
c. Esthetic concerns
d. Functional concerns

3. Sealants used for
a. Deep grooves, inactive white, brown or black spots
b. Open margins of decay free old fillings can be sealed to extend their life

4. Amalgams accumulate less plaque and the plaque is less cariogenic than on composite

5. Ditched amalgams are almost always decay free. The fact that you can stick an explorer in the ditch has no diagnostic value.

6. Characteristics of recurrent decay
a. Softening of tooth surface
b. Discoloration
c. Wetness

7. Salvage existing crowns/bridges
a. small chips – smooth and polish
b. large fractures – redo crown
c. decay around crown margins
1. X-rays won’t show extent of decay since X-ray won’t penetrate metal or some cores
2. Procedure – anesthetic, round bur to clean out decay, Se-bond, am
d. bridge loose on 1 end – cut it off

B. Chemotherapeutic approaches
1. By 2015 we should be able to test for decay causing bacteria, in the meantime we will observe the results of their activity and make assumptions.
2. Treatment steps
     a. 12% chlorhexidrine (CHX) mouth rinse
1. ½ ounce swished for 30 seconds twice daily
2. Fluoride and sodium lauryl sulphate neutralize CHX, so wait 30 minutes after CHX before brushing
3. Decay causing bacteria are very sensitive to CHX
4. When CHX is stopped, the decay causing bacteria returns to normal levels in 3-6 months.
5. CHX should be used for 1 week, the switch to fluoride paste for 3 weeks. This will help prevent the CHX from staining the teeth.
6. Stop when cavities activity controlled

    b. Fluoride varnish (Duraphat) – least important factor (optional)
1. Decay reduction of 38% when applied 2-4 times annually
2. Clean teeth with brush/floss, isolate a quadrate with cotton rolls, wipe with gauzes 2×2’s apply varnish, let set for 2 minutes, even if in contact with saliva.
3. After application:
a. No eating for 2-4 hours
b. Do no brush/floss until next morning

     c . Xylitol
1. A unique, natural 5 carbon chain carbohydrate found in fruits/vegetables (all other carbohydrates are 6 carbon chains) that cannot be digested by decay causing bacteria to produce the acid that demineralizes teeth. Tastes like sugar
2. Some studies show that Xylitol actually helps remineralize teeth
3. 2 pieces of gum or 3 mints should be used consecutively for a total of 5 minutes, 5 times daily
4. The higher the Xylitol content, the more effective it is.
5. Mothers who used Xylitol regularly had children with less decay.
6. Using Xylitol and prescription strength fluoride increased the resistance to decay by almost 74%
7. Bacteria ingesting Xylitol does not create plaque that can adhere as well to the sides of the teeth (easier to clean off).

    d. Diet
1. Substitute non-sugar items for worst sugar offenders
2. Substitute xylitol where possible for sugar snacks

e. Fluoride prescription
1. Advantages
a. Reduces decay causing bacteria in the plaque.
b. Slows enamel decay
c. Heals enamel attacked by decay by formation of fluorapatite
d. Modifies surface of enamel so plaque doesn’t stick as well

2. Choices
a. Toothpaste (5000ppm) 2x/day
b. Custom tray – (5000ppm) for 5 min
f. Low saliva Rate (See Dry Mouth Handout)
g. Calcium-phosphate toothpaste – less important
h. Glass ionomeer
i. Acid resistant

Recall Interval Based on Decay Potential

A.) Severe risk of decay
1. Concerns
a. Every 3 months to clean your teeth and review your progress
b. Decay x-rays annually

c. Current decay
d. Obvious plaque/gum disease
e. Inadequate saliva
f. Irregular dental cleanings
g. Frequent sugar
h. Poor OH

2. Interventions
a. Brush on prescription fluoride – use before bed, spit, don’t rinse – a 40% decay reduction (3 weeks each month)
b. Chlorhexidrine mouth wash – rinse for 30 seconds, spit, spit – use the 4th week each month in place of your fluoride prescription, paste. Use Colgate Total for this week.
c. Electric toothbrush – more effective than a hand brush
d. Diet review – final 1-2 high sugar food/drinks and substitute non-sugared products
e. Use xylitol products – reduce decay 38-45%
f. Your preventive care appointments with us.
1. Every 3 months to clean your teeth and review your progress
2. Decay X-rays annually

B.) Moderate risk of decay
1. Concerns
a. Decay in last 2 years
b. White spot lesions
c. Gum disease
d. Ortho appliances

2. Interventions
a. Brush on prescription fluoride-use before bed-brush, spit, don’t rinse-a 40% decay reduction (3 weeks each month).
b. Chlorhexidine mouth wash-rinse for 30 seconds, spit use the 4th week each month in place of your fluoride prescription, paste. Use Colgate Total for this week.
c. Electric toothbrush-more effective than a hand brush.
d. Diet review-find 1-2 high sugar food/drinks and substitute non-sugared products.
e. Use xylitol products-reduce decay 38-45%
f. Your preventative care appointment with us
1. Decay x-rays annually
2. 6 month cleanings – just like in the 1930’s

C.) Mild risk of decay
You still have a potential for decay, but you have several recalls with no problems. Your recall interval will begin to stretch out from 6 months toward once annually. This will reduce the cost of your dentistry by 50%.
1. Brush on prescription fluoride-use before bed-brush, spit, don’t rinse-a 40% decay reduction
2. Use xylitol products-reduce decay 38-45%
3. Your preventative care appointment with us
a. Every 6-12 months (varies)
b. Decay x-rays every 2 years

This client handout will help you understand xylitol’s role.

Xylitol – Epic

Xylitol is one of dentistry’s newest, best decay fighters. European studies over the last 20 years show xylitol reduces the potential for decay by 30-60%, if it’s used for 5 minutes, 3 times per day. It also has 40% fewer calories than sucrose sugar.

The advantages of xylitol are:

1. As sweet as sugar
2. No bitter tastes
3. 40% fewer calories
4. Can be used in cooking
5. Reduces the number of decay causing bacteria
6. Helps heal decayed areas
7. Reduces the ability of plaque to stick to the sides of the tooth (easier to keep clean)
8. Is a natural sweetener found in many fruits and vegetables
9. Increases the effectiveness of chorhexidrine mouth rinse
10. Many be an alternative to sealants
11. Can be used as substitute for sucrose sugar

Unfortunately, xylitol is expensive compared to sugar and other sugar substitutes. We recommend xylitol for our patients, but due to the expense our healthiest group may choose to not use it. Everyone else will save money since one of our smallest fillings would cost almost as much as a year’s supply of xylitol.

Xylitol is manufactured in 2 forms

1. Gum advantages
a. Stays in mouth at least 5 minutes
b. Increases saliva flow
c. Improves acid buffering of saliva
2. Mints (must suck, not chew)

Epic offers $35 first order free (plus shipping and handling). This offer is only available if you sign up at HealthPark. We will give them your telephone number so you can get the $35 offer and they will call you to answer your questions and outline their program of regular use of their xylitol.

Here are Terms of the Epic Agreement.

1. You begin or have had a thorough evaluation in our office within the las 2 years
2. Thoroughly clean your teeth
3. You buy/use xylitol as recommended daily
4. You return on time for your regular recall appointments

IF YOU GET A CAVITY AFTER YOU START THIS PROGRAM, THEY WILL REFUND ALL THE MONEY YOU SPENT WITH THEM IN THE LAST 12 MONTHS.

Notes

1. Safe to use during pregnancy.
2. Mothers using xylitol 3 months after delivery reduced decay in her child by the age of 2.
3. Not to be used by children under five years old.
4. Caution – using more than 20 grams of xylitol at one time or 65 grams per day may cause diarrhea.
5. Other products have xylitol, but to be effective, it must be the first ingredient listed.
6. Fluoride and xylitol can be used together.
7. More information www.epicdental.com, 1-866-920-4200
8. Start with 5 year old children.
9. 2 grams 5 times per day for 3-5 minutes provides maximum protection (number of times more important than number of grams)

Other companies selling xylitol. Xylitol must be listed as the first ingredient to be effective.

A. Available at commercial outlets
1. Carefree gum – Nabisco
2. Tic Tac – silvers
3. Trident Advantage – Warner Lambert
4. Everest, Stat Alert – Wrigley
5. Koolerz – Hershey’s

B. Available for bulk purchase
1. Epic – $35 free offer: www.epicdental.com pr at 1-800-920-4200
2. X clear Thera gum 40% discount for bulk 1-800-920-3386

C. Bulk Pricing

Company Gum#Pieces Retail #Pieces Retail Shipping
Epic 100 $9.95 500 $30.20 $3-$5
$35.00 off 1st order
X Clear 100 $8.25 600 $41.90 $5-47
Klear Choice
Omni 360 $349.95 – Client orders off web $5.00

Company Mints#Pieces Retail #Pieces Retail Shipping
Epic 250 $9.95 1000 $30.20
X Clear 240 $8.95