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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.
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
Young, et al. J Calif Dent AssocOct. 2007
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
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
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
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
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
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
Caries: A Brief HistoryCaries: A Brief History
The Caries EpidemicThe Caries Epidemic• Cause was a mystery!Cause was a mystery!
Caries: A Brief HistoryCaries: A Brief History
Treatment of CariesTreatment of Caries• 3 historical phases3 historical phases
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?
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
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
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
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…
Caries: Our Present UnderstandingCaries: Our Present Understanding
Caries is NOT gangreneCaries is NOT gangrene Caries is a complex DISEASECaries is a complex DISEASE
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
Bacteria in dentinal tubules
Liquefaction of dentin caused by fusion of bacterial accumulations
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
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
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
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
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!
Caries Management byCaries Management byRisk AssessmentRisk Assessment
(CAMBRA)(CAMBRA)
EducatorsEducatorsScientistsScientists
AdministratorsAdministratorsOrganized DentistryOrganized Dentistry
Third-PartiesThird-Parties
February, 2003
March, 2003
October, 2007
November, 2007
Caries Management by Caries Management by Risk AssessmentRisk Assessment
The Caries Imbalance
Demineralization & Remineralization
(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
(Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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
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
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
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)
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
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
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
Caries Management by Caries Management by Risk AssessmentRisk Assessment
Assessment Assessment Determine Risk Status Determine Risk Status• LowLow• MediumMedium• HighHigh• ExtremeExtreme
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
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
Caries Risk Assessment
Form
Disease Indicators
Risk Factors
Protective Factors
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
Saliva TestingSaliva Testing
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
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
Saliva TestingSaliva Testing
CRTCRT®®buffer (Ivoclar)buffer (Ivoclar) 5 minute test5 minute test
• Buffering capacity onlyBuffering capacity only
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
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
XerostomiaXerostomiaTreatment:Treatment:
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
Amorphous Calcium Phosphate Amorphous Calcium Phosphate stabilized by stabilized by
Casein PhosphopeptidesCasein Phosphopeptides
CPP-ACPCPP-ACP
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
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
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
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
CPP-ACP in plaque
CPP-ACPCPP-ACP
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
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)
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
MI Paste ApplicationMI Paste Application
Apply pea-size amount on fingerApply pea-size amount on finger
MI Paste IndicationsMI Paste Indications
High caries riskHigh caries risk
Infants & ChildrenInfants & Children
Expectant MothersExpectant Mothers
OrthodonticsOrthodontics
Prof.. L W
alsh
MI Paste IndicationsMI Paste Indications
Whitening Whitening sensitivitysensitivity
Root exposureRoot exposure
Chemotherapy, Chemotherapy, radiationradiation
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*)
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
Prof L Walsh, GC Asia
Prof L Walsh, GC Asia
Prof L Walsh, GC Asia
Prof L Walsh, GC Asia
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
Glass Ionomer SealantGlass Ionomer Sealant
Ultimate protection for newly- and partially-erupted molars!
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
Minimally-Invasive Smile Minimally-Invasive Smile EnhancementEnhancement
Management of Management of
White Spot LesionsWhite Spot Lesions
Image Courtesy of Dr. Steve Steinberg
White Spot Carious LesionsWhite Spot Carious Lesions
BEFORE AFTER
White Spot Carious LesionsWhite Spot Carious Lesions
BEFORE AFTER
Mild FluorosisMild Fluorosis
Moderate FluorosisModerate Fluorosis
Severe FluorosisSevere Fluorosis
Enamel HypomineralizationEnamel Hypomineralization
Enamel HypomineralizationEnamel Hypomineralization
BEFORE AFTER
Enamel HypomineralizationEnamel Hypomineralization
BEFORE AFTER
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
“Oral Health Improving for Most Americans, But Tooth Decay Among Preschool Children on the Rise”
-CDC news release April 30, 2007
To learn more…To learn more…
……visit the websites:visit the websites:• CDA FoundationCDA Foundation• WCMIDWCMID• BioteneBiotene• GC AmericaGC America• RecaldentRecaldent
Thank You!Thank You!
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