reminirelzation photos

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


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


The Caries EpidemicThe Caries Epidemic• Cause was a mystery!Cause was a mystery!


Treatment of CariesTreatment of Caries• 3 historical phases3 historical phases


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?


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


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


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


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


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


2.2. Caries is dependant on dietary Caries is dependant on dietary sucrosesucrose

• affects thickness and chemistry of affects thickness and chemistry of plaqueplaque


3.3. Caries is driven by the frequency of Caries is driven by the frequency of eatingeating

• demindeminremin balanceremin balance


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


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


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)


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


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)


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


4.4. Caries is modified by fluoride, Caries is modified by fluoride, calcium, and phosphatecalcium, and phosphate

Add fluoride, calcium, & phosphateAdd fluoride, calcium, & phosphate


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


Assessment Assessment Determine Risk Status Determine Risk Status• LowLow• MediumMedium• HighHigh• ExtremeExtreme


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


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-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


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

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

Mild FluorosisMild Fluorosis

Moderate FluorosisModerate Fluorosis

Severe FluorosisSevere Fluorosis

Enamel HypomineralizationEnamel Hypomineralization

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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