Lou Graham DDS University Dental Professionals The Catapult
4/12/2015 Lou Graham DDS University Dental Professionals The Catapult Group lgrahamdds@aol.com 1 4/12/2015 Dental spending is going to be flat for years and years to come There has been NO rebound since 2009 Average net incomes have declined since the mid 2000’s 2 our of 5 dentists say they are not busy enough Utilization from working adults is down, and per patient expenditures are down and the only positive growth is expected in patients above the age of 70 Larger group practices, and more efficient business models will create more competition for the independent dentist Younger patients are going to be very ‘value” based Shopping online and working with PPO’s Growth will be in the area of aging Americans… those from 70 and up The interesting fact is the OLDER PATIENTS don’t have insurance and they are growing Growth will be in the areas that are NON insurance dependent SLEEP APNEA, ADULT ORTHODONTICS SUCH AS INVISALIGN, 6 MONTHS SMILES, BOTOX ARE EXAMPLES Dentists are going to have to run their business’s far More efficiently both clinically and non clinically 2 4/12/2015 The key to this plan… It allows patients an affordable plan without any premium for overall care Cash in your account upfront Far easier to maintain patients on recall with Solution Reach and far less calls trying to fill hygiene appointments because the patient has paid for their hygiene care upfront! 3 4/12/2015 4 4/12/2015 Additional newsletters that went out this year. Why we now have a cone beam Why we are offering new radiation alternative diagnostics to our patients under 20 6 Month Smile updates Invisalign Updates Our UDP plan 5 4/12/2015 I want to utilize my team to do far more with both their time and customizing patient care 6 4/12/2015 • • • Automatically sends “Post Appointment Surveys” and gathers reviews to be posted on the web, on the practices Facebook page, or to the website. Allows you to catch any negative surveys and respond to them before a patient posts a negative review on the Web Allows you to respond directly to Google 3rd party reviews 7 4/12/2015 Age/Health related dentistry Conservative/Tooth preserving ideology A periodontal/restorative approach with state of the art periodontal therapies Hygiene based growth Diagnostic tools that enable my team to follow the philosophy Prevention at every age 8 4/12/2015 Each and every team member must know what their practice’s philosophical approach to clinical care is 9 4/12/2015 •Every Day has to be planned we review •Where patients are in various phases of hygiene care •Where patients are in their restorative treatment plans, work that still needs to be completed •Which patients on the doctors schedule are due for hygiene! •Who is do lab deliveries •Updates of the DAY and pass offs •Who requires a two-hour reminder for their appt or premedication via Solution Reach •Room for emergencies •Who is do for charting, Velscope, periodontal and periodic exams, radiographs, and follow up issues from yesterday Green is hygiene, Yellow is for doctors and assistants, Blue is front team Mrs. Jones 4910 NO YES NO YES Mr. Jones 4910 BW NO Implant 19 restoration next month Jimmy Sims 0110 Pan YES NO YES Insurance ends this year, wants 3rds out NO YES Restoring 2,3,4 replacing old restorations 10 4/12/2015 11 4/12/2015 Build Relationship Establish Credibility Clinical Screenings Share Findings Dr. Exam Oral Hygiene Instrumentation Either 50 or 60 minutes routinely….building Value Create Value Hand-Off Op Break Down Build Relationship Establish Credibility Clinical Screenings Share Findings Dr. Exam Oral Hygiene Instrumentation Create Value Hand-Off Op Break Down The key is allowing the hygienist enough time to be a total oral care provider 12 4/12/2015 Imagine your hygienist exam including: Occlusion Mobility Fremitus Using…articulating paper and tooth sleuths Reporting findings along with restorative, periodontal, oral pathology, along with diagnostic information X rays: individualized per patient: This is determined by periodontal and caries susceptibility along with age….Bite Wings Yearly, FMX every 4-5 years, Panorex, and now… Cone Beams Periodontal exam: absolutely annually with full probing and more Clinical Attachment levels, fremitus, mobility, BOP, inflammation, infection Restorative/Occlusal Exam with both the doctor and hygienist working together, this can include Spectra (when appropriate), Intra Oral imaging, and now the world of CariVu (may alternate with X-rays) transillumination, articulating paper, tooth sleuth, pulp vitality tester…..and more Build Relationship Establish Credibility Clinical Screenings Share Findings Dr. Exam Oral Hygiene Instrumentation Create Value Hand-Off Op Break Down 13 4/12/2015 Build Relationship Establish Credibility Clinical Screenings Share Findings Dr. Exam Oral Hygiene Instrumentation Create Value Hand-Off Op Break Down Saliva Testing for Xerostomia and far more coming…. DNA testing for those patients whom we have to know what are bugs behind the disease Sleep Apnea with written questions and a visual examination (Mallamapati) Oral Cancer the essentials of a 1/2/3 screening program…one of the most important responsibilities SPECTRA OR CARIVU 14 4/12/2015 33 year old mom of two Low caries rate, or so we thought Uses floss at Christmas for ornaments Twice a year hygiene visits Small breaking down class 1 restorations Asymptomatic 15 4/12/2015 16 4/12/2015 No question D1 caries 17 4/12/2015 18 4/12/2015 19 4/12/2015 20 4/12/2015 21 4/12/2015 22 4/12/2015 23 4/12/2015 Bader et al 2001 24 4/12/2015 25 4/12/2015 1330 REVIEW OF ORAL HYGIENE 0180 COMPREHENSIVE PERIODONTAL EXAM Dental History and Medical History Potential DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation, Sensitivity First Therapy 4355 Full Mouth Debridement with laser in decontamination setting Therapies 2 and 3 4341 Half mouth Debridement with lasers Systemic antibiotics were given Therapy 4 4341 Re-debride the areas treated that have deep pockets, these do not have to be in the same quadrant, use laser in either decontamination mode or debridement and apply Arestin at this point and or both Therapies 5 and 6 followed the same profile Re-evaluation 6 weeks later…NO probing 26 4/12/2015 The opportunity to remove the biofilm from the root surface in a systematic approach The deeper the presenting pockets the greater the opportunity for failure to remove such biofilms Unless your office is doing open flap procedures, multiple sequential appointments become the standard of care in debridement therapy In Full Mouth Cases, the approach is to an initial debridement with laser decontamination and truly do this supra gingivally. Then 2 visits of ½ full mouth scalings/plannings and then if necessary begin systemic antibiotics followed by further sequential therapy, reentering deeper pockets to complete debridement in 1-3 additional visits if required Debriding the most significant pockets (>6mm) after the initial debridement. This can include multiple quadrants in one appointment. The concept is to have subsequent opportunities to additionally fully debride these pockets in sequential visits. We use lasers at every appointment in one of two modes…Decontamination or De-epithelialization…depends if the laser is activated and where we are in therapy Every hygienist in my practice has their own laser and is laser certified…every patient gets the same quality of care 27 4/12/2015 Simple cases may only require 1-3 visits post the initial debridement due to only specific areas requiring treatment The more complex cases often need 3-6 visits because the disease process is more extensive and omnipresent WE treatment plan more and if less….great! This is variable based on their periodontal history, number of pockets, severity and more! Customized sensitivity treatments that may be prescribed include MI PASTE, ReMin Pro or other custom treatments for sensitivity prior to beginning treatment 28 4/12/2015 29 4/12/2015 1330 REVIEW OF ORAL HYGIENE 0180 COMPREHENSIVE PERIODONTAL EXAM Potential DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation, Sensitivity 4910 WITH ISOLATED S/P WITH LASER AND ARESTIN ONE VISIT RESTORATIVE DENTISTRY 4 WEEKS LATER PERIO PROTECT Periodic Scaling and Planning with 4910 for lower mandibular areas Laser treatment was active to debride the pockets Arestin was placed into the pockets at the same time of treatment Wait 4 weeks (maximizing Arestin) then redo crown #19 and DOFL composite number 30 Final impressions for Perio Protect and Perio Gel Maintain usage of Oral B Power Brush with additional power tip attachment for lower molars areas and cross action for remainder of the mouth. Uses Crest Pro-Health 30 4/12/2015 GC FORCEPS Removes temporaries, permanent crowns that are temporarily cemented, implant crowns that are cemented in…. Glass ionomer provisional luting cement Very retentive Will stick too tooth Releases fluoride (1600 μg/cm2 over 30 days) Easy clean up Low film thickness May help in reducing tooth sensitivity Pre operative 31 4/12/2015 3months 3months 3months 3months PERIO PROTECT 32 4/12/2015 Can we find better ways to compliment patients homecare beyond brushing, flossing and rinsing for those patients who have ongoing periodontal issues? Can we find approaches to shorten treatment times and enhance both long term outcomes? Perio Protect…. Before, During or After Treatment Patients after our sequential, laser therapy that still have BOP and inflammation and often good oral hygiene Patient prior to active therapy Patients after surgery that still have pocketing and BOP Patients with on-going implant issues and now…to prevent such issues! Patients who want to bleach and have been to sensitive High caries risk patients, especially xerostomic patients, and the geriatric group (can include MI paste treatments in trays) Oral Cancer patients with radiation ports Patients who don’t want to have required periodontal surgery The Perio Tray is an FDA cleared, prescription medical device to place solutions of the dentist’s choice into the gingival sulcus or periodontal pocket. Flexible comfortable material for non-invasive delivery. 33 4/12/2015 The Journal of Clinical Dentistry® THE INTERNATIONAL JOURNAL OF APPLIED DENTAL RESEARCH www.JClinDent.com Volume XXII 2011 Number 5 SENIOR EDITOR Robert C. Emling, EdD EDITORIAL BOARD Caren M. Barnes, RDH, MS Annerose Borutta, Prof.Dr.med.habil. Robert L. Boyd, DDS, MEd Kenneth H. Burrell, DDS, MS Mark E. Cohen, PhD David Drake, MS. PhD Heinz Duschner, Prof.Dr. William Michael Edgar, PhD, DDSc, FDSRCS Denise Estafan, DDS, MS Subgingival Delivery of Oral Debriding Agents: A Proof of Concept If peroxides can debride sub-gingival planktonic cells of the biofilm and significantly reduce the peripheral elements of biofilms, the peroxides may shift biofilm communities into a defensive growth mode, limiting their ability to reproduce or trigger inflammation. Patient 1 – male diagnosis: Periodontal disease Type II (Perio Tray wearing instructions: 4 x day, 15 min) Before Perio Protect treatment. Site: 14mb Probing Depth: 6 mm Microbial reduction: = 0%def. 2 days after Perio Tray delivery of hydrogen peroxide gel. The microbial situation consisted of a dense, multilayered poly-microbial biofilm, in which coccus-like bacteria dominated. After 2 days of treatment evaluation showed significantly less areas with biofilm. Microbial reduction: = 99% 34 4/12/2015 Conclusion: The prescription Perio Protect tray effectively placed the hydrogen peroxide gel in periodontal pockets with depths up to 9 mm over 15 minutes treatment time. Pathology reports reveal reductions in subgingival bacterial loads and improvements in pretreatment pocket depths of up to 8 mm after 1.7% hydrogen peroxide and Vibramycin Syrup were prescribed for use with the Perio Tray. Custom Tray Application of Peroxide Gel as an Adjunct to Scaling and Root Planing in the Treatment of Periodontitis: A Randomized, Controlled Three-Month Clinical Trial Mark S. Putt, MSD, PhD University Park Research Center Health Science Research Center Indiana University-Purdue University Fort Wayne, IN, USA Howard M. Proskin, PhD Howard M. Proskin & Associates Rochester, NY, USA Ab 35 4/12/2015 The Perio Tray differs from other trays or mouth guards in that the flexible material is custom formed with specialized seals and extensions for the shape and depth of each pocket so that a gasket-like seal directs and maintains medication in the pocket long enough for medication to have therapeutic effect. Crevicular flow cleans out the pocket area 40 times per hour under healthy conditions and even more so when the pocket becomes infected With the biofilms attached to the tooth and tissue, these areas become even more resistant to being flushed out 36 4/12/2015 In Vitro PEROXIDE GEL EXPERIMENT Confocal micrograph, untreated control, 3 days in vitro Streptococcus mutans (S. mutans, strain UA 159) biofilm. Confocal micrograph, 3 day in vitro S. mutans biofilm treated for 5 minutes with 1.7% hydrogen peroxide gel. 37 4/12/2015 REPORT ON PEROXIDE GEL EXPERIMENT Confocal microscope, S. mutans biofilm treated for 10 minutes with 1.7% hydrogen peroxide. Confocal microscope, S. mutans treated with placebo gel without hydrogen peroxide. 10 minutes BID as maintenance….TID during treatment So When? We recommend to place them in prior to am shower Then brush and do your regimen after Evening time is easy but it can be when you watch TV or really when you want Clean with your toothbrush and water 38 4/12/2015 The first step is to confirm the fit. This must be comfortable and secure The entire appliance should look fully seated to achieve the seal 39 4/12/2015 40 4/12/2015 41 4/12/2015 42 4/12/2015 1330 REVIEW OF ORAL HYGIENE 0180 COMPREHENSIVE PERIODONTAL EXAM Dental History and Medical History POTENTlAL DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation, Sensitivity BEGIN WITH PERIO PROTECT IMPRESSIONS THE DAY WE DNA TEST AND START HIM ON TRAYS 6 WEEKS BEFORE THERAPY Therapies 1 AND 2 4341 Half mouth Debridement with lasers Systemic antibiotics were given AFTER** EVALUATE 6 WEEKS LATER AND EVALUATE IF ISOLATED TREATMENTS ARE REQUIRED Continued use of PerioProtect twice a day for 10 minutes per treatment Continued Hygiene with Oral B Power Brush and Pro Health 43 4/12/2015 www.OralDNA.com 877-577-9055 144 DNA(bacterial) Testing (MyPerioPath®) establishes bacterial risk and can help guide therapy based on causation Bacteria Load DNA (genetic) Testing (MyPerioID® PST®) establishes genetic risk and can help guide therapy based on genetics DNA (viral) Testing (OraRisksm HPV) identifies HPV status Clinical Signs and Symptoms Genetic Susceptibility 145 Label: Put Name and DOB on Barcode Label, and place Barcode Label lengthwise on Collection Tube. Swish: Ask Patient to Swish for 30 seconds. Expectorate: Ask Patient to spit into Collection Tube. Seal tube. Note: Specimen should be collected prior to cleaning (e.g. debridement or rinsing with antimicrobials); probing and other evaluations ok. 146 44 4/12/2015 Crack open the seal, swish and spit into the Spitoon! 45 4/12/2015 Compliance: Is the patient taking the medication as prescribed? Drug Resistance Drug Interaction Side Effects…This is a huge issue today We only use systemic antibiotics in periodontal treatment when we have moderate to severe periodontal issues that are often omnipresent in our new patients or occasionally in our refractory patients who require “active therapy” Are the medications reaching MIC levels for the appropriate pathogens? That’s why we wait until after the debridement phase 46 4/12/2015 47 4/12/2015 48 4/12/2015 1330 REVIEW OF ORAL HYGIENE 0180 COMPREHENSIVE PERIODONTAL EXAM Dental History and Medical History Potential DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation, Sensitivity First Therapy 4355 Full Mouth Debridement with laser in decontamination setting, PerioProtect Impressions Therapies 2 and 3 4341’s Half mouth Debridement with lasers Delivery of PerioProtectTrays Therapy 4 4341 Re-debride the areas treated that have deep pockets, these do not have to be in the same quadrant, use laser in either decontamination mode or debridement and apply Arestin at this point and or both Re-evaluation 6 weeks later…NO probing 49 4/12/2015 1.0 1.5 Sound Enamel 2.0 2.5 > 3.0 Deep Enamel Caries Deep Dentin Caries E2 D2-D4 Beginning Dentin Caries Enamel Caries D1 E1 “Doppler Radar” for Caries Detection A Picture is Worth a Thousand Words Analysis of Spectra images Color Scale and Diagnostic Value 50 4/12/2015 51 4/12/2015 52 4/12/2015 TheraCal LC from Bisco…Today’s Dical but so much more…simply wet the tooth and line! The monomers are very hydrophilic as they interact with tubular fluid allowing the release of calcium to create new appatite It’s the Calcium exchange that allows the remineralization There is NO fluoride TheraCal insulates from heat greater than other liners 53 4/12/2015 24 h TheraCal 28 days TheraCal IADR 2011 Abst. #2520 Gandolfi et al. Apatite-forming ability of TheraCal pulp-capping material The hydroxide ion release through TheraCal creates an alkaline (basic) pH. Alkalinity creates an antibacterial environment which is important in promoting wound healing. Gandolfi MG, Suh B, Siboni F. Chemical-physical properties of TheraCal pulp capping material. Presented at: International Association of Dental Research (IADR). March 18, 2011; San Diego, CA. Abstract #2521. Mineral Trioxide Aggregate, Comprehensive Literature Review, Journal of Endodontics, March 2010 54 4/12/2015 55 4/12/2015 56 4/12/2015 57 4/12/2015 58 4/12/2015 59 4/12/2015 60 4/12/2015 Did I get all the decay? That doctor can’t see us, and OMG, no loupes or lights!!!! About’s in vivo study (2001) showed the RDT… Remaining Dentin Thickness was the most important feature in final pulpal outcomes. 61 4/12/2015 Mertz-Fairhurst Ribeiro and Colleagues Foley and Colleagues Fairborn and Colleagues Maltz and Colleagues Marchi and Colleagues All found partial caries removal and sealed restorations... reduce bacterial numbers dramatically within the restoration, yet…. 62 4/12/2015 63 4/12/2015 KALORE™ has one of the lowest % volumetric shrinkage of all composites tested. 206 Source: GC Corp. R & D 64 4/12/2015 KALORE™ demonstrated the lowest shrinkage stress of all competitive products tested. 65 4/12/2015 66 4/12/2015 67 4/12/2015 An absorbent paste that provides hemostasis and minor retraction to soft tissue: 15% Aluminum Chloride (AlCl) Paste is preloaded into disposable syringes Material is dispensed through a bendable tip Clay absorbs fluids & expands – helps dry the sulcus and enhance tissue displacement. Has an affinity to blood. In 2 minutes…this stops bleeding! I use this very often without the caps in so many clinical situations. 68 4/12/2015 Pulpdent RMGI Low Viscosity is a resin-modified glass ionomer preparation with both a bioactive resin matrix and bioactive glass fillers. In this context, ‘bioactive’ refers to the release of beneficial ions from the resin and glass fillers into the oral environment Reactive ionomer glass fillers that mimic the physical and chemical properties of teeth…bonding NOT required unless retention is needed The bioactivity allows ionic exchange that regulate the natural chemistry of teeth with saliva. This ionic exchange of the Fl, Ca and PO4 ions binds the resin to those minerals in the tooth, forming a strong resin-hydroxyapatite complex and a positive seal against micro-leakage. O O P Ca O 69 4/12/2015 Releases more fluoride than glass ionomers Chemically bonds and seals the tooth, hence low micro-leakage Low Solubility Reacts with various pH challenges and allows ionic exchange Fluoride Release Levels Activa responds to pH changes as the tooth does 70 4/12/2015 Surface Wear (µm) Can a composite restorative do this? Wear of ACTIVA Compared to Glass Ionomers, RMGIs and Flowable Composites Surface Changes After 10,000 Cycles 3 2.5 2 1.5 1 0.5 COLGATE NON-ABRASIVE ARM & HAMMER ABRASIVE 0 71 4/12/2015 n=50 Oral-B Vitality Baseline n=50 ADA Manual Week 4 •4-Week study comparing an Oral-B OscillatingRotating brush to an ADA manual brush •Assessment of gingivitis, gingival bleeding, and plaque at baseline and 4 weeks Klukowska M et al. IADR 2010 Abstract 3695 72 4/12/2015 Percent Reduction From Baseline 80 Plaque Index (RMNPI) 70 60 50 Oral-B Vitality ADA Manual 40 30 20 10 0 Interproximal Whole Mouth Gingival Margin Differences Statistically Significant*P<0.001 Klukowska M et al. IADR 2010 Abstract 3695 73 4/12/2015 Reacts with teeth to protect against caries Blocks dentin tubules to reduce tooth sensitivity Bactericidal Gram + and – Inhibits plaque metabolism/accumulation Reduces gingivitis and caries. Reduces Malodor Bioavailability of Stannous Fluoride in original Crest formulation F F F F Bioavailability of Stannous Fluoride in Crest Pro-Health Treatment Groups Dentifrice 0.454% SnF2 Regular Brush Power (R/O) Manual Rinse 0.07% CPC None (no floss) Two-week, randomized, examiner-blind, N=43 with 2 minute brushing and Digital Plaque Imaging endpoints-24 hr plaque 74 4/12/2015 Morning Prebrushing - Baseline Day 1 Standard manual brushing Morning Postbrushing - Day 1 Standard manual brushing Night Prebrushing - Day 1 (Daytime Plaque Accumulation) Standard manual brushing 75 4/12/2015 Morning Prebrushing – Day 2 (Overnight Plaque Accumulation) Standard manual brushing 24-Hour Anti-Microbial Effects of PRO-HEALTH Paste and Rinse Sodium Fluoride Stannous Fluoride + Cetylpridinium Chloride 76 4/12/2015 69 year old: Smoker and the nicest guy! Long history of periodontal issues and few restorations Last visit to the dentist 3 years ago Occlusion with fremitus: 4/5, 7/8 Literally no occlusion on the left side Decay:3D,8D,14D He wants to save his teeth! Where do you start????? Does he have what it takes???? 77 4/12/2015 Full Exam including Periodontal Exam Pictures Diagnostic Casts Discussion of current oral hygiene DNA Culturing Expectations and Desires Increased Antigens cytokines • Connective Increased LPS Host ImmunoMicrobial Challenge Inflammatory Tissue and Response MMP s Bone Metabolism PMN s Antibodies • Clinical Signs of Disease prostanoids Genetic Component and Environmental and Acquired Risk Factors Kornman 97 78 4/12/2015 1330 REVIEW OF ORAL HYGIENE 0180 COMPREHENSIVE PERIODONTAL EXAM Potential DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation, Sensitivity First Therapy 4355 Full Mouth Debridement with laser in decontamination setting 2nd and 3rd Therapies 4341 Half mouth Debridement, with lasers if you can, Systemic antibiotics were given 4th Therapy 4341 Re-debride the areas treated that have deep pockets if required, these do not have to be in the same quadrant, use laser in either decontamination mode or debridement and apply Arestin at this point and or both. 5th-6th Therapies follow the same profile This all depends on how many pockets and severity 79 4/12/2015 Compliance: Is the patient taking the medication as prescribed? Drug Resistance Drug Interaction Side Effects…This is a huge issue today We only use systemic antibiotics in periodontal treatment when we have moderate to severe periodontal issues that are often omnipresent in our new patients or occasionally in our refractory patients who require “active therapy” 80 4/12/2015 Are the medications reaching MIC levels for the appropriate pathogens? That’s why we wait until after the debridement phase 5 visits with lasers were set up after initial exam Synchronizing treatment essential Occlusal Adjustment and night-guards Home Care that changed drastically He liked Sensodyne…Brushed 4 times daily with an Oral B electric brush (the head size distinguishes it here) Flossed twice daily We added a Hydrofloss and loved it! Used every night Sent an e-mail to me detailing his daily protocol Continued to smoke Pictures then taken with follow up…his hygiene was awesome! Occlusal adjustment on 4/5/7/8 and opposing teeth to remove fremitus He instantly felt the difference 2nd appointment and beyond…continued adjustments Delivery for bruxism appliance Soft night guard while we made him a traditional full upper mouth guard 81 4/12/2015 82 4/12/2015 Phase 2 Lower right osseous surgery and extraction of 30 (finances were very important) Phase 3 Final restorative with 2 implants for the upper left and upper right bicuspid areas and lower cast partial Ongoing SPT every 3 months and Perio Protect Trays after Upper Implants delivered (today…I would just start the Perio Protect Trays in the beginning of treatment and remake them at cost…) The Upper Biscuspid/Molar Dilemma You would have loved more space, but the reality… you only had room for one implant 83 4/12/2015 Isolated Shade Mode Standard Shade Mode for Depth 84 4/12/2015 Note the emergence profiles…easy to cleanse 85 4/12/2015 The cement upon removal off the silicone abutments is more towards the deeper internal aspects and not near the margins Once inserted, I immediately spray light water at the margins Thick Floss (Easy Floss from Butler) is then brought around the crowns Water spray again Final explorer removal of any cement 86 4/12/2015 PERIO PROTECT 87 4/12/2015 88 4/12/2015 89 4/12/2015 90 4/12/2015 91 4/12/2015 92 4/12/2015 Vertical bitewings every year and full mouth X-rays every 3 years Varnish application Every Visit, MI Varnish from GCA , Embrace Varnish from Pulp Dent Hygiene visits every 3 months (weather is an issue) with pre rinse of OraCare (ACTIVE CHLORINE DIOXIDE) Customized Home Care treatments…routinely Oral B Brush and appropriate pastes and rinses Perio Protect, customized treatment for both perio and caries, so many indications in this population for prevention Looking into xerostomia product lines for long term benefits 93 4/12/2015 5% Sodium Fluoride (22,600 ppm) ・ 2% RECALDENT™ (CPP-ACP) MI Varnish is a natural Casein and the phosphopeptides (CPP) binds to the oral surfaces, Amorphous Calcium Phosphate (ACP), which is found in the RECALDENT™, is also a source of calcium and phosphate. Remains on the tooth surface longer than conventional fluoride varnishes. Enhances acid resistance of enamel and promotes calcium and phosphate enriched saliva. Flows easily into interproximal areas, due to its viscosity. Non-clumping white natural translucent shade. Excellent retention – stays on longer than the leading varnishes. Unique unit dose, easier to open, easy to access varnish, generous volume per unit dose, enough for a full adult dentition. 94 4/12/2015 Calcium and phosphate ions are essential for remineralization and MI Varnish™ delivers bioavailable calcium, phosphate and fluoride ions into the saliva. The amount of fluoride deposited in the tooth surface is considerably greater in demineralized versus sound tooth surfaces.* The benefits of fluoride varnish are greatest for individuals at moderate-risk or high-risk for demineralization or tooth decay.** Fluoride varnish works by increasing the concentration of fluoride in the outer surface of teeth, thereby enhancing fluoride uptake during early stages of demineralization. 95 4/12/2015 The varnish hardens on the tooth as soon as it contacts saliva, allowing the high concentration of fluoride to be in contact with tooth enamel for an extended period of time (about 1 to 7 days). This is a much longer exposure compared to other high-dose topical fluorides such as gels or foams, which is typically 10 to 15 minutes. 96 4/12/2015 Why is this so Important? An activated oral cleanser and health rinse… not just a mouthwash Chlorhexidine Anti-Bacteria Exceptional Exceptional Anti-Virus Good Poor Anti-Fungal Exceptional Fair Neutralizes VSCs Exceptional Poor Disrupts unhealthy bio-film layer Exceptional Poor Exceptional None Oxidizes Pro-inflammatory Cytokines 97 4/12/2015 Bacteria from bad breath to periodontal disease to tooth decay, are the primary causes of most oral health diseases and problems Viruses: thought to have a role in periodontal disease, can cause Oral Cancer (HPV), oral herpes, and oral warts. Fungi: cause of Candida Infections; very common in denture patients and can be a factor in periodontal disease. Activated Chlorine Dioxide is unique because it has been used to kill a wide range of Bacteria, Fungi, Bacteria Toxins (VSCs), viruses and breaks down unhealthy bio-film. 98% of bad breath is caused by bacteria and bacteria toxins, (VSCs) What Causes Bad Breath? When left on the tongue or in the periodontal pocket, the anaerobic bacteria can yield the "rotten egg" smell of volatile sulfur compounds (VSCs) such as hydrogen sulfide, methyl mercaptan, allyl methyl sulfide, and dimethyl sulfide. VSC toxins may also contribute to periodontal disease. 98 4/12/2015 Reduction of Volatile Sulfur Compounds (VSCs) that cause bad breath. 99 4/12/2015 100 4/12/2015 8,800 Side to Side oscillations per minute sweep plaque away 40,000 gentle inand-out pulsations per minute reach deep to loosen plaque 48,800 oscillatingrotating-pulsating movements/minute Brush Head Design along with OscillatingRotation-Pulsation Technology Lead to Outstanding Clinically Relevant Performance 101 4/12/2015 102 4/12/2015 103 4/12/2015 104 4/12/2015 105 4/12/2015 SORE THROATS SOAKING YOUR TOOTHBRUSH AFTER A COLD OR SIMPLY ONCE A WEEK CANCKER SORES AND ORAL VIRAL INFECTIONS IMPLANT MAINTENANCE DENTURE MAINTENANCE TREATMENT FOR CANDIDA Kills all 10 of the most virulent oral bacteria and the C. albicans fungus faster and in greater numbers than rinses already on the market, creating a sanitary oral environment for routine and complex procedures 106 4/12/2015 107 4/12/2015 Catapult University – Exclusive Offer! Save 10% on your first order of OraCare™. To order by phone, call: 1-855-255-6722 To order online, visit: www.DentistSelect.net To claim your introductory savings, provide code: CATLOU at checkout! Harness the Power of Activated Chlorine Dioxide and Xylitol! 108 4/12/2015 Tell me, and I will forget. Show me, and I will remember. Involve me, and I will understand. A study of the United States Department of Labor showed that 83% of all human learning is done visually whereas only 11% is done through hearing. It was found that people retain over 6 times more information when it is presented visually compared to just verbally 109 4/12/2015 A study conducted by the Wharton School of Business on the subject of Sales Presentation revealed that audiences found visual presentations about 70% more persuasive. It has been suggested that the majority of all plans that go untreated are a direct result of the patient’s lack of understanding. 110 4/12/2015 Air Techniques Polaris intra oral camera and Spectra fluorescence Kavo’s Diagnodent which is slowly being phased out Dexis Digital…replaced my last system that was 6 years old and now Dexis CariVu Shofu’s new digital camera, Eye Special 2…easiest and best in my hands yet to date, replaced Canon 20D and Canon 11G Velscope Guru for discussion and sharing 111 4/12/2015 112 4/12/2015 113 4/12/2015 1 lb One hand holds and one hand touches 114 4/12/2015 Standard Mode – For standard intraoral photography. Low-Glare Mode – For Photographing details of anterior teeth; working models and indirect restorations Surgery Mode – For intraoral photography from a certain distance. Whitening Mode – For shade comparison between before and after whitening. Mirror Mode – For intraoral photography Tele-Macro Mode – For photographing using a mirror; the image taken can be reversed. Face Mode – For shooting facial views or half-body portraits. anterior teeth, indirect restorations and working models in higher magnification. **Attach the close-up lens when taking pictures in this mode** Isolate Shade Mode – You can isolate the shade for optimal shade matching. 115 4/12/2015 116 4/12/2015 A1 A2 A2 A1 117 4/12/2015 118 4/12/2015 Caries attack begins in the enamel with demineralization and cavitation. Easily diagnosed visually, sharp explorer and radiographs. Traditional Decay Model Enamel does not cavitate because of protection from fluoride. Caries begins in dentin through fissures, pits, fractures, and enamel pores. Difficult to diagnose with traditional methods. New Model for Decay 119 4/12/2015 The role of genetics? 30- 35 % Multi- factorial disease Genetics, diet, medication, oral hygiene, stress Many strains of bacteria (over 40) contribute to the disease. Bacterial theory is changing! 120 4/12/2015 Trends Micrl. Solving the etiology of dental caries. Simón-Soro A1, Mira A2. Author information Abstract For decades, the sugar-fermenting, acidogenic species Streptococcus mutans has been considered the main causative agent of dental caries and most diagnostic and therapeutic strategies have been targeted toward this microorganism. However, recent DNA- and RNA-based studies from carious lesions have uncovered an extraordinarily diverse ecosystem where S. mutans accounts only a tiny fraction of the bacterial community. PLoS One. 2012;7(10):e47722. doi: 10.1371/journal.pone.0047722. Epub 2012 Oct 16. Beyond Streptococcus mutans: dental caries onset linked to multiple species by 16S rRNA community analysis. Gross EL1, Beall CJ, Kutsch SR, Firestone ND 121 4/12/2015 Streptococcus mutans was the dominant species in many, but not all, subjects with caries. Elevated levels of S. salivarius, S. sobrinus, and S. parasanguinis were also associated with caries, especially in subjects with no or low levels of S. mutans, suggesting these species are alternative pathogens, and that multiple species may need to be targeted for interventions. Veillonella, which metabolizes lactate, was associated with caries and was highly correlated with total acid producing species. This study evaluated 1341 lesions that were described as: • Having roughness • Surface opacity • Not detectable on x-ray • No cavitation • Staining The study concluded: For questionable lesions the recommended course of action was simple follow up. This is the same model in Scandinavia where they follow non cavitated lesions with no visible evidence on x-ray 122 4/12/2015 An explorer….a probe….traditional x-rays 123 4/12/2015 Transference of infective S mutans to other sites? 52% sensitivity / low reliability Loesche et al, J Dent Res 1979 Hujoel et al, Caries Res 1995 False positives & false negatives Lussi, Caries Res 1991 Disrupts intact surface layer, eliminating potential for reversal Al-Sehaibany showed tug back by an explorer was only 24% diagnostic, meaning that 76% of the time that tug back was present, there was no caries! Ekstrand showed that a sharp explorer tip can damage an early de-mineralized white spot lesion of the enamel by cavitating the surface . 40-60% demineralization required to produce an image to evaluate Underestimate size or depth Insufficient to determine activity level Low sensitivity 39% occlusal 50% interproximal Bader et al 2001 124 4/12/2015 Visual diagnosis can be highly subjective, Kefley and Holt 1993 Treat or NO Treatment Visual diagnosis can be more accurate than radiographic diagnosis for occlusal decay Ekstrand’s studies of 1995 and 1997 Francescut and Lussi found that with brown or black stains in fissures were NOT a good indication to drill because 57% of these lesions exhibited no caries or caries limited to the outer enamel……..so what about the other 43%? 125 4/12/2015 Steiner and colleagues (1998)found the dark brown and black stains to have the highest incidence of caries into dentin and concluded there were no clear guidelines as to management Lesions with with light brown or yellow stains had 42% demineralization into the middle 1/3 of dentin Lesions with an opaque look had 27% caries into the same 1/3 of dentin 126 4/12/2015 About 2/3rds advocate surgical treatment once the dentin has reached the outer dentin 1/3rd (D1) and with the aid of an x-ray (yet Low Sensitivity) The remainder teach treatment when decay is in the inner enamel (E2) In Florida, doctors who are graduates from all around the US do the following: 60% treat E2 lesions and 40% treat D1 How many times have you gone into a class 1 and thought it was shallow and “BOOM” your bur just drops into a large cavity? Or Another example, you are removing an alloy or a composite in a class 1 and you see “Brown” as you are approaching the interproximal? 127 4/12/2015 128 4/12/2015 120° Tactile Switch Control USB Cable assembly Centrally Located Controls Ultrasonically Welded & Sealed Switch Bezels Spectra Blue LEDs Polaris White LEDs The Spectra fluorescence camera have LEDs that emit high-energy blue-violet light at 405nm onto the tooth surface. This wavelength stimulates red porphyrins produced by cariesrelated bacteria to emit red light, containing less energy. Sound enamel, in contrast, sends out a green auto-fluorescence light. 129 4/12/2015 1.0 1.5 Sound Enamel 2.0 2.5 > 3.0 Deep Enamel Caries Deep Dentin Caries E2 D2-D4 Beginning Dentin Caries Enamel Caries D1 E1 “Doppler Radar” for Caries Detection A Picture is Worth a Thousand Words Analysis of Spectra images Color Scale and Diagnostic Value D0 – sound fissure system Diss. Madani, 2004 Uni Jena Histological Clinical Analysis Nomenclature of Dental Lesions The vast majority of my initial exams: Utilized to compliment x-rays for evaluation of class 1 lesions, evaluate older restorations for peripheral decay and for documentation For recall exams same as above For patients with low caries, patients under 30: This has become my adjunct to x-rays and for occlusal caries evaluation, do I really need an explorer for caries detection? Evaluating Caries Removal during excavation…When do you stop drilling? 130 4/12/2015 All Bond Universal as the Bonding Agent Shofu Bulk Fill Flowable (Universal) 131 4/12/2015 Infared light…no radiation Enamel appears transparent or light Porous lesions appear darker by trapping and absorbing the light: these include cracks and caries Video capture….live scans Stored in Dexis, excellent for communication to patient and yes…to insurance companies For Identifying decay pre-treatment, early lesions on smooth, occlusal, and proximal surfaces For Identifying decay during treatment For Identifying cracks, and to a certain level, the severity of the cracks For monitoring lesions and saving within the software The vast majority of my initial exams: Utilized to compliment x-rays for evaluation of class 2 lesions, evaluate older restorations for peripheral decay, evaluate for cracks, documentation. For recall exams same as above For patients with low caries, patients under 30: This has become my adjunct to x-rays and for those under 16, do I really need bite wings and in our practice, we use CariVu for these patients and a low dose panorex? 132 4/12/2015 133 4/12/2015 D0425 If used instead of bite-wings our fee is $61 If used instead of one bite-wing our fee is $32 which is our fee today for 1 peri-apical or bite-wing Cases in Point…. Using today’s technologies and advancements No explorer stick 134 4/12/2015 Visual diagnosis can be highly subjective, Kefley and Holt 1993 The studies are very controversial as stated earlier, Treat or NO Treatment Visual diagnosis can be more accurate than radiographic diagnosis for occlusal decay Ekstrand’s studies of 1995 and 1997 135 4/12/2015 Utilizing magnification and contrast to review digital x-rays, without question these images assist me than traditional x-rays 136 4/12/2015 137 4/12/2015 How many of us are leaving such lesions to grow under our “watch” Shades – Universal, Dentin Self- Leveling F03 Flow Rate Low viscosity, 18G needle tip, same as flow plus Quick 10 sec. cure with LED for Universal Shade only, Dentin is 20 seconds but add more time the deeper you go 138 4/12/2015 Low polymerization shrinkage stress (2.06 Mpa) 4mm depth of cure Self-leveling feature for optimal adaptation to cavity walls to reduce occurrence of voids Giomer technology that includes….Fluoride release/recharge acts as a preventative of secondary caries Shown to neutralize acid and create an anti-plaque effect Power Brush with Oral B EnamelOn toothpaste and Gel for caries management, flossing after Probiotics one tablet dissolved at night after brushing (no rinsing for 30 minutes prior) CariVu and Spectra as part of his protocol followups 139 4/12/2015 140 4/12/2015 1150 ppm SnF2 Toothpaste delivering ACP Low abrasive (RDA 39) Saliva-stimulating No SLS No gluten, dyes or dairybased ingredients The Gel with no abrasives, provide over 10,000 ppm uptake This image cannot current 1. Schemehorn BR, DiMarino JC, Movahed N. Comparison of the incipient lesion enamel fluoride uptake from various prescription and OTC fluoride toothpastes and gels. J Clin Dent 2014;25:57–60. 2. Negative Control (Water) recorded an uptake of 8 ppm Enamelon® (relative dentin abrasivity) Low abrasivity Saliva-stimulating No SLS No gluten No dyes No dairy-based ingredients Refreshing clean mint flavor Croll TP, DiMarino JC. Review of Contemporary Dentifrices. RDH. 2014 Sep;34(9):[Suppl]. This has replaced 5000 ppm fluorides in our practice This is for those patients who are high caries risk as their primary tooth paste This is prescribed for patients with sensitivity and erosion, based on low abrasiveness and some of our patients alternate with Sensodyne or Crest Pro-Health For high caries patients, we focus in our practice on the elderly and what is easiest for them to incorporate along with trying to increase saliva flow 141 4/12/2015 15 Distal Occlusal Pit 31 Occlusal 18 Occlusal Class1 E2 or Early D1 Without major occlusal function In my practice…options include: Equia, Shofu Bulk Fill or Activa 142 4/12/2015 143 4/12/2015 144 4/12/2015 Total Working time 2.30/3.25 Chemically bonds to tooth Physical properties similar to dentin Equia Coat can last 6 months Filled resin, penetrates into the GIC and is very thin NO air drying I Placed in 1984 HEMA-free/BPA-free No Phosphoric acid steps Radiopacity = Dentin Cariostatic/Bioactivity Acid Neutralization Fluoride Recharging Anti-Plaque Effect 145 4/12/2015 BeautiSealant Primer Phosphonic monomer Carboxylic monomer Water Acetone Catalyst Others BeautiSealant Paste Methacrylate monomer (UDMA、3G ) New fluoride charged S-PRG Filler Catalyst Pigment Others Step 1 Apply Primer and leave 5 sec. Step 2 Gentle air for 5 Sec. Step 3 Apply Paste Step 4 Cure 10 seconds Primed Enamel Healthy Enamel Etched Enamel 146 4/12/2015 The ability to monitor potential decay under sealants. Clear sealant material allowing us to see underneath it especially with fluorescent caries detection devices that is highly filled, and transparent Before sealing After sealing Six months after sealing 147 4/12/2015 148 4/12/2015 • No loss of retention, no secondary caries, no marginal discolorations, and no subjective sensitivity. • All restorations rated alpha for marginal integrity at the 3-year recall. • After periodic recalls up to 3 years, the new bioactive cement tested thus far has performed favorably as a luting agent for permanent cementation. 1. Steven R. Jefferies DDS, PhD, FAGD, FACD, FADI1, 2. Cornelis H. Pameijer DMD, DSc, PhD, FADM, FADI2, 3. David C. Appleby DMD, MScD, FACP3, 4. Daniel Boston DMD, FACD, FICD4, 5. Colin Galbraith BS5, 6. Jesper Lööf PhD6, 7. Per-Olof Glantz BDS, Odont.Dr., Dr.odonthc, FCM, FDSRCS, FADM7 149 4/12/2015 Compare mar gin sealing: Rely X Luting Rely X Unicem Fuji GI Ceramir ProRoot MTA Compare mar gin sealing: Rely X Luting Rely X Unicem Fuji GI Ceramir ProRoot MTA 150 4/12/2015 Compare mar gin sealing: Rely X Luting Rely X Unicem Fuji GI Ceramir ProRoot MTA Property Result Working time 2 min…TIME TO GET THOSE CROWNS INTO PLACE Net Setting time 5 min….CLEAN UP BEGINS AT 3 MINUTES… Film thickness 15µm NICE AND THIN Compressive strength ( 24 h) 160 Mpa Radiopacity 1.5 mmAl NO TRANSLUCENCY 151 4/12/2015 152 4/12/2015 153 4/12/2015 154 4/12/2015 155 4/12/2015 156 4/12/2015 157 4/12/2015 158 4/12/2015 30 year old alloy Clinical exam reveals Distal-lingual crack Positive response upon release when biting down Long history of cracked teeth 159 4/12/2015 160 4/12/2015 161 4/12/2015 162
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