mid

1. Healing Dental Caries:
The Minimal Intervention
Approach
Edmond R. Hewlett. D.D.S.

3. Maintenance & Sustainabililty
…of esthetic treatments
…of oral health

4.  bbb
Young, et al.
J Calif Dent Assoc
Oct. 2007

6. Young, et al.
J Calif Dent Assoc
Oct. 2007

7. Caries: The New Paradigm
 MEDICAL
management of
caries
 Treatment of
dental caries as a
disease

8. Caries: Terminology
 “Caries” – from the Latin for ‘rot’ or
‘rotten’
 DENTAL CARIES is a disease
• PEOPLE have caries
• TEETH have carious lesions

9. Caries: Terminology
 “Caries” – from the Latin for ‘rot’ or
‘rotten’
 DENTAL CARIES is a disease
• A rotten tooth = a carious tooth
• An area of rot = a carious lesion

10. Caries: A Brief History
 Ancient societies
• little/no enamel
caries
• some root caries
• associated with
gum recession/bone
loss
• progressed slowly

11. Caries: A Brief History
 Ancient societies
• little/no enamel
caries
• some root caries
• associated with
gum recession/bone
loss
• progressed slowly

12. Caries: A Brief History
 The Caries Epidemic
• Europe and U.S. in 1700’s
• REFINED SUCROSE!
• RAPID progression
• Began in tooth ENAMEL
• Cause was a mystery

13. Caries: A Brief History
 The Caries Epidemic
• Cause was a mystery!

14. Caries: A Brief History
 Treatment of Caries
• 3 historical phases
 

15. Caries: A Brief History
 Phase 1 (1700’s-early 1900’s)
• Caries = GANGRENE of the teeth
 Diagnosis = Pain
 Treatment:
• amputation (extraction)
• local debridement
• fillings?

16. Caries: A Brief History
 Phase 2 (early 1900’s-1970’s)
• Refined filling technology
• Fillings preferred over extractions
• Cavity shapes driven by filling material
properties
 INVASIVE
G.V. Black

17. Caries: A Brief History
 Phase 2 (early 1900’s-1970’s)
• Refined filling technology
• Fillings preferred over extractions
• Cavity shapes driven by filling material
properties
 INVASIVE

18. Caries: A Brief History
 Phase 2 (early 1900’s-1970’s)
 Diagnosis = DETECTION
• the earlier, the better
• visual, sharp explorer, radiograph
 Etiology
• acid-producing bacteria
 Prevention
• plaque removal and diet

19. Caries: A Brief History
 Phase 2 (early 1900’s-1970’s)
 Standard of Care = RESTORATION
 Phase 3: The Present…

20. Caries: Our Present Understanding
 Caries is NOT gangrene
 Caries is a complex DISEASE

21. Caries: Our Present Understanding
1. Caries is a bacterial disease
• S. mutans, lactobacilli, A. viscosus
• S. sobrinus
• acidogenic, acid tolerant

22. Bacteria in dentinal tubules
Liquefaction of dentin caused by
fusion of bacterial accumulations

23. Caries: Our Present Understanding
2. Caries is dependant on dietary
sucrose
• affects thickness and chemistry of
plaque

24. Caries: Our Present Understanding
3. Caries is driven by the frequency of
eating
• deminremin balance

26. Caries: Our Present Understanding
4. Caries is modified by fluoride
• harder tooth structure
• inhibits acid production by bacteria

27. Caries: Our Present Understanding
4. Caries is modified by fluoride,
calcium, and phosphate
• harder tooth structure
• inhibits acid production by bacteria

28. Caries: Our Present Understanding
5. Caries is modified by saliva
• buffering
• deminremin balance
• low flow = HIGH risk!

29. Caries Management by
Risk Assessment
(CAMBRA)
Educators
Scientists
Administrators
Organized Dentistry
Third-Parties

30. February, 2003
March, 2003

31. October, 2007
November, 2007

32. Caries Management by
Risk Assessment
The Caries Imbalance

33. Demineralization & Remineralization
(Image Courtesy of Dr. Steve Steinberg)

34. (Image Courtesy of Dr. Steve Steinberg)

35. (Image Courtesy of Dr. Steve Steinberg)

36. (Image Courtesy of Dr. Steve Steinberg)

37. Caries Management by
Risk Assessment
1. Caries is a bacterial disease
Change the microflora
 topical chlorhexidine and topical fluoride

38. Caries Management by
Risk Assessment
2. Caries is dependant on dietary
sucrose
Reduce dietary sucrose
Add Xylitol

39. Xylitol
 Acts directly on bacteria
 Sugar alcohol
 Gets substituted for fructose in
bacterial metabolism cycle
• No acid production
• Acidogenic bacteria die
• Environmental shift favoring non-
pathogenic bacteria
• New biofilm is not as harmful

40. Xylitol
 Works synergistically with other
remin therapies
 Caries in young children – whole
family should use xylitol to combat
the INFECTION
 6-10 g/day (6-10 servings of gum)

41. Caries Management by
Risk Assessment
3. Caries is driven by the frequency of
eating
Decrease the frequency of eating

42. Caries Management by
Risk Assessment
4. Caries is modified by fluoride,
calcium, and phosphate
Add fluoride, calcium, & phosphate

43. Caries Management by
Risk Assessment
5. Caries is modified by saliva
Increase salivary flow
• mechanical stimulation/vigorous chewing
• changing drugs which reduce flow

44. Caries Management by
Risk Assessment
 Assessment  Determine Risk Status
• Low
• Medium
• High
• Extreme

45. Caries Management by
Risk Assessment
 Clinical Protocol (specific for risk status)
• Frequency of radiographs
• Frequency of caries recall exams
• Saliva test (flow rate, bacterial culture)
• Antimicrobials (chlorhexidine, xylitol)
• Behavior Modifications
• Fluoride (OTC, Rx, varnish)
• Calcium/Phosphate
• Sealants
• Restorations

46. Caries Management by
Risk Assessment
 Monitor
• Are the non-invasive interventions
working?
• Adjust risk status and clinical protocol
accordingly

47. Caries
Risk Assessment
Form

48. Disease Indicators

49. Risk Factors

50. Protective Factors

51. Saliva Deficiency
Causes
 Medication Side Effects
 Stress
 Dehydration
 Salivary Gland
Dysfunction
 Disease
 Hormonal Imbalance
 Smoking
Signs
 Difficulty Eating or
Swallowing
 Tongue Sticking to the
Roof of your
Mouth/Cheeks Sticking
to Teeth
 Changes in Taste
 Inadequate Denture
Retention
 Increased Rate of Decay
 Soft Tissue trauma

52. Saliva Testing

53. Saliva Testing
 Saliva-Check® (GC America)
 10 minute test
• Salivary Production
• Salivary Consistency
• Resting Saliva pH
• Stimulated Saliva Flow
• Stimulated Saliva pH
• Saliva Buffering Capacity

54. Saliva Check® (GC America)
When?
 New Patient Diagnostic Tool
treatment planning
 Prior to extensive treatment
determine cause of problems
focus future management
• Prior to Ortho procedures
• Risk assessment
• Monitor patients

55. Saliva Testing
 CRT®buffer (Ivoclar)
 5 minute test
• Buffering capacity only

56. Xerostomia
Treatment:
 increased water intake
(spray bottles)
 change medications
 saliva substitutes
• Biotene® and Oral Balance®
 Lubricating gel intraorally
• KY Jelly
• GC Dry Mouth Gel
 Vaseline or Lansinoh cream on lips

57. Xerostomia
Treatment:
 toothpastes without additives
(e.g., Biotene®)
 DO NOT USE lemon & glycerine
swabs/toothettes (turns to
alchohol)
 DO NOT USE alcohol containing
mouthwashes

58. Xerostomia
Treatment:

62. ACP Products
 Enamel Care (Arm & Hammer)
 Enamel Pro (Premier)
 Nite White ACP (Discus)
 Aegis products (Bosworth)
• P&F sealant, C&B cement, ortho
adhesive
 Best for pts. w/mild remin probs and
high motivation

63. Amorphous Calcium Phosphate
stabilized by
Casein Phosphopeptides
CPP-ACP

64. CPP-ACP
 1946 - anticariogenic properties of milk
were due to casein, calcium and
phosphate
 1981, Australia – Prof Eric Reynolds et al.
at University of Melbourne:
 milk, milk concentrates, powders and
cheeses have anticariogenic activity in
animals and in situ caries models

65. CPP-ACP
 1980s-90s
 Casein Phosphopeptides (CPP) are
responsible for the tooth-protective
activity
 CPP can bind calcium and phosphate and
keep them in a soluble, amorphous state

66. CPP-ACP
Amorphous Calcium Phosphate
Free & available to be incorporated into the
tooth structure

67. CPP-ACP
CPP provides
SUBSTANTIVITY to ACP
ACP is available for
over 3 to 4 HOURS

68. CPP-ACP in plaque
CPP-ACP

69. 1980s-90s:
•normally, calcium + phosphate = insoluble
calcium phosphate crystals (Enamelon)
•in the presence of CPP, calcium and
phosphate stay in a form that can actually
penetrate into the tooth enamel, work
synergistically with fluoride and repair
demineralized areas
CPP-ACP

70. CPP-ACP
1990s:
•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)

71. CPP-ACPs
1990s-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

72. MI Paste Application
Apply pea-size amount on finger

73. MI Paste Indications
 High caries risk
 Infants & Children
 Expectant Mothers
 Orthodontics
Prof..
L
Walsh

74. MI Paste Indications
 Whitening
sensitivity
 Root exposure
 Chemotherapy,
radiation

75. MI Paste Plus - with Fluoride
•CPP-ACP: 10%
•NaF: 900 ppm*
•ph: 7.2
(OTC toothpaste: 1000 ppm*)

76. WHY ADD FLUORIDE?
CPP-ACP Plus Fluoride
exhibits superior anti-caries
effect than Fluoride alone
Designed for Patients at high
risk for dental caries and
dental erosion
MI Paste PlusTM 5:3:1...
5/Calcium - 3/Phosphate – 1/Fluoride

77. Prof L Walsh, GC Asia

78. Prof L Walsh, GC Asia

79. Prof L Walsh, GC Asia

80. Prof L Walsh, GC Asia

81. Incipient caries, no cavitation
6 weeks MI Paste 2 x daily
Sept 2005 Nov 2005

82. Glass Ionomer Sealant
Ultimate protection for newly- and partially-erupted molars!

83. Resin Sealants vs. GI Sealants
+ Durability & Seal
- Partial Eruption
- Tech. Sensitive
- Static
- No available Fl, Ca
or Phosphate
- Inhibits Enamel
Maturation
- Durability
+ Partial Eruption
+ Moisture-Friendly
+ Dynamic
+ Fl, Ca & Phosphate
are available
+ Enhances Enamel
Maturation

84. Minimally-Invasive Smile
Enhancement
Management of
White Spot Lesions

85. Image Courtesy of Dr. Steve Steinberg

86. White Spot Carious Lesions
BEFORE AFTER

87. White Spot Carious Lesions
BEFORE AFTER

88. Mild Fluorosis

89. Moderate Fluorosis

90. Severe Fluorosis

91. Enamel Hypomineralization

92. Enamel Hypomineralization
BEFORE AFTER

93. Enamel Hypomineralization
BEFORE AFTER

94. White Spot Lesions
 Arrested lesion:
• Check saliva
• Remove sealed skin
 Acid etch for 60 sec
 Scrub with pumice and rubber cup
 Repeat until no more shiny surface
 Apply MI Paste

96. “Oral Health Improving for Most
Americans, But Tooth Decay
Among Preschool Children on
the Rise”
-CDC news release
April 30, 2007

97. To learn more…
 …visit the websites:
• CDA Foundation
• WCMID
• Biotene
• GC America
• Recaldent

98. Thank You!