Lou Graham DDS University Dental Professionals The Catapult

4/12/2015
Lou Graham DDS
University Dental Professionals
The Catapult Group
[email protected]
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