Contemporary Esthetic Dentistry

George A. Freedman

• Publisher: Mosby
• Year: 2011
• ISBN:
  9780323088237
• Topic: Medizin
• Subtopic: Zahnmedizin

Covering both popular and advanced cosmetic procedures, Contemporary Esthetic Dentistry enhances your skills in the dental treatments leading to esthetically pleasing restorations. With over 1, 600 full-color illustrations, this definitive reference discusses the importance of cariology and caries management, then covers essential topics such as ultraconservative dentistry, color and shade, adhesive techniques, anterior and posterior direct composites, and finishing and polishing. Popular esthetic treatment options are described in detail, including bleaching or tooth whitening, direct and porcelain veneers, and esthetic inlays and onlays. Coverage of advanced cosmetic procedures includes implants, perioesthethics, ortho-esthetics, and pediatric esthetics, providing a solid understanding of treatments that are less common but can impact patient outcomes. Developed by Dr. George A. Freedman, a renowned leader in the field, Contemporary Esthetic Dentistry also allows you to earn Continuing Education credits as you improve your knowledge and skills.

• Continuing Education credits are available, allowing you to earn one to two CE credits per chapter.
• Detailed coverage of popular esthetic procedures includes bleaching, direct and porcelain veneers, inlays and onlays, posts and cores, porcelain-fused-to-metal restorations, zirconium crowns and bridges, and complete dentures.
• Coverage of advanced procedures includes implants, perioesthethics, ortho-esthetics, pediatric esthetics, and sleep-disordered breathing, providing a solid understanding of less-frequently encountered topics that impact the esthetic treatment plan and outcomes.
• Coverage of key esthetic dentistry topics and fundamental skills includes cariology and caries management, understanding dental materials, photography, understanding and manipulating of color and shade, adhesive techniques, anterior and posterior direct composites, and finishing and polishing.
• Over 1, 600 full-color photos and illustrations help to clarify important concepts and techniques, and show treatments from beginning of the case to the final esthetic results.
• Well-known and respected lead author George A. Freedman is a recognized author, educator, and speaker, and past president of the American Academy of Cosmetic Dentistry and co-founder of the Canadian Academy for Esthetic Dentistry.
• Expert contributors are leading educators and practicing clinicians, including names such as Irvin Smigel (the father of esthetic dentistry), Chuck N. Maragos (the father of contemporary diagnostics), Wayne Halstrom (a pioneer in the area of dental sleep medicine), David Clark (one of the pioneers of the microscope in restorative dentistry and founder the Academy of Microscope Enhanced Dentistry), Edward Lynch (elected the most influential person in UK Dentistry in 2010 by his peers), Joseph Massad (creator, producer, director, and moderator of two of the most popular teaching videos on the subject of removable prosthodontics), Simon McDonald (founder and CEO of Triodent Ltd, an international dental manufacturing and innovations company), and many more!

Chapter 1

Cariology and Caries Management

Section A

Caries Risk Assessment

V. Kim Kutsch

Relevance to Esthetic Dentistry

Dental caries is a transmissible infectious bacterial disease, a biofilm disease of the teeth that leads to decay and ultimate loss of the teeth. It is not corrected by eliminating a patient's cavities, but requires diagnosis and treatment of the biofilm disease to correct the infection. Patients who undergo major restorative dentistry (often esthetic dentistry) are generally patients who have had a lifelong, chronic experience with dental caries. Unless the infection is diagnosed and treated, they remain in a diseased state, putting all of their expensive restorative dentistry at high risk for recurrent decay and loss.

Brief History of Clinical Development and Evolution of the Procedure

Historically dentistry has treated dental decay with a surgical model, drilling the decayed tooth structure away and replacing it with a restorative material. Dental caries has been recognized for over 100 years as a disease that contributes to decay. Early pioneers—G.V. Black, Leon Williams, and others—recognized the relationship of dental plaque to decay. Over a period of decades, several bacteria have been identified and connected to the decay process. These bacteria include primarily Streptococcus mutans and Lactobacillus. Both of these types of bacteria are saccharolytic (metabolize carbohydrates), acidogenic (produce small molecular organic acids from the carbohydrate metabolism), aciduric (survive in acidic or low pH environments, pH ranges that dissolve the calcium and phosphate minerals from the teeth), and cariogenic (contribute to the decay process as a result of these characteristics). The prolonged periods of low pH on the teeth lead to a net mineral loss from the dental tissues and produce decay, cavitation, and loss of the teeth. Many studies over the last 30 years correlate high levels of mutans streptococci and lactobacilli with dental caries. However, this is more than a single- or double-pathogen disease process in the classic model of infection. Dental caries has multifactorial causation, with environmental risk factors, individual risk factors, and behavioral and dietary influences as well as the biofilm component. Literally any saccharolytic, acidogenic, and aciduric bacteria could contribute to the caries biofilm and lead to dental caries. In 1989 Philip Marsh demonstrated conclusively through a series of studies that it is not the sugar availability that leads to decay, but rather the acid production from the metabolism of the sugars. The resulting low pH environment provides the selection pressure to favor these bacteria in a patient's mouth. Today up to 24 different bacterial species have been implicated in dental caries. Preza and co-workers demonstrated that additional species of bacteria need to be considered in the root surface caries biofilm, including Atopobium, Olsenella, Pseudoramibacter, and Selenomonas. In 2008, Takahashi and Nyvad demonstrated that during protracted periods of low pH in the oral biofilm, even the potential commensal oral streptococci become more acidogenic and aciduric and contribute to the disease process. They identified Streptococcus gordonii, Streptococcus mitis, Streptococcus oralis, and Streptococcus anginosus and termed these bacteria low-pH, non-MS streptococci. They described this phenomenon as an extension of Marsh's earlier “ecological plaque hypothesis.” But it brings to light that it is important not only which bacteria are present in a patient's biofilm, but what those bacteria are doing. In addition, other factors have been reported and studied with regard to their role in the disease process. Known risk factors now include previous history of decay, radiographic lesions, white spot lesions, visible plaque on the teeth, frequent snacking, low saliva and poor saliva buffering capability, xerostomia-producing medications, poor diet, suboptimal fluoride exposure, poor dental care habits, and low socioeconomic status. Today dental caries necessitates a caries risk assessment with a validated questionnaire to evaluate and correct the modifiable risk factors for an individual patient. It necessitates diagnosis of the bacterial infection using bacterial metric testing or culture. Finally, it necessitates specific targeted antimicrobial therapy of the biofilm infection to predictably and effectively treat the disease. Simply drilling and filling cavities, a surgical approach to treating a bacterial infection, does not diagnose or treat the disease and is no longer acceptable as a standard of care.

Relating Function and Esthetics

Caries risk assessment is related to function and esthetics in that drilling and filling restorative dentistry has little to do with treating the infection, although it does restore the teeth to function and eliminates pain in the short term. For predictable long-term success with regard to function and esthetics in restorative dentistry, the dental caries biofilm disease must be assessed, diagnosed, and treated as the disease process it is. Unless this is done, most restorative dentistry is destined to fail with “recurrent decay” (although the disease process is actually left in place). About 70% of all restorative dentistry is the replacement of previous restorations.

Clinical Considerations

Indications

Caries risk assessment should be performed at least annually on every patient. Although a patient may be in a low risk category and not have any signs or symptoms of the disease, risk factors change over time. A patient may become at high risk for dental caries at any point of life. For example, an adult who has been decay free for 20 years may develop hypertension and begin taking antihypertensive medications, which have the side effect of xerostomia, or a dry mouth. This alone may be enough to tip the scales and create an environment that favors cariogenic bacteria, placing the patient at high risk for caries and leading to decay. This condition might be further complicated if the patient begins chewing gum, candy, or lozenges that contain sugar. The goal of caries risk assessment is to identify patients at risk for the disease and treat them before cavities appear.

Contraindications

There are no contraindications to caries risk assessment, because all of the benefits outweigh any risks. However, there is little benefit to providing caries risk assessment for people who are edentulous, although they may benefit if they also have xerostomia and are experiencing problems. Candida albicans is acidogenic and aciduric and may be a problem for these patients. C. albicans can be treated with pH-elevating or pH-neutralizing products.

Material Options

Dental Caries Treatment Strategies

For all patients, any restorative and biomechanical needs must be addressed. Restoration of the defects may return the teeth to function but have little to do with correcting the dental caries biofilm disease. Many different options are available for treating the biofilm disease process. A comprehensive approach to treating the dental caries patient involves addressing every aspect of the disease. These strategies can be broken down into major groups and ideas. First in most treatment considerations are the reparative procedures required to correct the physical damage to the teeth. This includes remineralization of lesions that have not cavitated and still have an intact enamel surface with fluoride and calcium phosphate or hydroxyapatite, plus minimally invasive restorations using biomimetic materials for lesions that have cavitation and decay present. The next strategies are focused on the therapeutic approach to correcting the bacterial biofilm component of the disease. These procedures include antimicrobial agents, pH corrections, and metabolic agents (xylitol). Additional strategies include behavioral changes to improve the oral environment to favor a healthy biofilm. Typically this involves oral hygiene instructions for improved home care and plaque control plus dietary counseling. Some nonmodifiable factors may need to be addressed by adding more protective factors to the patient's risk-and-caries balance equation. Special needs patients and those with xerostomia or medication-induced xerostomia fall into this category.

Remineralization Therapy

Remineralization has historically involved the use of topical fluoride. Stannous fluoride and acidulated fluorides were introduced first, but more recently neutral fluoride products have been used. The fluoride is applied in many different methods, such as 1 ppm public water fluoridation, 1100 ppm fluoride dentifrice, 5000 ppm fluoride gels and foams, 223 ppm fluoride rinse, and 23,000 ppm fluoride varnish. Fluoride's basic mode of action enhances remineralization and inhibits demineralization. Fluoride ions incorporate into remineralizing enamel and dentin carbonated apatite to produce a more acid-tolerant fluorapatite-like form. Fluoride also makes hard tissues more acid resistant and inhibits bacterial intracellular enzymes.

More recently, nano-particle hydroxyapatite and CPP-ACP have made calcium and phosphate ions bioavailable to aid in the remineralization process. The benefits of additional sources of these ions is unclear. Some clinicians believe that the need to supplement sources of calcium and phosphate is limited to the xerostomic patient, in whom these molecules may be in short supply. Others believe there is added benefit to increasing the availability of calcium and phosphate in high-risk caries patients. Clearly, more studies are needed to answer this question. Products include Recaldent (Recaldent Pty Ltd, Australia), NovaMin (GlaxoSmithKline, United Kingdom), Trident (Warner-Lambert, Morris Plains, New Jersey), MI Paste (GC America, Alsip, Illinois), and pHluorigel HA and HA Nano Gel (Carifree, Albany, Oregon).

Restorative Strategies with Minimally Invasive Dentistry

Dental caries can be site, tooth, patient, and population specific. Ideally, successful caries prevention implies there will be no irreversible changes to any tooth site or surface (occlusal, approximal, smooth, or root surface). If prevention fails at any site, the greatest benefit for the patient begins with early lesion detection. Such detection should trigger protocols for chemical remineralization and interventions to arrest and reverse early damage caused by demineralization before surface cavitation occurs. Only if surface cavitation develops should surgical restoration be performed, and then it is done by using the most minimally invasive approach possible, maintaining the maximum amount of healthy tissue and structural integrity of the tooth. The restoration is completed with the most appropriate dental restorative material suited for that particular lesion and that particular patient.

Traditionally dentists identified cavitated lesions using a sharp explorer tip, visual examination, and/or radiographs. The explorer in a given dental practice may not have been sharp, so defining lesions in specific...

Table of contents

• Cover image
• Title Page
• Table of Contents
• IFC
• Copyright
• Dedication
• Foreword
• Preface
• Acknowledgments
• Contributors
• 1 Cariology and Caries Management
• 2 Dental Materials
• 3 Photography
• 4 Ultraconservative Dentistry
• 5 Smile Design
• 6 The Nonsurgical Face Lift
• 7 Color and Shade
• 8 Adhesion
• 9 Anterior Direct Composites
• 10 Posterior Direct Composites
• 11 Polishing
• 12 Fiber Reinforcement
• 13 Glass Ionomer Restoratives
• 14 Bleaching
• 15 Direct Veneers
• 16 Porcelain Veneers
• 17 Esthetic Inlays and Onlays
• 18 Esthetic Posts
• 19 Single-Tooth All-Ceramic Restorations
• 20 Ceramics
• 21 Porcelain-Fused-to-Metal and Zirconium Crowns and Bridges
• 22 Dentist–Lab Technician Communications
• 23 Cements
• 24 Complete Denture Esthetics
• 25 Precision and Semi-Precision Attachments
• 26 Technology and Esthetics
• 27 Minimally Invasive Implant Esthetics
• 28 Perioesthetics
• 29 Ortho-Esthetics
• 30 Pediatric Dental Procedures
• 31 Sleep and Snoring
• 32 Sterilization and Disinfection
• 33 Communication
• 34 Practice Management
• 35 Evaluating Esthetic Materials
• Index