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minimum intervention, maximum return

Breakthroughs in science and practice:

mid
Timeline of advances in preventive dentistry No more tears or extractions: A paediatric dentists journey to MID

Issue 2

Graham Mount re ects on the evolution to MID

Fluoride-releasing glass ionomer material that truly embraces MID principles

precisely when you

protection

Superior need it:

Fuji Triage from GC.


Glass ionomer cement with high uoride release for:
Fissure protection Prevention and control of hypersensitivity Root surface protection Endodontic treatment Available in white and pink as capsule or powder/liquid.

Part of GCs Minimum Intervention program.

GC EUROPE N.V.
Head Ofce Tel. +32.16.74.10.00 info@gceurope.com www.gceurope.com

GC UNITED KINGDOM Ltd.


Tel. +44.1908.218.999 info@uk.gceurope.com www.uk.gceurope.com

minimum intervention, maximum return

minimum intervention, maximum return

Issue 2

mid

Breakthroughs in science and practice:

mid
Timeline of advances in preventive dentistry No more tears or extractions: A paediatric dentists journey to MID

Issue 2

Graham Mount reflects on the evolution to MID

Fluoride-releasing glass ionomer material that truly embraces MID principles

4. MID Worldwide
Thanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate bene t of the patient community.

6. Q&A
Dr Andrew Brostek answers a question about his article on running a fully integrated and pro table MID practice in MID 1

8. Resources
Networks, websites, books, events and journal articles relating to advances in MID

10. Practice perspectives


Child-friendly, tooth-friendly dentistry Glass-ionomer Cements: Scientific analysis

18. Clinical corner


The Journey to Minimum Intervention Dentistry The current status of tooth crmes for enamel remineralization

30. Evidence
FAQ on Evidence-Based Dentistry

32. MI toolkit
GC Fuji Triage GC Fuji II LC Comparison of RECALDENT ToothMousse Protocol GC GC Saliva-Check Buer
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MID worldwide

MID Worldwide

Thanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate bene t of the patient community.

Belgium

Henri Lenn, President of GC Europe


Initially, dentists were afraid when they heard about this new MID approach as they thought they would have to turn their entire practice management systems around. By gradually explaining to them the principles of identi cation, prevention and recall they soon discovered that most of this is in one way or the other already part of their daily practice routines. Nowadays, a growing number of dentists are beginning to realise it is a very logical approach to the management of caries and are discovering the advantages of working according the MI principles. Looking at the number of publications and events that are organised throughout Europe nowadays we can see that MI dentistry is de nitely gaining popularity in Europe. We clearly see a trend that young dentists are very eager to learn more about this approach. Another positive sign is that more and more insurance companies and social health care systems are also looking for cooperation in this area. We are absolutely sure that any dentist that implements the MI principles in his daily routine will be able to run a very successful practice. MI is moving away from the standard recall systems as you create a personalized treatment protocol for every patient; some need to visit the practice regularly, low risks patients, around once a year. Today dentists still believe that they can only earn money when making restorations. We need to make them understand that implementing the steps of identi cation and prevention is from a business point of view probably even better. When executed properly, MI is a way to create a long term relationship with every patient. Our aim is to make dentists understand that MI is the treatment of the future.

mid worldwide

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GC Europe introduces Minimum Intervention Treatment Plan


One of the most frequently asked questions by dentists when they hear about Minimum Intervention Dentistry is: How can I integrate MI in my daily practice? In order to address this, the GC Europe MI Advisory Board was established as a Pan-European group of top level academicians, researchers and general dental practitioners. Working together, they designed a Treatment Plan for the implementation of the MI philosophy into routine dental practice. Members of the MI Advisory Board are Dr Frederic Roussel (Brussels, Belgium), Dr Elmar Riech (University of Cologne, Germany). Board members include Dr Avijit Banerjee, (Kings College London) Dr Matteo Basso, (University of Milan, Italy) Dr Michel Blique, (General Practitioner, Luxemburg) Dr Sophie Domjean-Orliaguet (University of Auvergne, France) Dr Cline Gaucher, (University of Paris V, France) Dr Ivana Miltic, (University of Zagreb, Croatia) Dr Jose Zalba, (General Practitioner, Spain) and Dr Piyush Khandelwal (GC Europe, Belgium) and Dr Laetitia Lavoix (Paris, France).

Minimum Intervention Treatment Plan

As a result of advancements in cariology resulting in a better understanding of the carious process, GC has taken the initiative to translate these oral health philosophies into your routine dental practices. The GC approach is based on the Minimum Intervention (MI) concept and more particularly through balancing the natural biological functions of demineralization and remineralisation of the tooth structure. With the MI treatment plan GC brings solid and clear guidelines to the general practitioner for MI treatments and planning, illustrated in many clinical cases: Diagnosis, Treatments and recalls plans Patient actions and tools, Preventive and non-invasive treatments, Atraumatic and Minimally Invasive Restorative Treatments, Tentative models for the financial and practical implementations

Identify

The examination of a patient is not limited to the teeth, but takes the risk factors for caries into account like diet, brushing habits, the quality and bu ering capacity of saliva, the amount of cariogenic bacteria (like Mutans Streptococci) in saliva and the cariogenicity of plaque. In order to diagnose and monitor caries, the diagnostic threshold has to be reduced to the rst clinical signs of caries in enamel. These early forms are clinically detectable in ssures and on at surfaces as well as on x-rays for the interproximal areas. The use of diagnostic tools like GC Saliva Check Mutans test kit, GC Plaque Indicator kit, GC Saliva Check Bu er kit not only helps you to get the most relevant information about your patients susceptibility but also helps to motivate your patient.

Prevent

Preventing caries from advancing is possible, if a patient is willing to change his habits. Diet and tooth-brushing must be optimized to be e ective in caries prevention. In practice active preventive treatments aims at reducing the caries risk factors and promoting remineralization. Very e ective are a combination of professional mechanical tooth cleaning, a ntibacterial drugs, a healthy diet and medicaments like the GC Tooth Mousse and the MI paste Plus which help to promote remineralization and bring the oral ora back to normal.

Recall

In cariology standard recall schemes (see your dentist twice a year) have long been used. That approach is for a highly susceptible patient is too long and for those with very low susceptibility is perhaps too short. Hence with the MI treatment plan you can give your patients the most individualistic recall period taking into consideration their own risk factors.

Restore

Modern restorative System like EQUIA, the long term glass ionomer glass ionomer based restorative system and the Gradia LoFlo, the owable composites require less removal of tooth structure as compared to the traditional materials like amalgam or gold. They adhere to the tooth structure and ful l high aesthetic demands by the patient. Atraumatic and minimally invasive restorative treatments conserve tooth structure and promote longevity of restorations. Other products that can also be used as per the MI philosophy are the Fuji II LC (Resin modi ed GIC), Fuji IX (Condensable GIC) and the Gradia Composite lling materials (High strength, high aesthetic composite resin).
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Q&A

The question below was address to Dr Andrew Brostek about his article on running a fully integrated and profitable MID practice in MID 1
Name: Jack Stellpflug Country: USA Question: In reference to the patient case study, in the part of the remineralisation protocol in which you recommend OTC tooth past FL level as opposed to 5,000ppm, what is the reason for avoiding high FL for remineralisation?

Answer Dr Andrew Brostek:


Dear Jack, The rationale behind the remineralisation protocol using CPP-ACP (GC Tooth Mousse/MI Paste) with the lower concentration fluoride toothpaste (1000 ppm), is to allow remineralisation to occur in the deeper parts of the tooth first and the surface last. This does not occur if you use the 5000 ppm fluoride concurrently with the GC Tooth Mousse. As you know, the high 5000 ppm fluoride is very effective in forming fluoroapatite which creates an intact shiny surface leaving the deeper layers mineral -poor, i.e. the white scar of the white spot lesion remains. Studies and clinical experience with CPP-ACP shows that deeper remineralisation occurs more readily with the lower toothpaste fluoride concentration, allowing the white-spot lesion to almost disappear over about 6-8 weeks of topical daily CPP-ACFP patient application (I think the in-situ enamel CPP-ACFP studies show ~ 60% total remineralisation or more depending on concentration of the CPP-ACFP). Out of interest, that is why the recommended dentist clinical protocol is to acid-etch the surface of enamel for ~20 seconds to clear any protein or lipid blocking the surface pores in order to obtain the maximum possible remineralisation. In my practice I recall at monthly intervals to review and re-etch if necessary. Hope that helps! All the best Andrew Brostek Perth, Australia If you have a question for Andrew, click here.

Highlights from the MI Compendium


QUESTION: In patients with comparable caries risk, does GIC have a better cariostatic effect than composite?
ANSWER: The analysis results of dichotomous data showed no difference in caries incidence on tooth tissue adjacent to these materials. The analysis of continuous data showed significant higher microhardness and significantly less mineral loss of tooth tissue adjacent to GIC after acid attack than tooth tissue adjacent to composite.

http://www.midentistry.com/secure-folder/content/3/mic11B1.asp
6 q&a mi.gceurope.com

Identify natural protection for teeth with Saliva-Check Buffer from GC.
Chairside test to evaluate salivas ability to protect teeth and motivate your patients

When a patient presents new signs of accelerated tooth wear, abrasion, sensitivity, halitosis or any other major oral changes, the first question for the dentist should be to identify what has lead to an oral imbalance. Saliva testing is aimed to identify if changes in the salivary condition can be a contributing factor, and to motivate your patient to improve his oral heath status.

Part of GCs Minimum Intervention program.

GC EUROPE N.V.
Head Ofce Tel. +32.16.74.10.00 info@gceurope.com www.gceurope.com

GC UNITED KINGDOM Ltd.


Tel. +44.1908.218.999 info@uk.gceurope.com www.uk.gceurope.com

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q&a

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MID resources Online

Networks, websites, books, events and journal articles relating to advances in MID

Events

Journal of Minimum Intervention in Dentistry http://www.midentistry.com/journal.html Minimal Intervention Dentistry


Compiled by Graham J Mount , Wyatt Rory Hume and Brian Monteith

http://www.midentistry.org/index.html

Compendium of Minimum Intervention in Dentistry http://www.midentistry.com/ MI on Monday: taking your first steps to MID Issued by GC Asia at the MID Symposium in Singapore in September 2009 Click here to view pdf The ABCs of childrens teeth: A 21st century guide for parents by Dr Angela Gilhespie http://www.teethforlife.co.za/news/news.htm American Dental Association Center for Evidencebased Dentistry http://ebd.ada.org/ Centre for Evidence-Based Dentistry (UK) http://www.cebd.org/home/ Journal for Evidence-Based Dentistry http://www.nature.com/ebd/index.html National Maternal and Child Oral Health Resource Center http://www.mchoralhealth.org/ Toothfriendly Foundation http://www.toothfriendly-foundation.org/ The Forsyth Center for Evidence-Based Dentistry http://www.forsyth.org/research/centers/evidence. html

ORCA 2010 Montpellier, France 7-10 July 2010 www.orca2010.com

The World Congress of Minimally Invasive Dentistry 11th Annual Conference Downtown Westin San Diego San Diego, CA August 19-20, 2010 As I travel to various dental meetings and even here within the ivy-covered walls of academia where I teach, I see evidence of and hear increased talk about minimally invasive dentistry. Admittedly, Im not always comfortable with how that phrase is being used or what procedures it is being applied to describe, but at least people, dental providers and patients alike, are thinking more about preventing dental diseases in the first place, and questioning when and to what extent cutting of oral tissues is necessary. Thats a good thing! Our message is being heard by more patients, dentists, hygienists, and dental industry representatives each successive day. Time is indeed on our side. Alan W. Budenz [MS, DDS, MBA] WCMID President The WCMID Annual Conference programme will feature a number of key opinion leaders covering the essential topics with Minimally Invasive Dentistry. The keynote address will be delivered by Bill Blatchford and other speakers will include Graeme Milicich, Brian Novy, John Crispin, Randy Wolcott, Beth Thompson, Robert Supple, Ray Becker, Pat Pine, Shirley Gutkowski, Bud Evans, Ryan Swain and Toni Adams.

resources

mi.gceurope.com

Published
The following articles and text books have been published in recent years relevant to a study of minimal intervention dentistry.
Preservation and Restoration of tooth structure 2nd edition Mount GJ, Hume WR, Knowledge Books and Software, Brisbane, Australia. 2005 Longevity in glass-ionomer restorations; Review of a successful technique GJ Mount Quintessence 1997. 28; 643-650. An Atlas of Glass Ionomer Cements : A Clinicians Guide. GJ Mount, 3rd Edition Martin Dunitz, London 2002. A new classification for dentistry Mount GJ, Hume RW. Quint Int. 1997, 28; 301-303 Minimal intervention dentistry a new concept for operative dentistry GJ Mount, H. Ngo, Quintessence Int. 2000; 31: 527- 533 Minimal intervention dentistry the early lesion Mount GJ, Ngo H. Quintessence Int. 2000; 31 :535-546 Minimal intervention dentistry the advanced lesion Mount GJ, Ngo H, Quintessence International, 2000; 31: 621-629 A new classification and techniques for simple restorative dentistry Mount GJ, Ann. Roy. Australian. Coll. Dent. Surg. 1998; 14:94-98 Glass-ionomers in contemporary restorative dentistry: A clinical update Hewlett ER, Mount GJ. J. Calif. Dent. Assoc. 2003; 31: 467-492 The science and practice of caries prevention Featherstone JD. J Am Dent Assoc 2000;131(7):887-99. Caries Management by Risk Assessment:Consensus Statement, April 2002 Featherstone JDB. et. al. J Cal. Dent Assoc. 2003;31(3):257-269 Cariology in the new world order: moving from restoration towards prevention Featherstone JDB. J. Calif. Dental Assoc. Feb 2003 The Caries Balance: Contributing Factors and Early Detection Featherstone JDB. J. Calif. Dental Assoc. Feb 2003 www.apexezine.com resources 9 Cariology in the New World Order: Moving From Restoration Toward Prevention, Part II Featherstone JDB, Roth JR. J. Calif. Dental Assoc. Mar 2003 Fluoride-Releasing Restorative Materials and Secondary Caries Hicks J, Garcia-Godoy F, Donly K, Flaitz C. J. Calif. Dental Assoc. Mar 2003. A Review of the Efficacy of Chlorhexidine on Dental Caries and the Caries Infection Anderson MH. J. Calif. Dental Assoc. Mar 2003. New caries detection technologies and modern caries management: Merging the strategies Young DA. Gen Dent 2002;50(4):320-31. Defining, Classifying and Placing Incipient Caries Lesions in Perspective Mount GJ. Dent. Clin. of N. Am. 49 (2005) 701-723 Minimal Intervention Dentistry: Rationale of Cavity Design Mount GJ Operative Dentistry, 2003, 28, 92-99 Ionic Exchanges between Glass-ionomers and Demineralised Dentine Ngo HC Thesis for PhD, The University of Adelaide, 2005 Changes in operative dentistry Beyond G.V.Black Mount GJ. in Adhesive Technology for Restorative Dentistry. Eds.J-F Roulet, G Vanherle. p47-53; 2005. Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study Ngo HC, Mount GJ, McIntyre J. Tuisuva J, vonDoussa J. J. Dent. 2006. 34; 608-613. A proposal for a new classification of lesions of the exposed tooth surfaces Mount GJ, Tyas MJ, Duke ES, Lasfargues J-J, Kaleka R, Hume WR. International Dental Journal, 2006; 56: 82-91.

Child-friendly, tooth-friendly dentistry


Paediatric dentist, Dr Angela Gilhespie, talks about her journey to MID and the reasons why her young patients love to come to her practice.
Walking into Angelas practice you cannot help but notice that everything is child-height and positioned from a childs perspective. You are greeted by a row of photographs of happy smiling children all of Angelas patients, who see themselves this way at every appointment. Nigel the fluffy two metre crocodile grins on the floor with his sparkly white teeth, a teddy bear is seated on the panoramic x-ray seat and the dental chair is covered with a bright cover and teddy arms to wrap around you or hold on to. Parents bringing their children in for appointments are prepared for this approach because they are sent detailed information prior to the day. But many are amazed at the results of Minimum Intervention Dentistry. Angelas near-death experience in the dental chair at a young age has contributed to her commitment to create happy associations for young children visiting the dentist. Eureka moment After 25 years of running two dental practices 6 days a week, Angela has seen a sharp increase in Early Childhood Caries (ECC). She used to treat the most severe cases in the youngest children under general anaesthesia, and at one stage became accustomed to doing these up to three times a week. She had invested in a HealOzone but found it to be a very steep learning curve. I wanted to throw it out of the window I couldnt get seals and I didnt see the power of it. But one day a child came in, aged 5, the same age as when I had my near-death experience. This child was in pain; had been for the past three days and the parents were distraught. I told the parents wed have to use general anaesthesia and remove the tooth but they could not afford this and refused to leave until I helped their child. The only alternative was to try the newlyacquired HealOzone. I could barely get the cup on and I knew it wouldnt work. I administered a dose and syringed some GC Fuji Triage in and expected they would have to go to another dentist and have the tooth pulled out eventually. A year later, this same patient came in skipping into the practice. I took an x-ray and couldnt believe my eyes: a reparative band had formed on the tooth. She had no pain and had no inflammation. This was a Eureka moment for me in dentistry. I knew then that teeth could heal. For the past five years I have not used general anaesthesia once and the results Ive seen are nothing short of amazing. The right tools In her journey to practising MI dentistry, Angela identified a number of products and equipment that enable her to get the most out of this approach. Caries detection is critical, particularly in very young patients where bottle caries can easily go unnoticed without the correct diagnostic approach. You simply cannot see caries with a mirror and probe. An intraoral camera is essential and I take a panoramic x-ray of all my patients as soon as I can. It allows me to see so much more in the mouth, she explains. She also uses a Diagnodent which helps her to see the complexity of decay on the palatal aspects of fissures, for example. You cant treat what you cant see, she adds.
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practice perspectives

A typical consultation with Angela Gilhespie


I try to prepare myself, as well as the parent, before the first appointment. I send them to my website to download application forms. Their information is then on the system which cuts down on their first appointment time. There is a detailed questionnaire which gives me most of the information I need to categorize the child i.e. age, existing dental problems, parents attitudes, etc. The first appointment may just be mum and child playing in the waiting room. Only when the child is comfortable would we schedule an actual appointment. If the child is cooperative, especially if I take a panoramic x-ray, I would book a 45-minute appointment. (A trained dental hygienist could carry out most of this work which frees the dentist). Parents consider their child abnormal because they enjoy going to the dentist! Recently, a mom told me she had to take her son to the doctor. His response was: couldnt he rather go to the dentist? Perhaps the best endorsement is by childrens body language. I always say, if you want to know, its in the feet! Perfect relaxation: feet at 180

Children who have their deciduous teeth extracted will always be at an disadvantage not only because the decay often infects the adult teeth but they may often require extensive orthodontic treatment later in life.
She also believes in fissure sealants and has developed a specific technique to apply glass ionomer materials to semi-erupted teeth in babies where necessary. In the past, glass ionomer cements were awful to use but we knew they were the future. Now the GC range is amazing and I can use these syringable materials for one-year-olds. Angela prescribes Tooth Mousse to her high risk patients and recommends they apply it twice daily after brushing and flossing. Chewing xylitol gum after meals is another useful tool in caries prevention. Parental lack of caries knowledge ECC is a growing problem around the world and affects children from all socio-economic backgrounds. Some of the patients with the worst cases I have seen had parents who were educated, affluent and very caring yet they failed to see their childrens mouths were full of abscesses, she continues. In her experience of speaking with parents, Angela has identified a number of misconceptions that parents have about their childrens oral health. In todays society, it is common for both parents to work full-time. There are many lifestyle habits that negatively impact on a childs oral health. Due to a lack of time, parents feed their children processed meals and give them sweet treats and sugary drinks every day. Babies are given bottles at night so parents can get a good nights sleep. I find every child that
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comes in to my practice has at least one white spot lesion if not more, she says. Angela has also found that parents do not realise that chronic medication can also impact negatively on the oral health of their children. Asthma and hyperactivity medication can reduce salivary flow, she says. Another thing that some parents misunderstand is that young children with painful teeth cannot verbally express their pain, they just stop eating fibrous food, or stop eating entirely. Parents are horrified when they realise all of this. It upsets them because in other areas they look after their children very well, she explains. Every child that comes into my practice has this disease. And the parents know nothing about what causes it and how it can be avoided, she says. Thanks to skewed media emphasis, Angela believes that most parents will take their children out of school to avoid catching swine flu, but are reluctant to take them out of school to see the dentist. We have to change the whole model of how children go to the dentist. Parents only bring their children when they have a toothache, so we have to change this mindset, she continues. Seven years ago, Angela began to address these issues by writing hand-outs for parents in her waiting room. I may as well have written the stuff in hieroglyphs for the amount of understanding the moms had for childrens oral health. They dont think deciduous teeth are important, dont understand that
practice perspectives 11

acid causes the problems, not sweets and they have no concept of mother to child transmission. Some parents think the origin of tooth decay is genetic and blame is on one of the parents. Everyone thinks caries is prevented with toothbrushing, she adds. Oral health advocacy beyond dentistry Angela soon realised that it was not enough to tell people about child oral health, she would have to show and train them. Her book The ABCs of childrens teeth: a 21st Century guide for parents addresses all the common misconceptions that she has found most parents to have, and also presents her Preventive Jigsaw, a 9 piece puzzle that consists of the following essential pieces: Flossing, fissure sealants, brushing, no bottle, diet, saliva, CPP-ACP, xylitol and fluoride. Angela advocates that all these pieces together create optimal oral health in babies and children. She realised this message needed to be spread to healthcare professionals who were not in dentistry. Traditionally, the day after a baby is born the nurses teach new mothers how to clean their ears, noses, nails. The one orifice they dont teach mothers to clean is the mouth, which is arguably the dirtiest

of them all with more than 600 different species of bacteria, she explains. This sparked a series of training events and educational roadshows where she presented to midwives, nurses and other childbirth educators. By educating the professionals who educate pregnant women the message of prevention will be carried through in prenatal education. I focus on connecting to small groups who have energy to propel this message forward, she explains, adding that the ultimate goal through this is to establish oral health homes for young children and mothers. Teaching pregnant women about their own oral health, and the facts about transmitting dental disease to their babies is an essential part of prenatal education. The systemic links with periodontal diseases and low birth weight, preterm birth and other adverse pregnancy outcomes have been proven in many research studies and for Angela it is important to raise awareness of that with mothers. Similarly, it has been proven that maternal Vitamin D levels during pregnancy can affect the development of teeth in unborn children. One of the tools Angela gives expectant mothers is a mouth mirror. Every new mom is instructed to clean their babys mouth from day one. The mouth

Common misconceptions that the general public has about ECC


Baby teeth fall out, so decay is not a problem You do not need to brush a very young childs teeth Only brushing and toothpaste can stop tooth decay Only sugar causes decay Not transmissible between a mother and baby Fruit juices and energy drinks are okay for children Medication will not affect a childs oral health
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mirror is given to examine the babys mouth she adds. Introducing good oral health habits What Angela sees on a daily basis in her practice is the day and night difference between a healthy child and a child with caries. Children who have their deciduous teeth extracted will always be at an disadvantage not only because the decay often infects the adult teeth but they may often require extensive orthodontic treatment later in life, she says. Due to the challenges involved in prescribing a complete change in diet for her young patients, Angela instead focuses on positive behaviour that can be included in a childs daily routine. Everyone knows to cut down on sweets but the parents snack on sweets themselves so it comes down to behavioural changes which are very challenging, she explains. A big breakthrough came to me with one of my patients when he was 2 years old. He constantly had plaque from ear to ear, one day he came into my practice sucking on a lollipop! And we were never able to change that behaviour. But for some reason, his mom took our advice with xylitol chewing gum and Tooth Mousse and she became absolutely religious with this. I saw him recently and nearly fell off my chair: he is now 6 and has virtually no plaque. Thats the power of the combination where youve got xylitol to break down the biofilm and prevent the adhesion of bacteria to the tooth surface and the Tooth Mousse to repair the teeth. All the lesions in his mouth started to repair, she says.
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With the trend of children eating more processed food means they chew less, which means they have less saliva in the mouth to rather than breakdown the formation of biofilm say neutralize plaque acids. Weve got to get these children chewing and keep them hydrated. This is the problem with fruit juice and energy drinks. If your child needs fruit let them eat whole fruit pieces instead. Other ways to stimulate saliva is to give children small pieces of cheese after a meal. These are the things parents can do to help their children, she concludes. Dr Angela Gilhespie, (BSc BDS London) is a full-time dentist in private practice in Johannesburg, South Africa. She has over 25 years experience, mainly in childrens dentistry. She has recently released her book The ABCs of childrens teeth. Her mission is to wipe out ECC in children. She believes this can only be achieved by firstly training health care professionals in the perinatal arena because they participate in the health of a child from the very beginning. For more information about Angela visit www.teethforlife.co.za Queries

practice perspectives

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Glass-ionomer Cements: Scientific analysis


By Prof.Dr.Karl-Heinz Friedl, Germany

In modern operative dentistry the focus is on minimal removal of tooth tissues and on the application of adhesive restorative materials that possibly perform therapeutic actions on demineralized dentin. Those requirements are perfectly matched by glass-ionomer cements (GICs). Highly viscous GICs achieve superior physical properties compared to traditional GIC by optimizing polyacid and particle size distribution and resulting in a high cross-linkage in the GIC matrix 1.
However, one has to know that highly viscous GIC perform worse in a number of standardized in vitro testing aspects compared to most hybrid composite resins, and they are, therefore, still considered a semi-permanent restoration material by a number of universities 2-5, although they are widely used as a permanent restoration material in private practices. However, not only mechanical properties, but a series of practical aspects have to be taken into account for assessing the benefits of GICs (much better performance with a coating protective layer) for the patient and the dentist. Facts on highly viscous GIC GIC interact with tooth substrate and there mayeven be an in situ transformation of glassionomer into an enamel-like material 6-9. GIC contract during setting like composite resins, but they show significant differences in the development of viscosity and stiffness in the early stage of setting. This is of clinical importance, since during the early setting stage GIC are better capable of reducing the contraction stresses than resin composites, thus increasing the likelihood that the bond with the cavity walls will form and survive during setting. Shortly spoken, materials with a shrinking characteristic like composites need higher bond strength to achieve the same sealing ability like GIC 10-14. Bond strength of GIC is not as susceptible to moisture like most adhesive systems and bond strength improves with the maturation of the material 15-17. Physical and mechanical properties might be a slightly inferior or sometimes equal to hybrid composite resins, but they increase during maturation whereas composite properties
14 practice perspectives mi.gceurope.com

decrease. However research works indicate that, when placed in a cavity the resistance to fracture of occlusal enamel supported by either a composite resin (Filtek Z250) or Fuji IX was not different 18-26. GIC release fluoride, show antibacterial activity and may have a caries protective potential. Literature: 27-36 . Performance and longevity of restorations If we try to summarize clinical outcomes of amalgam, composite or glass ionomer trials, we have to face the fact that clinical results are very difficult to interpret and to compare for different reasons. There are not only differences in the validity among the trial designs (e.g. randomized controlled prospective, retrospective, cohort, case control, etc.), furthermore, the studies partly suffer from high drop-out rates 37;38. Important details, like cavity size etc. are often missing and in a number of clinical investigations cavity-type-specific survival rates cannot be clarified 39;40 . Furthermore, the clinical success of dental restorations does not only involve the restorative material per se but also different operative techniques. Technique-sensitive materials like adhesive systems may behave completely different when used by differently experienced operators in different clinical environments. One investigation on the preparation quality of 610 cavities showed big differences among the 8 participating dentists 41, which supports other findings on a significant effect of the operator on the longevity of the restoration 5;42. Differences in performance mainly become obvious, if different types of materials are evaluated within one study 43. A composite resin may show good longevity data when applied in conventional cavities but not in modified operative approaches. Completely different restoration techniques hamper an judgement on composite longevity 44 because different restorative procedures like chemically cured bulk technique, a light-cured bulk technique, and different light-cured layering techniques may have small, but significant effects on stress development 45. Polymerization shrinkage during curing of an adhesive restoration and mismatch in mechanical properties can lead to the initiation and development of interfacial defects. Those defects, which could have a detrimental effect on the longevity of the restored tooth, are often dependent from filler content and shape 46. Promising prospective longitudinal data of highly viscous GIC were shown in the ART approach, e.g. in a prospective longitudinal study a total of 1117 Class I and Class II GIC (Fuji IX and Ketac Molar) and amalgam restorations were placed in permanent teeth of 370 and 311 children, respectively, by eight dentists. The cumulative survival rates after 6.3 years were 66.1% for GIC and 57.0% for amalgam. Differences between the GICs were not significant 47;48 . However, it has to be considered that the relation
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between class I and class II restorations was around 10:1. Studies not performed under ART conditions in Class I and II cavities are scarce, but also promising. In a study on 169 Class I (n=67) and Class II (n=102) GIC restorations (Fuji IX) in 116 patients placed by 3 dentists the survival rate was 98% after 2 years. The reason for replacement was fracture of the filling 49. In a 6-year retrospective clinical study 116 Class II GIC restorations (Fuji IX GP) in 72 patients placed by 2 dentists in a private practice were examined. Until 1.5y no failures were observed. From 1.5 3.5y survival dropped to 93%. After 3.5y failure rate increased and at 6y survival was 60% 50. The Equia Restorative System (Fuji IX GP Extra + G- Coat Plus) The new concept of EQUIA to combine a highly viscous GIC (Fuji IX GP Extra) with a nano filled, light curing varnish (G-Coat Plus) is unique and shall combine the main advantages of the highly viscous GIC (self-adhesion, bulk application, improved mechanical properties) with a protection in the early maturation phase and an improved surface hardness. However, if EQUIA is to be used as an alternative restorative material to amalgam or composite resins, a few questions need to be addressed: 1. Are the mechanical properties strong enough? 2. What about the clinical success? 3. What are the economical aspects Properties of the material Summarizing the mechanical properties of highly viscous GICs in comparison to composite resins, GIC may compete with composites, if the maturation characteristics can be further improved and/or the GIC is effectively protected during the maturation phase (SEM-pictures). The benefits of G-Coat Plus have been shown before 51. Parameters like fluoride release and the possible effect of caries protection are even advantageous compared to Amalgams and composite resins. Clinical success It is a fact that that there is a discrepancy between existing results from ongoing pro- and retrospective studies with EQUIA in Europe, and the positive experiences of EQUIA users all over Europe, which are only empiric. These are the positive experiences with highly viscous GIC as outlined before and the in vitro proven and clinically expected positive effect of the coat, which, by the way, also has an impressive aesthetic effect. On the other hand, there are numerous studies ongoing in various Universities to indicate the longevity of the EQUIA restorative system. Economical aspects The economical aspect is very important in public
practice perspectives 15

health systems with a kind of basic and economic approach. Economical calculations have shown that EQUIA may be a valuable solution for the dentist in cases, where the patient is not able to or willing to pay additional costs for composite resin restorations and does not want to opt for an Amalgam filling for its bad aesthetics.
Article originally published in Romanian Journal of Dentistry Medicine, vol XII, no 6/2009. Reprinted with permission.

References

(1) Guggenberger R, May R, Stefan KP: New trends in glass-ionomer chemistry. Biomaterials 1998; 19(6):479483. (2) Hickel R, Manhart J, Garcia-Godoy F: Clinical results and new developments of direct posterior restorations. Am J Dent 2000; 13(Spec No):41D-54D. (3) Hickel R, Manhart J: Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent 2001; 3(1):45-64. (4) Manhart J, Chen H, Hamm G, Hickel R: Buonocore Memorial Lecture. Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition. Oper Dent 2004; 29(5):481-508. (5) Manhart J, Garcia-Godoy F, Hickel R: Direct posterior restorations: clinical results and new developments. Dent Clin North Am 2002; 46(2):303-339. (6) van Duinen RN, Davidson CL, de Gee AJ, Feilzer AJ: In situ transformation of glass-ionomer into an enamel-like material. Am J Dent 2004; 17(4):223-227. (7) Knight GM, McIntyre JM, Craig GG, Mulyani: Electron probe microanalysis of ion exchange of selected elements between dentine and adhesive restorative materials. Aust Dent J 2007; 52(2):128-132. (8) Czarnecka B, Limanowska SH, Nicholson JW: Microscopic evaluation of the interface between glassionomer cements and tooth structures prepared using conventional instruments and the atraumatic restorative treatment (ART) technique. Quintessence Int 2006; 37(7):557-564. (9) Ferrari M, Davidson CL: Interdiffusion of a traditional glass ionomer cement into conditioned dentin. Am J Dent 1997; 10(6):295-297. (10) Dauvillier BS, Feilzer AJ, de Gee AJ, Davidson CL: Visco-elastic parameters of dental restorative materials during setting. J Dent Res 2000; 79(3):818-823. (11) Bryant RW, Mahler DB: Volumetric contraction in some tooth-coloured restorative materials. Aust Dent J 2007; 52(2):112-117. (12) Feilzer AJ, Kakaboura AI, de Gee AJ, Davidson CL: The influence of water sorption on the development of setting shrinkage stress in traditional and resin-modified glass ionomer cements. Dent Mater 1995; 11(3):186-190. (13) Castro A, Feigal RE: Microleakage of a new improved glass ionomer restorative material in primary and permanent teeth. Pediatr Dent 2002; 24(1):23-28. (14) Lott JR, Fitchie JG, Creasy MO, Puckett AD, Jr.: Microleakage of three conventional glass ionomers using 45Ca and methylene blue. Gen Dent 2007; 55(1):15-18. (15) Banomyong D, Palamara JE, Burrow MF, Messer HH: Effect of dentin conditioning on dentin permeability and micro-shear bond strength. Eur J Oral Sci 2007; 115(6):502-509. (16) Czarnecka B, regowska-Nosowicz P, Limanowska-Shaw H, Nicholson JW: Shear bond strengths of glassionomer cements to sound and to prepared carious dentine. J Mater Sci Mater Med 2007; 18(5):845-849. (17) Lucas ME, Arita K, Nishino M: Toughness, bonding and fluoride-release properties of hydroxyapatiteadded glass ionomer cement. Biomaterials 2003; 24(21):3787-3794. (18) Algera TJ, Kleverlaan CJ, Prahl-Andersen B, Feilzer AJ: The influence of environmental conditions on the material properties of setting glass-ionomer cements. Dent Mater 2006; 22(9):852-856. (19) Peez R, Frank S: The physical-mechanical performance of the new Ketac Molar Easymix compared to commercially available glass ionomer restoratives. J Dent 2006; 34(8):582-587. (20) Mitra SB, Wu D, Holmes BN: An application of nanotechnology in advanced dental materials. J Am Dent Assoc 2003; 134(10):1382-1390. (21) Grisanti LP, Troendle KB, Summitt JB: Support of occlusal enamel provided by bonded restorations. Oper Dent 2004; 29(1):49-53. (22) Wang XY, Yap AU, Ngo HC, Chung SM: Environmental degradation of glass-ionomer cements: a depthsensing microindentation study. J Biomed Mater Res B Appl Biomater 2007; 82(1):1-6. (23) Ellakuria J, Triana R, Minguez N, Soler I, Ibaseta G, Maza J, Garcia-Godoy F: Effect of one-year water storage on the surface microhardness of resin-modified versus conventional glass-ionomer cements. Dent Mater 2003; 19(4):286-290. (24) Yap AU, Cheang PH, Chay PL: Mechanical properties of two restorative reinforced glass-ionomer cements. J Oral Rehabil 2002; 29(7):682-688. (25) van Duinen RN, Kleverlaan CJ, de Gee AJ, Werner A, Feilzer AJ: Early and long-term wear of fast-set conventional glass-ionomer cements. Dent Mater 2005; 21(8):716-720. (26) Yap AU, Teo JC, Teoh SH: Comparative wear resistance of reinforced glass ionomer restorative materials. Oper Dent 2001; 26(4):343-348. (27) Wiegand A, Buchalla W, Attin T: Review on fluoride-releasing restorative materials--fluoride release and uptake characteristics, antibacterial activity and influence on caries formation. Dent Mater 2007; 23(3):343362. (28) Kantovitz KR, Pascon FM, Correr GM, Borges AF, Uchoa MN, Puppin-Rontani RM: Inhibition of mineral loss at the enamel/sealant interface of fissures sealed with fluoride- and non-fluoride containing dental materials in vitro. Acta Odontol Scand 2006; 64(6):376-383. (29) Amaral MT, Guedes-Pinto AC, Chevitarese O: Effects of a glass-ionomer cement on the remineralization of occlusal caries--an in situ study. Braz Oral Res 2006; 20(2):91-96. (30) Burke FM, Ray NJ, McConnell RJ: Fluoride-containing restorative materials. Int Dent J 2006; 56(1):33-43. (31) Beiruti N, Frencken JE, vant Hof MA, Taifour D, van Palenstein Helderman WH: Caries-preventive effect of a one-time application of composite resin and glass ionomer sealants after 5 years. Caries Res 2006; 40(1):52-59. (32) Kotsanos N: An intraoral study of caries induced on enamel in contact with fluoride-releasing restorative materials. Caries Res 2001; 35(3):200-204. (33) Shimada Y, Kawashima M, Higashi T, Foxton RM, Tagami J: Histologic evaluation of adhesive restorations on dentin caries in rat molar teeth. Quintessence Int 2004; 35(3):200-205. (34) Boeckh C, Schumacher E, Podbielski A, Haller B: Antibacterial activity of restorative dental biomaterials in vitro. Caries Res 2002; 36(2):101-107. (35) Brambilla E, Cagetti MG, Gagliani M, Fadini L, Garcia-Godoy F, Strohmenger L: Influence of different adhesive restorative materials on mutans streptococci colonization. Am J Dent 2005; 18(3):173-176. (36) Davidovich E, Weiss E, Fuks AB, Beyth N: Surface antibacterial properties of glass ionomer cements used in atraumatic restorative treatment. J Am Dent Assoc 2007; 138(10):1347-1352. (37) Scheibenbogen-Fuchsbrunner A, Manhart J, Kremers L, Kunzelmann KH, Hickel R: Two-year clinical evaluation of direct and indirect composite restorations in posterior teeth. J Prosthet Dent 1999; 82(4):391397. (38) Lund RG, Sehn FP, Piva E, Detoni D, Moura FR, Cardoso PE, Demarco FF: Clinical performance and wear resistance of two compomers in posterior occlusal restorations of permanent teeth: six-year follow-up. Oper Dent 2007; 32(2):118-123. (39) Nikaido T, Takada T, Kitasako Y, Ogata M, Shimada Y, Yoshikawa T, Nakajima M, Otsuki M, Tagami J, Burrow MF: Retrospective study of five-year clinical performance of direct composite restorations using a self-etching primer adhesive system. Dent Mater J 2006; 25(3):611-615. (40) Nikaido T, Takada T, Kitasako Y, Ogata M, Shimada Y, Yoshikawa T, Nakajima M, Otsuki M, Tagami J,

Burrow MF: Retrospective study of the 10-year clinical performance of direct resin composite restorations placed with the acid-etch technique. Quintessence Int 2007; 38(5):e240-e246. (41) Jokstad A, Mjor IA: The quality of routine class II cavity preparations for amalgam. Acta Odontol Scand 1989; 47(1):53-64. (42) Smales RJ: Longevity of low- and high-copper amalgams analyzed by preparation class, tooth site, patient age, and operator. Oper Dent 1991; 16(5):162-168. (43) Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitao J, DeRouen TA: Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc 2007; 138(6):775-783. (44) Lindberg A, van Dijken JW, Lindberg M: Nine-year evaluation of a polyacid-modified resin composite/ resin composite open sandwich technique in Class II cavities. J Dent 2007; 35(2):124-129. (45) Kuijs RH, Fennis WM, Kreulen CM, Barink M, Verdonschot N: Does layering minimize shrinkage stresses in composite restorations? J Dent Res 2003; 82(12):967-971. (46) Kahler B, Kotousov A, Swain MV: On the design of dental resin-based composites: a micromechanical approach. Acta Biomater 2008; 4(1):165-172. (47) Frencken JE, Taifour D, van t Hof MA: Survival of ART and amalgam restorations in permanent teeth of children after 6.3 years. J Dent Res 2006; 85(7):622-626. (48) Taifour D, Frencken JE, Beiruti N, vant Hof MA, Truin GJ, van Palenstein Helderman WH: Comparison between restorations in the permanent dentition produced by hand and rotary instrumentation--survival after 3 years. Community Dent Oral Epidemiol 2003; 31(2):122-128. (49) Burke FJ, Siddons C, Cripps S, Bardha J, Crisp RJ, Dopheide B: Clinical performance of reinforced glass ionomer restorations placed in UK dental practices. Br Dent J 2007; 203(1):E2-1. (50) Scholtanus JD, Huysmans MC: Clinical failure of class-II restorations of a highly viscous glass-ionomer material over a 6-year period: a retrospective study. J Dent 2007; 35(2):156-162. (51) Kato K, Yarimizu H, Nakaseko H, Sakuma T. Influence of coating materials on conventional glassionomer cement. http://iadr.confex.com/iadr/search.epl . 2008. Ref Type: Electronic Citation

Professor Karl-Heinz Friedl obtained a DDS Degree from the University of Erlangen-Nuremberg, Germany in 1988. His career has included various teaching positions both at the Department of Operative Dentistry and Periodontology in Regensburg, Germany and the University of Texas, Houston Health Science Center, Houston, TX, USA. In 2000 he achieved a PhD degree and since then has had a private practice in Regensburg, Germany. He has extensively published articles in leading dental journals and presented at leading conferences throughout his career.

Queries

Highlights from the MI Compendium

QUESTION: In deep cavities of comparable size, is RMGIC as a liner less biocompatible to pulp tissue than calcium hydroxide?
ANSWER: The evidence suggests that RMGIC are as biocompatible as calcium hydroxide. However, the internal validity of the available evidence is limited and needs to be validated by future randomized control trials.

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16

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forward thinking practice perspectivespaperless dentistry 17

Probably the most important contribution now can be made by individuals and groups in general practice who have adopted MI Dentistry principles.

The Journey to Minimum Intervention Dentistry


Graham Mount reflects on his work in MID, dentistrys advances in the field over the last few decades and what elements are needed to make this approach more widespread and established in order for more patients to benefit.
What inspires you to continue your work in MID? Graham Mount: As an undergraduate in the early 1940s I was trained in the GV Black principles of restorative dentistry. These were a rather rigid set of rules based upon the requirements of the trade of carpentry wherein a cavity designed to repair a caries lesion had to fulfil precise factors of design almost regardless of the extent of the lesion. First, all softened or discoloured tooth structure had to be removed and all the walls had to extend out to caries free areas. Retention elements were also part of the design. These basic requirements led to the removal of considerable amounts of sound tooth structure thus weakening the remaining crown to some degree. Over the following years of clinical practice I adhered strictly to these rules and developed pride in my ability to cut a precise cavity with flat floors and sharp line angles. However, it also became apparent over time that I had to protect, replace or repair a large number of cusps of teeth that had been weakened by these design principals. In fact, much of my practice in later years became involved in the design and construction of extra-coronal crowns and inlays that were required to support and protect these weakened cusps. It became apparent that the restorative materials we used were there to simply fill in the hole and in many ways were very intrusive and made no contribution to the health and strength of the remaining tooth crown. It seemed to me that the ideal restorative would provide some level of positive adhesion within the crown thus strengthening it. One of the oldest restorative materials was silicate cement and this became known for the release of fluoride ions into adjacent tooth structure thus limiting the recurrence of caries. We had great faith in fluoride at that time on the grounds that it may be a preventive for caries so any material related to its release was regarded as desirable. Micro-leakage into the interface between a restorative material and tooth structure was regarded
18 clinical corner

as a major risk factor in relation to the recurrence of caries. There was therefore a need for a material which would chemically seal this interface. In 1976 the glass-ionomer cements became available and it seemed that they had the potential to accommodate all the above requirements at the same time. They released fluoride ions, they adhered to tooth structure (both enamel and dentine) they sealed the interface thus preventing micro-leakage and they were tooth coloured. They represented a major break though in the area of restorative materials and therefore deserved some level of further research. It is interesting to note that in this same period, from the 1970s onwards, there was concurrent research in to the disease of caries itself. This showed clearly that it is caused primarily by bacteria which flourish and do their damage when the condition of the oral environment is condusive to a lowering of the pH within the adhesive biofilm which always covers the tooth crown. Research proved that if the oral flora can be controlled then the pH can be

A quadrant of GV Black amalgam restorations showing the typical over-extension of the cavity designs leading to weakening of the cusps. The cusps are so exposed to occlusal load that loss of one or more in predictable. mi.gceurope.com

Timeline of MID developments


1836-1915
controlled and demineralisation of tooth structure is far less likely to occur. It was the combination of the above research that inspired me to look more deeply in to the control of the disease and more limited restoration of the tooth crown from the damage that will result from caries. When they were first released I conducted research into the glass-ionomers to determine the best methods of obtaining optimum results in their clinical application. This lead to investigating modifications of cavity designs with the object of making the most of the caries resistance and the adhesion potential of the GICs. It then became apparent that there was a degree of remineralisation available using these cements and further investigation was warranted. All of these investigations have been conducted concurrently and have succeeded to the extent that it is now apparent that the profession has opened a new paradigm in operative dentistry wherein natural tooth structure can be saved, retained, remineralised and aesthetically reinstated to the extent that GV Blacks techniques are almost completely out of date. It is this concept that has helped to maintain my enthusiasm for change. What are the most important developments in Minimum Intervention Dentistry today? And what do they mean for the future of dentistry as a whole? Graham Mount: The one most important development that has lead to the evolution of MI Dentistry is the recognition of the fact that caries is GV Black and carpentry dentistry = all softened or discoloured tooth structure was removed and all the walls had to extend out to caries free areas. GV Black identifies the fact that the presence of bacteria was a necessary factor in caries and suggested that the profession had an obligation to continue to research this problem.

1908

Dr Frederick McKay (Colorado, USA) corresponded with GV Black about a brown stain which he found to be common in school children in his area of practice. Recognition that excess fluoride in the water supply was the cause of brown stains and a notable reduction in the caries rate in those affected.

1931

1940s 1950s

Restorative materials: silicate cement with fluoride releasing ions Kingston/Evanston experiment in the USA showed conclusively that there was benefit to be gained by offering children, to the age of 12 years, controlled levels of the fluoride ion.

1960s

Dental profession and most of the public finally agreed that all age groups benefit from the continuous presence of low levels of the fluoride ion in the oral environment.

1970s

Research reveals that decay is caused primarily by bacteria which flourish and do their damage when the condition of the oral environment is condusive to a lowering of the pH within the adhesive biofilm which always covers the tooth crown. Research proved that if the oral flora can be controlled then the pH can be controlled and demineralisation of tooth structure is far less likely to occur.

1976

The same patient presented again three years later showing the loss of two of the buccal cusps.

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Glass ionomer cements are developed which are: Tooth coloured, release fluoride ions, adhere to tooth structure (both enamel and dentine), seal the interface preventing micro-leakage. They represented a major break though in the area of restorative materials and therefore deserved some level of further research. The profession opens a new paradigm in operative dentistry wherein natural tooth structure can be
treatment plan

25

A patient showed a sudden increase in the caries rate with several new proximal lesions. A very conservative approach was adopted to cavity design. Removal of a large occlusal amalgam in the molar gave access to the proximal lesion and the three lesions on the proximal surfaces of the bicuspids were prepared as tunnels in order to preserve the marginal ridges.

The ultimate restorations using glass-ionomer cements in all three teeth with an amalgam laminate in the molar. The two bicuspids could also be reinforced with composite resin laminates if the occlusal load is considered to be too great.

a bacterial disease. It is interesting to note that GV Black himself identified the fact that the presence of bacteria was a necessary factor in caries and he suggested that the profession had an obligation to continue to research this problem. He did not have the facilities available himself and it was only a couple of years before he died that he became involved in the recognition of fluoride and its role in caries control. He understood the complexity of the oral environment and knew that bacteria play a significant role but he was not able to get it all fully in to perspective. Research over the last three decades has shown clearly that bacteria play the primary role in the disease. It has been shown that if the oral environment remains in fine balance then all factors can live together. The tooth surface is constantly undergoing some degree of de- and re-mineralisation as the pH of the environment fluctuates but variations in the intra-oral balance can allow certain bacteria to become dominant. As some bacteria (notably streptococcus mutans) are both aciduric and acidogenic, there is likely to be a higher level of demineralisation occurring in their presence on the tooth surface leading to an accumulated loss of ions with insufficient compensatory uptake and replacement. The other factors making up the balance of the oral environment include such things as the pH of the saliva and its capacity to buffer lowered levels of pH, saliva flow at rest and during function, presence of refined carbohydrates to provide nutrition for the bacterial flora, intake of low pH fluids and, most importantly, level of oral hygiene. It is apparent that the oral flora are very diverse and possibly no single strain is wholely responsible for caries. However, it is also apparent that if the population of acidogenic
20 clinical corner

bacteria is low then the biofilm on the tooth surface will remain capable of maintaining control over the flow of ions in to and out from the tooth surface. This means in total that, if the bacterial flora can be controlled, then the pH of the biofilm can be controlled. In the absence of high levels of acid the tooth surface will remain free of permanent damage and the exchange of ions will be balanced. Thus caries can be regarded as a disease which is primarily of bacterial origin. The GV Black system of simply removing tooth structure to prevent the disease was fraught with risk simply because further removal reduced the strength of remaining tooth structure and this is a very negative concept. Further, such surgery did not eliminate the disease. The second most important development is the discovery that it is possible to remineralise and heal an initial enamel caries lesion as long as the tooth surface remains smooth. Once there is permanent loss of surface contour it is no longer possible to eliminate bacterial activity entirely because plaque will accumulate in surface defects. However, over recent years several researchers have shown that, if the open lesion can be sealed and the bacteria deprived of further nutrition, there can be some degree of remineralisation of the underlying lesion. This first became apparent when it was realised that the enamel margins around an occlusal lesion could be etched and sealed with a resin material. The results were even better when glass-ionomer was used as the sealant because it is capable of developing a seal with both enamel and dentine. Also, being a water-based material, there can be migration of calcium, strontium and phosphate ions between the restoration and the underlying tooth structure thus allowing a high level of remineralisation of even carious dentine.
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This factor alone allowed the development of very conservative cavity designs with the retention of large amounts of tooth structure that could be reinstated but had previously been sacrificed in the development of the precise cavity carpentry required by the GV Black system. These two factors together have led to a complete redesign of the principles of restorative dentistry that is to say there is a new paradigm for restorative dentistry. Youve travelled and presented extensively in countries around the world: which regions or countries do you feel are the most progressive or forward thinking in how they deliver dentistry based on MID principles? Graham Mount: It is difficult to identify any one or more countries and suggest that they are in the lead because much of the research revolves around a team or teams of researchers. Most of the basic research on the glass-ionomer cements has been carried out by the manufacturing companies in Japan, the USA and Germany but the research in MI Dentistry has to be clinically based and covers subjects such as caries, bacteriology, remineralisation and cavity preparation and design. There are a number of researchers in the Netherlands who have been very active in the areas of caries research and some of these people have also produced significant thoughts on the GICs. There have been teams in the United States who have been similarly active in caries research and have produce landmark papers with significant results. The Scandinavian countries have also been very active particularly in clinical research. This is often difficult to carry out because of the problems of directly comparing the results of techniques between allied communities. In vivo research has been made very difficult these days because ethics committees have problems allowing research to be carried out in patients. At the same time it is almost impossible to reproduce the oral environment with any degree of accuracy on the laboratory bench. The glassionomers are essentially a water-based material and rely to some extent upon the dentine fluid flow and the saliva to reach full maturity. Any form of ion migration is dependent upon the presence of water so it is really not possible to reproduce this essential element on extracted teeth. Other dental materials such as amalgam and resin composite can be tested to some extent in vitro but even these results are questionable to some degree. You will find that there are a number of other countries including Australia that have encouraged research in this group of materials and in these techniques and the changes in the principles of restorative dentistry. However, their contributions have often been limited by lack of money and resources. There have been isolated cases of industrious researchers applying themselves to
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saved, retained, remineralised and aesthetically reinstated to the extent that GV Blacks techniques are almost completely out of date.

1980s-till present

Modifications of cavity designs are investigated with the object of making the most of the caries resistance and the adhesion potential of the GICs. It then became apparent that there was a degree of remineralisation available using these cements and further investigation was warranted. Important developments in the evolution of MI Dentistry: The recognition that caries is a bacterial disease. The possibility to remineralise and heal an initial enamel caries lesion as long as the tooth surface remains smooth.

Today

The most important contribution now can be made by individuals and groups in general practice who have adopted MID principles. They must be encouraged to maintain their records with a high degree of accuracy and to report in the literature on their level of success or failure. Research is essential in the general practice environment so that problems can be identified and the system perfected for the long term benefit of our patients. Even though it has taken almost one hundred years to evolve an understanding fluoride is now known to be the safest method available to minimise the effects of a disease that has been crippling communities for several centuries. It will not cure the disease and neither will it prevent it but it will raise the bar beyond which the disease will cause damage within the oral environment.

A bitewing radiograph showing a tunnel lesion in the lower second bicuspid using Ketac silver. It has been in place for three years and it was decided to replace the amalgam in the first molar. clinical corner 21

innovative techniques, such as remineralisation of tooth structure, with quite spectacular results and it is to be hoped that this situation will continue. Probably the most important contribution now can be made by individuals and groups in general practice who have adopted MID principles. They must be encouraged to maintain their records with a high degree of accuracy and to report in the literature on their level of success or failure. Research is essential in the general practice environment so that problems can be identified and the system perfected for the long term benefit of our patients. What advice would you give to practising dentists about MID? Graham Mount: A. The majority of dentists in practice today were educated in the GV Black system and therefore will simply identify the presence of lesions and immediately begin to restore them. There has to be a major change in mind-set to the extent that the profession must first seek evidence for the presence or absence of the disease, prior to getting involved in surgical repair of the lesions. It is possible for it to be present in the absence of surface cavitation. It will certainly be present in the presence of cavitation. It will not be possible to completely control it in the presence of cavitation so the concept of the transitional restoration should be encouraged. However, the first stages of patient education must be instituted in either situation. It is the patient who has the disease and it is the professions responsibility to show the patient how to overcome it. This represents a significant change in the approach to caries diagnosis and treatment planning that can only be introduced by the profession and requires re-education for those who have not been aware before. B. Caries is a bacterial disease. The primary bacterial species involved cannot be eliminated from the oral environment but both the population level and the oral environment in general can be controlled. C. The patient is responsible for the level of infection and must be educated, instructed and monitored in the proper control techniques. D. The disease is transmissible and re-infection can occur in any age group. E. Saliva is the patients best defence and variations in texture, flow and flora must be monitored. It is the essential progenitor of oral biofilm and it is the biofilm that controls the ion exchange on the tooth surface. Modifications to saliva flow will most often be related to general health including some specific disease groups, drug routines (both
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The amalgam has been removed from the molar allowing visual access to the adjacent second bicuspid. Note the extent of the remaining demineralised enamel on the surface of the bicuspid. As the disease of caries has been controlled in this patient that surface has been remineralised and can be regarded as sound.

Highlights from the MI Compendium


QUESTION: In patients with comparable caries risk, does GIC have a better cariostatic effect than amalgam?
ANSWER: The evidence suggests that GIC have a higher cariostatic/caries preventive effect than amalgam.

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22 clinical corner

pharmaceutical and recreational) and levels of personal hydration, but levels are not specifically related to advancing age. What are the top five products that no dentist can practice MID without? Graham Mount: 1. Saliva and plaque testing equipment. While the results of these tests are not necessarily conclusive they are certainly indicative of the state of play within the oral environment. Tests can indicate saliva flow rate, texture, buffering capacity and bacterial load. Plaque tests are particularly valuable for patient education and can indicate the level of pathological infection and the areas involved. In combination these results can be used to offer sound advice to the patient who, in turn, is the only one who can control the disease. Like all bacterial diseases dental caries is a personal problem. 2. The glass-ionomer cement restorative group. This material is not difficult to handle and has certain unique properties. Primarily it will seal the lesion completely through an ion exchange mechanism. This same ion exchange will encourage remineralisation of demineralised dentine on the floor of the cavity so that it is both unnecessary and undesirable to remove all softened or discoloured dentine as required by the GV Black technique. It also releases the fluoride ion thus discouraging the formation of bacterial flora on the surface of a restoration as well as assisting in remineralisation of adjacent tooth structure. It should be the foundation for all restorations even though it may require protection from undue occlusal load using lamination techniques. 3. Antibacterial oral lavages to assist in control the bacterial flora. Oral hygiene alone is often not sufficient and materials such as chlorhexidene, applied at a concentration of 0.2% twice a day can be a valuable adjunct for producing a rapid decline in the population. In extreme cases of active caries it should be applied twice a day for up to two weeks and there is a psychological value for the patient if a significant reduction can be shown over such a short period. As long term maintenance for the problem patient it can be diluted by 50% and used routinely once a day. The main advantage is that it is taken up into the soft tissue of the oral cavity and slowly released over the following 3-4 hours thus showing a prolonged effect. Applied for about two weeks every 6 months it will assist the most recalcitrant patient to maintain some level of control over the composition of the oral flora. There will be some level of calculus build-up and brown stain on the surface of the teeth evolving over time but this can be removed and may be a better alternative than active caries. As long term maintenance for the problem patient, such as the
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The patient has a low caries rate but there was a small lesion at the distal contact on the first molar. A very conservative tunnel cavity has been designed to obtain access to the lesion. The disease has been controlled.

The patient is responsible for the level of infection and must be educated, instructed and monitored in the proper control techniques. It is the patient who has the disease and it is the professions responsibility to show the patient how to overcome it.

The lesion has been restored with glass-ionomer cement and is shown here twelve years later. The restoration has been a success. clinical corner 23

Glass-ionomer restorations were placed at the cervical of both the canine and the lateral incisor. This photograph was taken 15 year later demonstrating the longevity that is possible with this material

elderly, housebound or hospitalised patient, it can be diluted by 50% and used routinely once a day. 4. Casein phosphopeptide-amorphous calcium phosphate complex (CPP-ACP). This is a relatively recent development which has been shown to reliably assist in the remineralisation of both enamel and dentine following an attack by the caries process. There have been a number of unsuccessful attempts to heal the early lesion (the so-called white spot lesion) but this material will effectively penetrate to the full depth of the demineralised enamel rods. It must be noted that demineralisation of an enamel lesion will penetrate most rapidly in the centre and grade out gradually to the periphery. The centre of the lesion will then collapse first leaving a graduated amount of demineralisation around the periphery at the outer edges of the lesion while the tooth surface will still be smooth but demineralised. Using CPP-ACP for a short period will lead to recovery of calcium and phosphate ions into the full depth of the damaged area so the extent of the lesion is likely to be reduced. Where GV Black insisted on removal of all demineralised tooth structure this is no longer required and cavity design can be limited to the cavitated area only while the surrounding areas can be healed. 5. A handpiece capable of intermediate high speed that is 50-100,000rpm. The main advantage of this speed group is that there remains a fine tactile sense during removal of tooth structure thus leading to limited cavity size. The essence of MID is
24 Clinical corner

maintenance of sound tooth structure. If an ultra-highspeed handpiece is routinely used enamel in particular will be removed very rapidly and it will be difficult for the operator to be sure of depth of penetration or extent of removal of otherwise sound tooth structure. At intermediate high speed it is possible to feel the moment of penetration in to a carious area and the risk of over extension is limited. Once the cavity is identified the full extension required can then be determined. A slow speed hand piece is then required to clean the surrounding walls only thus allowing the development of an ion exchange adhesion with a GIC restoration. Remaining demineralised dentine can be left on the axial wall or occlusal floor and total isolation of the lesion is assured. From the patients point of view intermediate high speed is no more uncomfortable than ultra high speed and it is far safer and more conservative of natural tooth structure. About the author Graham Mount (BDS, DDSc) trained in Sydney and practised in Adelaide, Australia and became involved in university teaching from 1950 and continues to be a Visiting Research Fellow at the University of Adelaide. In his career he served on numerous editorial boards, including the Journal of Esthetic Dentistry, Quintessence International and the American Journal of Dentistry. He has authored several books, most notably Glass Ionomer Cements. He has received many awards: Fellow of the Academy of Dentistry International [Regent, Australasian Section, 1986-1996, 1998 2000, 2002-2003] Distinguished Service Award SA Foundation for Dental Education and Research 2000 Medal of Paris, presented at the FDI Meeting, Paris (Bronze) Honourary life memberships of Oral Health Society For more information visit www.midentistry.org

Queries
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clinical corner

25

The current status of tooth crmes for enamel remineralization


By Professor Laurence J. Walsh
In recent years it has become easy for the dental practitioner to become confused regarding the bona fides of the many agents which have been promoted as agents for remineralizing enamel. This article looks at the process of remineralization, and from that examines some current products and therapies, to try to make sense of the fruit salad of apples, oranges and pears. The characteristics of an ideal remineralizing agent are summarized in Table 1 1, and this gives a useful measure of how the available materials and technologies perform.
Enamel minerals: back to nature The mineral in human enamel is not pure hydroxyapatite, but rather a mixture of compounds including a number of carbonated apatites, which together occupy up to 98 weight per cent and up to 96 volume per cent, when constitutional water is included. Of these various apatites, fluorapatite is less acid soluble than hydroxyapatite, which in turn is less soluble than carbonated apatite. While it is somewhat simplistic, looking at the major apatites makes it clear that the ratio of components required for remineralization is 10 calcium ions to 6 phosphate ions to either 2 fluoride or 1 hydroxyl ions or 1carbonate ion, a ratio of 5:3:1. It is also clear that calcium availability remains the singular limiting factor in enamel remineralization, and herein lies the problem, since the majority of calcium compounds are very insoluble. If we want remineralization then we will need calcium and phosphate ions (ideally assisted by fluoride) to rebuild a new surface on existing crystal remnants and this must occur in subsurface lesions, and not simply precipitate onto the surface. Making it real If one is going to assess potential remineralization agents, this must be done in realistic conditions, such as by using in situ models where enamel slabs are carried in patients mouth and removed in order to
26 Clinical corner

measure mineral changes. This aproach is necessary to take into account the effects of saliva, particularly its glycoproteins (which adsorb onto tooth structure to form pellicle) and its phosphoproteins (which regulate calcium saturation). The early pellicle glycoproteins, acidic proline-rich proteins and statherin, promote remineralization of the enamel by attracting and binding calcium ions, attaching strongly to hydroxyapatite, and inhibiting crystal growth and precipitation of calcium phosphate salts. 2 In situ studies which examine enamel slabs that have been in the mouth of patients allow full expression of the impacts of saliva. In contrast, some laboratory bench models exclude the involvement of saliva, and this can lead to nonsensical interpretations from the standpoint of clinical practice. 3 This is a problem which has plagued both the historical and the more recent literature on remineralization. A particular problem occurs when investigators take a dry physical chemistry approach rather than a wet natural biological approach to planning and executing their experiments. A current (July 2009) example of this dilemma is the somewhat simplistic advertising statement which compares a recently developed toothpaste (3M Espe ClinPro Tooth Crme) with an established topical remineralizing agent (GC Tooth Mousse Plus ), with the words (quoted from the 3M website) Introducing Clinpro Tooth Crme, the winning formula that helps
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prevent cavities. Strengthens teeth and reverses white spot lesions better than GC Tooth Mousse Plus. This statement as worded would naturally lead the reader to believe that (1) there is published evidence that ClinPro can cause visible reversal of a natural white spot lesion in a patients mouth, (2) there has been a direct comparison of ClinPro and Tooth Mousse Plus in a controlled clinical trial and there was a statistically significant benefit of the former over the latter; and (3) there is evidence that the formula of ClinPro prevents dental caries (reduces caries increment) in controlled clinical trials, at least to the same level seen with conventional toothpastes, if not better. Regrettably, at the time of writing, none of these three statements are correct. The dry physical chemistry approach which was used to evaluate ClinPro measures fluoride release from a toothpaste (a standard test configuration used for toothpaste registration by the US FDA), but is a not a measure of, nor a surrogate for actual remineralization of enamel under real-life clinical conditions. Laboratory in vitro testing protocols using ionic solutions are known to have significant limitations, and cannot simulate the complex biological processes involved. 4,5 Remineralization, after all, is not just a chemical reaction; it is a natural biological process. The argument could also be made that a comparison of the two is an apples versus organs situation, since ClinPro is a fluoride toothpaste and therefore should release some fluoride; whilst Tooth Mousse Plus is a pH-response long acting remineralizing crme which should not release much of its bound fluoride or calcium or phosphate until triggered by acidic pH conditions to do so. Details of product composition and other points of information regarding these products are presented in Table 2. With ClinPro, it is unclear how much of the calcium contained in the product is bio-available, and how much would be expectorated along with toothpaste at the completion of toothbrushing. Assuming a best case scenario where similar amounts of each product are used, ClinPro could only deliver a small amount of unbound, non-stabilized calcium in the 2 minutes of
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brushing before being expectorated from the mouth, whilst Tooth Mousse Plus delivers large amounts of stabilized calcium over an extended time period. One would expect therefore rather different clinical effects because of the different levels of calcium release and from the stability or otherwise of this released calcium, but not from the fluoride levels which would likely be similar. So, is there any clinical evidence of visible reversal of a natural white spot lesion in a patients mouth? There is published work showing this with GC Tooth Mousse, with the first of these perhaps being an early clinical case of a patient treated by this author in 2004 over a period of 12 weeks 6. Of much greater importance than this anecdote is the recent controlled clinical trial which documented visible reversal of white spot lesions in orthodontic patients over 12 weeks. Tooth Mousse was shown to be achieve this, and to be superior to a conventional 1000 ppm fluoride toothpaste. 7,8 Tooth Mousse and Tooth Mousse Plus differ in that the latter has 900 ppm fluoride within its composition (gained from the addition of 0.2% sodium fluoride). At the present time there has been limited research on the TCP technology used in ClinPro 9-10 and thus it would be premature to make assertions of superiority, one way or the other, until proper clinical trials are conducted. Nature thought of it first The problem of stabilizing calcium ions so that bioavailable calcium can be delivered when needed is a major biological challenge which impacts on all dental and other hard tissues in the body. Within milk, the casein phosphopeptides (CPP) stabilize calcium and phosphate ions through the formation of complexes. The calcium phosphate in these complexes is biologically available for intestinal absorption, and the same concept has now been applied to create materials with bio-available calcium and phosphate in the appropriate form and molecular ratio for remineralization of subsurface lesions in enamel. Clusters of phosphorylated seryl residues are responsible for the interaction which occurs in bovine milk between the caseins and
clinical corner 27

calcium phosphate. 12 Understanding this natural process of calcium stabilization, transport, and delivery and applying it to dentistry resulted in the development of CPPACP technology by Professor Eric Reynolds and co-workers at the University of Melbourne, and its inclusion into chewing gums (such as Recaldent gum and Trident White) as well as into the Tooth Mousse crmes. There is extensive clinical as well as laboratory evidence for the effects of CPP-ACP as a remineralizing agent, as well as a truly anti-cariogenic agent, with the latter being demonstrated in both animal and in situ human caries models 2,3,6-8, 12-22. The material is pH responsive, with increasing pH increasing the level of bound ACP and stabilizing free calcium and phosphate, so that spontaneous precipitation of calcium phosphate does not occur. This is also inherently an anti-calculus action, as well as evidence that CPP-ACP may influence the properties and behaviour of dental plaque through (1) binding to adhesin molecules on mutans streptococci and thus impairing their incorporation into dental plaque, (2) elevating plaque calcium ion levels to inhibit plaque fermentation; and (3) providing protein and phosphate buffering of plaque fluid pH, to suppresses overgrowth of aciduric species under conditions where fermentable carbohydrate is in excess. Conclusions: apples and oranges Looking at the evidence base available at the present time, it is important to clearly distinguish between these two products. In fact, one could argue that they share only two features their nominal fluoride concentrations are similar, and both use vanilla as a flavour. In fact, human in situ and clinical trial data
Parameter

is needed to support the use of ClinPro over other common 1000 ppm fluoride toothpastes, to validate the inclusion of TCP into a toothpaste formulation. Dental professionals should remember that it takes significant time (and expense) to establish the bona fides of a new technology, and that a watching brief is important in working through the various products and their therapeutic claims. About the author Laurence J. Walsh is Professor of Dental Science at The University of Queensland in Brisbane, Australia, and has been the Head of the School of Dentistry for the past 6 years. He is a clinical specialist in special needs dentistry, and has been researching preventive agents for the past 25 years. He developed the clinical protocols which are currently used with the Tooth Mousse series of products in his clinical practice. He has served for many years as an advisor to a range of dental companies involved in preventive dentistry. He has no financial interests in either the Tooth Mousse or ClinPro products discussed in this article.

Queries

fTCP Technology, as used in ClinPro Tooth Creme Subsurface effects up to 15 microns (microhardness testing). No clinical studies available at the time of writing.

CPP-ACP Technology, as used in GC Tooth Mousse and Tooth Mousse Plus Subsurface effects up to 150 microns (microhardness testing and mineral analysis of forming apatites) Visual and radiographic reversal of white spot lesions in patients in trials

Diffuses into the subsurface, or delivers calcium and phosphate into the subsurface

Does not deliver an excess of calcium Does not favour calculus formation Works at an acidic pH Boosts the remineralizing properties of saliva For novel materials, shows a benefit over fluoride

NA NA No NA Lab data Yes Animal models - NA Clinical - NA

Yes Yes Yes (down to pH 5.3) Yes Lab data Yes Animal models - Yes Clinical - Yes

Parameters of an ideal material are based on Zero, 2006 [Ref. 1]. NA = data not available. Table 1. Requirements of an ideal remineralization material 28 Clinical corner www.gceurope.com

ClinPro Tooth Creme Technology foundation TCP (USA). 3 laboratory studies of physical aspects. No clinical trials, or systematic reviews.

GC Tooth Mousse Plus CPP-ACP (Australia) Large literature (> 45 published papers) including randomized controlled clinical trials and systematic reviews

Production Chemical synthesis of TCP, followed by ball milling Purified natural peptides isolated from to create particles with surface coating of SLS bovine milk casein proteins and then complexed with forming nanoparticles of ACP Fluoride level (label) 950 ppm from 0.21% NaF Calcium-based ingredient 0.5 % TCP (500 ppm) Ca3P2O8 Ionic concentrations 48 mM Calcium 32 mM Phosphate 50 mM Fluoride (assuming maximal release occurs; however no data on bioavailability exists) Ratio of ionic species Calcium : 1 Ca: 0.6 P: 1 F Phosphate : Fluoride Calcium ion release Not yet documented for this product Application Toothpaste, Expectorated after use. Exposure time 2 minutes (duration of toothbrushing) Interaction with saliva Saliva dissolves SLS (detergent) coating on particles. Enhancement of calcium levels in No data available saliva and dental plaque Stabilization of calcium ions in No saliva and plaque fluid to prevent precipitation Binding to pellicle or soft tissues No Table 2. A stepwise comparison of two products 900 ppm from 0.2% NaF 10% CPP-ACP (10,000 ppm)

325 mM Calcium 187 mM Phosphate 48 mM Fluoride (measured bioavailability, with 90% ion release in 30 minutes) 6.8 Ca : 4 P : 1 F Complete release of calcium ions over 30 minutes following acid challenge Crme, applied topically and left in place 2-3 hours (protein binding and then slow proteolysis) CPP-ACP phosphoprotein works in partnership with salivary phosphoproteins to deliver and stabilize calcium Yes a property of the phosphoproteins Yes a property of the phosphoproteins

Yes - a property of the phosphoproteins

References

1. Zero DT. Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health. 2006;6 (Suppl 1):S9-S22. 2. Huq L, Cross KJ, Ung M, Reynolds EC. A review of protein structure and gene organization for proteins associated with mineralised tissue and calcium phosphate stabilization encoded on human chromosome 4. Arch Oral Biol. 2005; 50:599-609. 3. Reynolds EC. Calcium phosphate-based remineralization systems: scientific evidence? Aust Dent J. 2008;53(3):268-73. 4. White DJ. The application of in vitro models to research on demineralization and remineralization of the teeth. Adv Dent Res. 1995;9(3):175-93. 5. Roberts AJ. Role of models in assessing new agents for caries prevention - nonfluoride. Adv Dent Res. 1995;9(3):304-11. 6. Walsh LJ. GC Tooth Mousse Portfolio, 4th edn. 2006. Singapore, GC Asia Dental Pte Ltd. pp. 14-15. 7. Morgan MV, Bailey DL, Adams GG, Tsao C, Hyslop A, Escobar K, Manton D, Reynolds EC. A clinical trial measuring white spot lesion progression and regression. J Dent Res (Sp. Iss). IADR 2008 Toronta, Abstract 0112. 8.. Clinical trial of Tooth Mousse on white spot lesions. J Dent Res 2009 (In press). 9. Karlinsey RL, Mackey AC. Solid-state preparation and dental application of an organically modified calcium phosphate. J Mater 2009 (In press). 10. Karlinsey RL, Mackey AC, Stookey GK. In vitro remineralisation efficacy of NaF systems containing unique forms of calcium: a pilot study. Am J Dent (In press). 2009. 11. Karlinsey RL, Mackey AC, Stookey GK, Pfarrer A. In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent (In press). 2009. 12. Cross KJ, Huq NL, Palamara JE, Perich JW, Reynolds EC. Physicochemical characterization of casein phosphopeptide-amorphous calcium phosphate nanocomplexes. J Biol Chem. 2005;280(15):15362-9. 13. Walsh LJ. Tooth Mouse: anthology of applications. 2007, Singapore: GC Asia Pte Ltd.

14. Cross KJ, Huq NL, Reynolds EC. Casein phosphopeptides in oral health - chemistry and clinical applications. Curr Pharm Des. 2007;13(8):793-800. 15. Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. Spec Care Dentist. 1998;18(1):8-16. 16. Reynolds EC. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res. 1997;76(9):1587-95. 17. Manton DJ, Walker GD, Cai F, Cochrane NJ, Shen P, Reynolds EC. Remineralization of enamel subsurface lesions in situ by the use of three commercially available sugarfree gums. Int J Paediatr Dent. 2008;18(4):284-90. 18. Walker G, Cai F, Shen P, Reynolds C, Ward B, Fone C, Honda S, Koganei M, Oda M, Reynolds E. Increased remineralization of tooth enamel by milk containing added casein phosphopeptide-amorphous calcium phosphate. J Dairy Res. 2006;73(1):74-8. 19. Morgan MV, Adams GG, Bailey DL, Tsao CE, Fischman SL, Reynolds EC. The anticariogenic effect of sugar-free gum containing CPP-ACP nanocomplexes on approximal caries determined using digital bitewing radiography. Caries Res. 2008;42(3):171-84. 20. Reynolds EC, Cai F, Cochrane NJ, Shen P, Walker GD, Morgan MV, Reynolds C. Fluoride and casein phosphopeptide-amorphous calcium phosphate. J Dent Res. 2008 ;87(4):344-8. 21. Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds EC. Enamel subsurface lesion remineralisation with casein phosphopeptide stabilised solutions of calcium, phosphate and fluoride. Caries Res. 2008;42(2):88-97. 22. Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res. 2004;38(6):551-6.

Originally published in Dental Inc. July/August 2009 Reprinted with permission.


clinical corner 29

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FAQ on Evidence-Based Dentistry


By Dr Ste en Mickenautsch 1. Why are Randomized Control Trials (RCT) better evidence than other types of studies? Because they are designed in such a way that systematic error, also called bias, is prevented. Bias leads to wrong, mostly overestimated results. Here is an example: Lets say someone wants to show that resin-based ssure sealants protect better against caries than GIC based sealants. He places resin-based sealants in children from well-to-do private schools and GIC sealants in the same number of same-old children who live in poor orphanages. The children in the private schools know all about oral hygiene and keep their teeth clean and eat less sweets while the orphans dont even know what a tooth-brush is, but consume loads of sweets especially after bedtime. After two years the researcher will then nd that children in the orphanages have more caries than the one in the private schools and thus he concludes resin-based ssure sealants protect better against caries than GIC. That of course is wrong because a selection-bias was introduced, by selecting children with poor oral hygiene for the GIC group, which lead to an overestimation of the caries protective e ect of resin-based sealants. RCTs prevent such bias by conducting a randomized selection of children to be included in a study. This is usually done by e.g. out-of-the-hatdraws, like a lottery, where any child will have an equal chance to be chosen (= means their selection is not pre-conceived but completely random/ completely by chance) for either receiving resin- or GIC based ssure sealants, without the researcher having any in uence on that selection. In that way, both groups will be the same and therefore are comparable. They will only di er in the type of ssure sealant material (Resin or GIC) and so any di erence in caries after two years can then be truly attributed to the material properties and not to other reasons (e.g. lack of oral hygiene in one group), which have nothing to do with the type of sealant material. 2. Is bias really a problem? Yes, bias is a big problem. It may lead to underestimation of true clinical e ects but mostly to overestimation. Such overestimation has been measured and found to reach up to 41%! Here is another example: If a researcher has done a study showing that children with resin-based ssure sealants have 25% less caries than children with GIC sealants and his study is biased (e.g. like the study example mentioned above) then in reality children with GIC would have a 16% lower caries rate than children with resin-based sealant!! (If the 25% lower caries rate su ers from 41% overestimation then this would mean that the resin-based sealants would protect 16% worse than GIC). This means that bias leads to ine ective materials or procedures being identi ed and promoted or endorsed as being e ective. This is not only unethical but can even harm patients. Therefore quality products should always be based on low-bias or bias-free research. 3. What are systematic reviews? Systematic reviews identify and select studies (such as RCTs) with low-bias and exclude studies with highbias. This is done by a. searching databases for all studies relevant to a particular topic; b. reviewing each relevant study; c. applying criteria for study selection. Such criteria (like: random selection of study participants/patients as shown under question 1) are proven to assure low-bias and are generally accepted and recommended e.g. by the Cochrane group. A systematic review includes further a presentation and discussion of the results from only the low-bias studies and presents a combined conclusion and recommendation on their basis.
(Note: A systematic review must not be confused with a narrative review where an author presents the results of studies relevant to a

Bias leads to wrong, mostly overestimated results

30

evidence

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topic without having critically judged these studies according to criteria for low-bias. Narrative reviews are all high-bias because the author only selects studies which support his point-of-view).

4. What is META-analysis? Meta-analysis is a statistical method by which the separate results of several studies are combined to one average result. Meta-analysis is often used in systematic reviews: First the systematic review identi es low-bias studies. Next, the results of the individual low-bias studies are then combined into one single result, which constitute the average between these individual study results. The average result of a meta-analysis is often presented in a Forest Plot shown below. The Forest Plot is easiest explained as a sort of football- eld consisting of: - Two goals each favouring one of the compared materials; - One line of no e ect between the two goals. The football is the black diamond, which shows the combined result of the meta-analysis. When the black diamond lies in either of the two

goals it means that this particular material is superior to the other. If the diamond touches the line of no e ect (like in the case below) this means that both materials are equal. Dr Ste en Mickenautsch quali ed as dentist in Germany and has been awarded his PhD by the University of Nijmegen, the Netherlands. In South Africa, he is advisor to the MI research and training programme of the University of the Witwatersrand, Johannesburg. Dr Mickenautsch has written several scienti c papers published in national and international journals and facilitated numerous clinical courses related to Minimum Intervention (MI) in dentistry and the Atraumatic Restorative Treatment (ART) approach. His academic work focuses on the review, analysis and dissemination of scienti c evidence of MI. MI update is now on Facebook

Queries

List of low-bias studies with individual results Two goals line of no e ect

black diamond

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evidence

31

MI toolkit
Fuji Triage
Fuji Triage is a highly fluoride-releasing glass ionomer material for fissure and root surface protection, hypersensitivity prevention and provisional treatment procedures such as intermediate endodontic sealing. It is a product that truly embraces the principles of minimum intervention dentistry. With Fuji Triage, newly erupted molars can be protected in a very early stage when they are not matured and vulnerable for acid attacks. It can be applied quickly and easily to coat and occlude pits, fissures and the tooth surface, so protecting them from acid attack and the development of caries. This unique material oers all advantages of a conventional self-curing glass ionomer such as hydrophilic properties and chemical adhesion to tooth structure, eliminating etching and bonding procedures. This means no need to wait for a dry occlusal table and no need for acid etch, so the procedure can take half the time. The low viscosity, combined with levels of fluoride release 6 times higher than conventional glass ionomer, make Fuji Triage ideal for protection of teeth in a very early stage. Fuji Triage is available in a powder/liquid form or in capsules and this in two colours: white and pink. The translucent pink shade oers a visible control during recalls, whilst the white shade is best for patients who desire an aesthetic result.

Clinical cases

Figure 1: Before treatment

Figure 2: Cleaning of the tooth surface Clean the tooth surfaces (prophylaxis with pumice and water) in usual manner.

Watch the video to learn more:

Figure 3:Application of GC Cavity Conditioner To improve adhesion, GC Cavity Conditioner can be optionally applied for 10 seconds (or GC Dentin Conditioner for 20 seconds) to the bonding surfaces using a cotton pellet or sponge. Rinse thoroughly with water. Dry by blotting with a cotton pellet or gently blowing with an air syringe. DO NOT DESICCATE. Best results are obtained when prepared surfaces appear moist (glistening).
32 mi toolkit mi.gceurope.com

Figure 4: Mixing of the capsule Before activation, shake the capsule or tap its side 2 or 3 times on a hard surface to loosen the powder. To activate the capsule, push the plunger until it is flush with the main body. Immediately place the capsule into a GC Capsule Applier and click the lever once. The capsule is now activated. Note: the capsule should be activated just prior to mixing. Immediately remove the capsule from the applier and set the capsule into a capsule mixer or amalgamator. Mix for 10 seconds at high speed (approximately 4,000 RPM).

Figure 6: Spread a thin film over the entire surface Use a brush or an instrument to spread a thin film of GC Fuji Triage directly over the root surface or hypersensitive area or over the occlusal surface and into the pits and fissures. If needed, a matrix can be placed.

Figure 7: Optional curing with VLC-unit If a faster set is desired, use a visible light curing device for 20-40 seconds. Place light source as closely as possible to the cement surface. After placement, when the material starts to lose the glossy appearance (or after curing with the light curing device), remove the matrix and apply GC Fuji VARNISH (blow dry) or GC Fuji COAT LC (light cure) to the sealed area and the margins using a cotton pellet or sponge. Finishing under air water spray can be performed 6 minutes from start of mix (chemically set) or 4 minutes if light cured. Use a superfine diamond bur or a silicone finishing point.

Figure 5: Application of the mixture onto the tooth surface Immediately remove the mixed capsule from the mixer and load it into the GC Capsule Applier. Make two clicks to prime the capsule then syringe. The working time is 1 minute 40 seconds from the start of mixing at 23C (73.4F). Higher temperatures will shorten the working time. Extrude the mixture onto the tooth surface.
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Figure 8: Application of Fuji Coat LC Apply GC Fuji Varnish or GC Fuji COAT LC to the area again.
mi toolkit 33

Clinical cases

Fuji II LC
Fuji II LC is a light cured, resin modified Glass Ionomer cement. This product is the ideal solution for Class III & Class V restorations, particularly cervical erosion / abfractions and root surface restorations. Used as a base or liner in a sandwich technique, Fuji II LC makes any restoration last longer by preventing marginal leakage, eliminating sensitivity and providing superior fluoride release many times more than competitors. The 11 Vita shades, which Fuji II LC oers, make colour matching quick and easy. Excellent translucency allows Fuji II LC to blend with patients natural tooth colour for lifelike results. Unlike products with fluoride additives, Fuji II LC oers clinically significant fluoride protection. Its rechargeable fluoride release and excellent marginal seal help provide remineralisation. And research has shown that high fluoride release into the tooth helps prevent recurrent decay, making Fuji II LC the ideal choice for pediatric and geriatric restorations and patients with rampant caries and multi-level treatment needs. Fuji II LC is available in a powder/liquid form, oering an outstanding value for money, and in user friendly capsules. Whatever form you choose, finishing and polishing can be completed immediately after light curing for beautiful aesthetic results.

1. Cervical lesion

6. Finish under water spray using superfine diamond bur, silicone point and polishing strips;

2. After preparation of tooth, apply conditioner; 7. After polishing apply coating to protect the GIC during the first 24 hours

3. Washing and drying

8. Finished restoration

4. Form the contour and place a transparent matrix if required

5. Light cure for 20 seconds


34 mi toolkit mi.gceurope.com

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forward thinking mi toolkitpaperless dentistry 35

Comparison of RECALDENT

Comp
HOW PRODUCTS WORK
RECALDENT (CPP-ACP) utilizes CPP peptides derived from the milk protein casein to maintain Ca and PO 4 in an amorphous form (ACP). The CPP will bind to surfaces such as plaque, bacteria, soft tissue and dentin, providing a reservoir of bioavailable Ca and PO4 in the saliva and at the surface of the tooth. The Amorphous Calcium Phosphate (ACP) is released from the CPP complex during oral acidic challenges. Stabilization of ACP by the CPP ensures the delivery of Ca and PO4 ions into the tooth structure before they precipitate/crystallize.

COMPARISON OF RECALDENT (CPP-ACP) TEC


ACTIVE INGREDIENTS
RECALDENT contains Casein Phosphopeptides (CPP) and Amorphous Calcium Phosphate (ACP). Casein Phosphopeptides (CPP) are peptides derived from the milk protein casein that are complexed with calcium (Ca) and phosphate (PO 4 ). In this complex, the CPP maintains/stabilizes the Ca and PO 4 in an amorphous form (ACP) without precipitation.

RECALDENT (CPP-ACP)

Not to be used if patient has a casein allergy, but OK if lactose-intolerant.

ACP - Amorphous Calcium Phosphate

AMORPHOUS CALCIUM PHOSPHATE (ACP)

ACP is an inorganic Amorphous Calcium Phosphate made by combining soluble salts of calcium (Ca) and phosphate (PO4 ). A two-phase system with Ca in one phase and PO 4 in the other, they mix together and react to form an ACP material that precipitates onto the tooth surface.

When mixed together, CA and PO4 , react to form an Amorphous Calcium Phosphate (ACP) precipitate (note that this material is not maintained/stabilized in a delivery system like RECALDENT and Novamin are, and so has lower substantivity). Precipitated Amorphous Ca and PO 4 is highly soluble, so continuous acidic attacks will rapidly wash the Ca and PO4 away. ADA Foundation ACP is not bioavailable after the product, whether it is toothpaste or gel, is rinsed away or removed.

NOVAMIN *

NovaMin is composed of calcium, phosphorus, sodium and silica. Its chemical name is Calcium Sodium Phosphosilicate.

NovaMin particles bind to the tooth surface and, when the particle comes in contact with saliva and water, it reacts and releases Ca and PO 4 ions. The Ca and PO 4 ions are protected by glass particles which need to be trapped for the Ca and PO 4 to be localized. Sodium ions in the particles exchange with hydrogen cations; this then allows calcium and phosphate ions to be released. A calcium phosphate layer is formed which then crystallizes into hydroxycarbonate apatite. The physical occlusion of dentinal tubules results from both the hydroxycarbonate apatite layer and the residual Novamin particles. The arginine complex binds to the tooth surface and allows the calcium carbonate to slowly dissolve and release calcium.

SENSISTAT

SensiStat contains arginine, a common amino acid found in saliva, in combination with calcium and bicarbonate/carbonate.

RECALDENT is a trademark of Recaldent Pty. Ltd. and is used under license. GC America would like to acknowledge Dr. Jane Chalmers, BDSc, MS, PhD, Associate Professor, College of Dentistry, University of Iowa. * These are not products of GC America Inc.

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parison of RECALDENT
PEER-REVIEW STUDIES
90+ peer-reviewed abstracts and studies on RECALDENT (CPP-ACP) technology Textbook - Additional aids to the remineralization of tooth structure. Reynolds EC, Walsh LJ. In Preservation and Restoration of Tooth Structure 2nd Edition 2005, p111-118.

CHNOLOGY WITH ACP, NOVAMIN & SENSISTAT


CLINICAL USES
Strengthens tooth enamel with the release of Ca and PO 4, preventing demineralization and promoting remineralization of the tooth by increasing the hydroxyapatite Reduces sensitivity by occluding dentinal tubules Reduces dentinal hypersensitivity, especially with bleaching, scaling and root planing Bu ers plaque acid Reduces decalci cation in orthodontic treatment Repairs white spot lesions Reduces erosion Helps with dry mouth (xerostomia and salivary gland hypofunction) Reduces patient sensitivity and restores enamel luster ACP releases Ca and PO4 ions, reducing micro-leakage-related decay

WHAT PRODUCTS CONTAIN THIS


ToothMousse - GC America Inc. Trident White * Gum - Cadbury Adams USA

rem

re
ARM & HAMMER * Enamel Care * - Liquid Calcium * Mentadent * Replenishing White * - Church & Dwight Co. Inc. Zoom2 * ACP, Day White ACP, Nite White ACP - Discus Dental * Aegis * Products with ACP - Bosworth Company Enamel Pro * prophy paste with ACP - Premier Dental Products Co NuCare * Prophy Paste - Sunstar Butler SootheRx * - Omnii Oral Pharmaceuticals DenShield* Oravive *

Amorphous Calcium Phosphate is licensed by ADA Foundation A few peer-review studies by ADA Foundation

10+ published abstracts and studies, mainly from the manufacturers

Relief of root surface hypersensitivity Physically occludes dentin tubules to protect the nerve and prevent pain

Advertisement claims only Little peer-review evidence

Relief of root-surface hypersensitivity Sealing dentinal tubules will stop the ability of uid movement in the tubules to elicit pain

ProClude * DenClude * - Ortek

MI P Pro and Com Cha

SKU 650207

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Tooth Mousse Protocol


Case When to Apply Tooth Mousse* FL Toothpaste (ppm) 1-2 Times Daily

Bleaching Children & Adults (moderate to high caries risk)

Before & after treatment

1000 ppm uoride toothpaste

Daily
Note: Children should not use if IgE casein-allergic*

1000 ppm uoride toothpaste

Orthodontic Treatment

During treatment. Post treatment: After bands are removed

1000 ppm uoride toothpaste

Gingival Recession Pregnancy (especially if nauseated or vomiting) Excessive Tooth Erosion

Daily

Apply 1000 or 5000 ppm** uoride toothpaste 2X daily (morning and night). After evening application, apply ToothMousse prior to/at bedtime.

During pregnancy

1000 ppm uoride toothpaste

ng

isit

Daily

1000 or 5000 ppm** uoride toothpaste

High Caries Risk and Special Needs Patients (may need to also use an ant Xerostomia and/or SGH (all medical and autoimmune conditions)

Daily

1000 or 5000 ppm** uoride toothpaste

Radiation/Chemotherapy

Daily (pre-, during and post treatment)

1000 or 5000 ppm** uoride toothpaste

Meth Mouth and/or Mountain Dew Mouth

Daily

1000 or 5000 ppm** uoride toothpaste

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Note: Do not use antimicrobial rinses (such as chlorhexidine gluconate or CPC) within 2 hours of uoride toothpaste containing sodium lauryl sulfate. Acknowledgments: GC America would like to acknowledge Dr. Jane Chalmers, BDSc, MS, PhD, Associate Professor, College of Dentistry, University of Iowa, USA and Dr. *** MI Paste contains casein (milk protein) and should not be used if patients have an IgE casein allergy. MI Paste does not cont ain lactose and is safe for lactose-intolerant 2. Brush with toothpaste and then apply MI Paste afterw *** Do NOT mix MI Paste together with 5000 ppm uoride toothpaste or gel because it may precipitate out as CaF mi toolkit mi.gceurope.com *** MI Paste requires a thick application and needs to sit on the teeth for at least 3 minutes. Do not rinse after applying MI Paste. MI Paste can be used as a prophylaxis pas banded orthodontic patients. If a patient chews gum, advise them to use Trident White Gum with RECALDENT TM (CPP-ACP). Patients can use both MI Paste and Trident

MI Paste Protocol
Tooth Mousse Applications Per Day
1-2 applications of Tooth Mousse after uoride toothpaste, depending on severity of hypersensitivity
(wait 1 hour before applying home bleach at night)

Duration

Tooth Mousse Application


(Finger: rub pea-sized amount on all teeth *** )

Several days or up to 2 weeks, depending upon severity of hypersensitivity

Finger or custom tray

1-2 applications of Tooth Mousse after uoride toothpaste

As needed to prevent demineralization

Finger or custom tray

1-2 applications of Tooth Mousse after uoride toothpaste


Note: May use remineralization technique during post treatment (see MI Paste brochure)

As needed to prevent demineralization

During treatment: Finger, brush or custom tray. Rub Tooth Mousse around brackets/bands and directly onto demineralized areas. Post treatment: Finger or custom tray

1-2 applications of Tooth Mousse after uoride toothpaste**

As needed/ongoing for hypersensitivity on exposed root surfaces and demineralized area

Finger or custom tray

1-2 applications of Tooth Mousse after uoride toothpaste. If nauseated, apply Tooth Mousse in place of uoride toothpaste. 1-2 applications of Tooth Mousse after uoride toothpaste**

As needed; may help with minimizing erosion

Finger or custom tray

As needed

Finger or custom tray

timicrobial rinse/spray and other saliva stimulants/substitutes)


Apply Tooth Mousse after uoride toothpaste and as needed during the day, especially prior to/at bedtime for dry mouth** Apply Tooth Mousse after uoride toothpaste and as needed during the day, especially prior to/at bedtime for dry mouth** Apply Tooth Mousse with nger all over teeth and oral soft tissue as a lubricant and salivary enhancer. Can also use custom tray if needed. Apply Tooth Mousse with nger all over teeth and oral soft tissue as a lubricant and salivary enhancer. Can also use custom tray if needed. Apply Tooth Mousse with nger all over teeth and oral soft tissue as a lubricant and salivary enhancer. Can also use custom tray if needed.

Ongoing as needed

Ongoing as needed

Apply Tooth Mousse after uoride toothpaste and prior to/at bedtime**

Ongoing as needed

Hien Ngo, BDS, MDS, PhD, FADI, FICD, FPFA, Associate Professor, University of Adelaide, Australia, for devel opment of the MI Paste Protocol Chart. t patients. Contact a physician if recommending for a renal dialysis patient. wards. www.apexezine.com mi toolkit ste, especially in patients with a dry mouth. MI Paste should not be brushed on like toothpaste with a toothbrush, since it requires a thick layer, except in active t White Gum, especially if they have a dry mouth.

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GC SalivaCheck Buer
Saliva-Check Buer is a user friendly test that can help you to understand your patients oral environment in just 5 simple steps. The procedure will help you to show the possible caries risk, by testing quality, pH and buering capacity of saliva. The first 3 steps involve un-stimulated saliva while the last 2 steps test the stimulated saliva. The functions and characteristics of these two forms of saliva are dierent and by evaluating both, the results become a very powerful diagnostic and communication tool. In this way you can make, for every patient, an individual treatment and prevention program. Characteristics & benefits Checks the flow rate, viscosity and consistency of un-stimulated saliva. This will give information about how the patients lifestyle may be aecting their oral health Checks the pH of the patients resting saliva. This will tell when acid levels may be dangerously high, and cause erosion or caries problems Checks the quantity of stimulated saliva a patient can produce. This helps identify any major salivary gland disease Checks the buering capacity (quality) of stimulated saliva. This establishes the eectiveness of the saliva in neutralising acids in the mouth Saliva testing is mainly aimed to identify if changes in the salivary condition can be a contributing factor, and to motivate your patient to improve his oral health status. Fuji Triage is available in a powder/liquid form or in capsules and this in two colours: white and pink. The translucent pink shade oers a visible control during recalls, whilst the white shade is best for patients who desire an aesthetic result.

Watch the video to learn more:

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Clinical cases
Step 1 - Resting Flow Rate
Visually assess the lower lip labial secretion. Evert the lower lip, gently blot the labis mucosa with the small piece of gauze and observe the mucosa under good light. Droplets of saliva will form at the orifices of the minor glands. If the time taken for this to occur is greater then 60 seconds, the resting flow rate is below normal. Low Normal High Greater then 60 seconds Between 30-60 seconds Less then 30 seconds

Step 2 - Salivary Consistency

Visually assess the resting salivary consistency in the oral cavity. Strongly increased Sticky frothy viscosity saliva Increased viscosity Frothy bubbly saliva

Step 3 - Testing pH - Resting Saliva

Instruct the patient to expectorate any pooled saliva into the collection cup. Take a pH strip, place this into the sample of resting saliva for 10 seconds and then check the color of the strip. Highly acidic saliva will be in the red section, pH 5.0-5.8. Moderately acidic saliva will be found in the yellow section, pH 6.0-6.6. Healthy saliva will be in the green section pH 6.8-7.8. Results: Compare the color of the test strip while the paper is still moist. Note the pH reading and record the results.

Step 5 - Testing Buering - Stimulated Saliva

Step 4 - Testing Quantity - Stimulated Saliva

Ask the patient to chew the supplied piece of wax. After 30 seconds ask the patient to expectorate (spit) into the collection cup. They should then continue chewing the wax for a further 5 minutes, expectorating every 15 - 20 seconds in the cup provided. Note:Measure the volume of liquid in the cup excluding froth and record the result. Note: Keep saliva for the next step Volume of Saliva Very Low Low Normal

Open the Buer test foil pack. Use the pipette to draw up some saliva from the cup. Dispense 1 drop from the cup onto each of the 3 test pads. Turn the test strip on its side to drain excess saliva onto a tissue. After 2 minutes compare the color of each pad with the table below, total the 3 scores and record the results. Green Green/Blue Blue Blue/Red Red 4 points 3 points 2 points 1 point 0 points

Where a colour combination provides an unclear result, use intermediate scores. Buering Ability Very Low Low Normal Combined Total 0-5 6-9 10-12

<3.5mL 3.5-5.0mL >5.0mL

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