Chapter 13 (abridged) : Beyond the Death Spiral: Modern Dentistry 1908 vs. 1985

From Mouth Matters by Carol Vander Stoep, RDH, BSDH, OMT.              Minimally Invasive Preventive Dentistry, Biomimetic Dentistry and ozone use in dentistry

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We don’t know what we don’t know.
If we don’t know what we don’t know,
We will always do what we have always done.
And if we always do what we have always done,
We will always be what we have always been.

– Omer Reed, DDS

Drill-less Dentistry (1985)

A three-year-old child rests quietly in a dental chair, arms upturned in total relaxation. Back teeth severely rotted, the child’s parents have brought him to this clinic because they abhorred the traditional diagnosis/treatment recommended for their child: general anesthetic and unsightly, ill-fitting full stainless steel crowns for his back molars. They had heard of a better way…

The dental team works smoothly in a fifteen-minute, oft repeated choreograph. The assistant maintains eye contact and speaks softly to the child while the dentist behind his microscope silently plies the tools of his trade. Air abrasion powers away most of the tooth decay. A blast of ozone gas to each tooth penetrates deeply to inactivate remaining germ invaders and their toxins. This changes their internal chemistry to allow rapid remineralization – essentially petrifying the tooth. It may also help preserve the pulp’s vitality. Next, the dentist paints minerals on prepared tooth surfaces to facilitate rebuilding. After applying a series of optional resins with today’s superior adhesive qualities, a quarter of his mouth is restored!

Benefits: A brief, relaxed, anesthetic-free (anesthetic is rarely necessary when warm water is used in parallel with the tiny abrasive particles or with low air pressure) visit for both child and dental team translate into economical lifetime solutions. Compared with all-too-frequently recommended stainless steel crowns placed while under general anesthetic, natural-colored tooth repairs leave children with higher self-esteem, better function, and pleasant feelings about dental visits.

Welcome to the world of drill-less dentistry!

And why is it taking so long to catch on?

What Is Minimally Invasive Preventive Dentistry?

Many dentists use the term “Minimally Invasive Dentistry”. Its meanings are diverse. For some, it means taking away as little tooth structure as possible after diagnosis using tiny drill burs or a laser. A critical broader definition starts with correct, early diagnosis. Sometimes a tooth pit is just the right width to catch a dental explorer, so is incorrectly diagnosed as decay. More often, decay is missed or “watched”.  Because of the way teeth form, tiny defects can lead to decay that is difficult to detect using standard x-rays and a dental explorer. It is estimated these techniques used alone are correct only 25% of the time.

X-rays can only detect decay that is 2-3 millimeters deep into the second layer of a tooth – the part that underlies the enamel. Decay is fairly extensive at this point as it moves toward the vital pulp. Air abrasion combined with laser detection can help explore questionable lesions. When early diagnosis and air abrasion is combined with ozone, tooth structure and function is preserved.

Traditional filling designs used since the Civil War require a drill and a traditional flat-bottom design with sharp angles. These sharp angles concentrate chewing and clenching forces. Almost certainly a tooth will eventually break along these predetermined lines. Drill burs remove tooth structure indiscriminately. Microscopically, they shatter our precious enamel and dentin. These tiny cracks can then propagate throughout a tooth much like a windshield crack will. To worsen the problem, hardened mercury-laden filling materials called “amalgams” or “silver filling” by most dentists, expand more than teeth do when they get hot. This further encourages breakage along predetermined lines.

Air abrasion has many benefits. It discriminately removes unsound tooth structure and avoids the cracks in teeth initiated by dental drills and can even help clean up the cracks formed around old mercury fillings. Additionally, the particle flow creates smooth, rounded internal transitions within the tooth preparation, avoiding many of the stresses created by traditional designs. Bond strength of resin filling material to tooth is better because it scours away what is termed the “smear layer”.

Economy is built into this new dentistry. Regular visits and early intervention help people avoid the traditional dental repair-replace-repair cycle, estimated to be at least $2187.00 in services by age 79 per initial cavity in 2003 dollars.

Things Are Rarely What They Seem

“Do I have a cavity?” It would seem an easily answered question, yet most dentists in the United States were not trained to definitively diagnose them – and do not know it. On the other hand, early and appropriate diagnosis is a fundamental standard for those who practice Minimally Invasive Dentistry (MID). You may not think how the health of your teeth is assessed matters, but as with early detection of any problem, long-term success and cost savings depend on it.

Traditional dentists use x-rays and a sharp explorer to detect decay. MID dental professionals call that the “poke and hope” method. They do not rely on these tools because they know they are less reliable than the flip of a coin – correct 25% of the time:

    1. 1969, 1987, 1993 – Using a pointed explorer is an unreliable way to diagnose cavities in tooth grooves. In fact, not only are sharp explorers inaccurate, they “may damage the enamel surface covering early…lesions. Using explorers to detect decay became obsolete in Europe over two decades ago. This has not stopped clinicians in the United States from relying on them to detect end-stage decay.

 

    1. 1996 – Doctors attempting to diagnose decay in tooth fissures using sharp explorers are accurate about 25 percent of the time. Magnification of cross sections from teeth confirmed that 75 percent of the time, seemingly intact enamel surfaces concealed extensive lesions in underlying layers of tooth.

 

    1. 1967, 1987 – Additionally, probing restored teeth can be misleading, since a probe may catch in a margin discrepancy that is not in fact [decay]. (This is known as a false positive.)

 

    1. 1967, 1987 – Probing of root…lesions with a sharp explorer using controlled, modest pressure, may create surface defects that prevent complete remineralization of the lesion. Based on MID findings since 1987, lesions never completely remineralize anyway. Once the crystalline enamel structure is gone, it is gone forever. It hardens, but the loss of structure allows acids to seep through the enamel to continue structural damage in deeper layers. This is one reason keeping a balanced oral pH is important.

 

    1. 1988 – Decay does not generally show up in x-rays unless it has progressed 2mm to 3mm deep into the softer sub-enamel layer.

 

    1. 1993 – Typical “check-up” x-rays miss about 23 percent of deep lesions originating in the top surface of molars.

 

  1. Depending on explorers to reveal decay sometimes leads to placing fillings in sound surfaces. In these cases, the fissure walls are simply angled in just such a way as to catch an explorer tip.

In summary, as Dr. Tim Rainey, the foremost pioneer of MID says, “For anything to be considered to be within the realm of science, it must be repeatable. If you give ten dentists an explorer and ten patients, the ten dentists cannot agree amongst themselves on where the decay is. Their diagnosis is not repeatable. Further, if you have them return in a week to examine the same ten patients, they do not agree with their own previous diagnosis. That clearly is not a science!… We know how to fix things but can’t agree and are not sure about what it is we should be fixing.”

What About Sealants?

Sealants are still a common dental procedure, but obviously, without an accurate diagnosis, this practice can hide damage for a long time. So, not only is it essential to diagnose fissures carefully before recommending sealants, know that only properly placed and maintained sealants provide protection. Scanning electron microscope observations of sealant gaps and fractures suggests they fail because their adhesives degrade. Also that gaps and unetched areas may cause failure rates totaling more than 21 per cent after only six months.

If a sealant is applied to a decalcified area, it will not bond properly. A porous tooth allows acids and other fluids to leak under sealants, also causing failure.

If you have had sealants placed, frequent, routine check-ups are essential because, as one study says, “Maintained sealants provided nearly 100% protection for the tooth over a 15 year period … As long as the presence of defective fissure enamel is diagnosed accurately and effectively placed, preventive resin restorations are very successful.” This information suggests sealants should not be placed on populations who do not seek or otherwise receive routine care. As stated elsewhere, only half of Americans ever seek dental treatment and of those that do, only half visits routinely.

Two parting thoughts: Sealant retention is related to each person’s incidence of decay. Those patients needing sealant protection most are least likely to have long-term retention. The expected rate of sealant loss in permanent molars is 5% – 10% a year.

Mimicking Nature: Biomimetic Dentistry

Face it. Most of us have at least a few teeth operating with compromised strength because they received traditional dental therapy. You just read how traditional dentistry causes teeth to break apart. This allows bacterial entry, which can then hollow teeth long before anyone suspects a problem. It can also lead to irreparable fractures and tooth loss or health-compromising root canals.

Dental schools still teach – and dental state board exams still test – traditional, mechanical dentistry. Mechanical dentists drill holes and fill them, or as these repairs fail, cut teeth down to accept full coverage crowns. Is placing these large crowns our only choice?

No! About five percent of dentists have followed the science and moved to Minimally Invasive Dentistry and when necessary, biomimetic adhesive dentistry. Biomemetic dentists specialize in helping teeth survive late intervention. They make advantageous use of the advanced ceramic materials and adhesive technology that have been available over the last quarter of a century.

As David Alleman, an early pioneer in biomimetic dentistry explains, biomimetic dentistry treats weak, fractured, and decayed teeth in a way that keeps them strong and seals out bacterial invasion. Resin material cannot just be “blobbed” in. Biomimetic dentists rebuild a tooth so that its walls are connected from side-to-side, front-to back, and top-to-bottom. The new materials and special techniques allow a tooth to move and flex the way a tooth is supposed to. This eliminates the need for up to 90% of crowns and root canals.

“Instead of simply filling cavities as though they were potholes, biomimetic dentists ensure the dental work will fail in a repairable way, rather than letting teeth fail. Carefully placed repairs last far longer than traditional repairs. Many people most appreciate biomimetic dentistry because these special techniques nearly always eliminate post-treatment discomfort!”

Again, these techniques taken together prevent fracturing of teeth and filling materials without crowns.  Aside from systemic toxicity of mercury fillings (amalgams) and the poor repair designs they require, MID dental professionals know there are other reason these fillings are harmful. Because mercury is biologically toxic, teeth wall themselves off from these fillings by forming fluid-filled zones underneath the fillings. Chewing forces cause a trampoline-like effect as these fillings compress into the voids. Teeth bulge under the intense pressure. This eventually causes small cracks to form on virgin surfaces in between teeth. When plaque remains between teeth, the microclimate here is acidic. As teeth flex during function, these cracks open and shut, pumping acids into the teeth. This eventually causes tooth failure. Similar cracks can develop on teeth with resin (white) fillings not done using biomimetic techniques or materials.

Biomimetic dentists have solutions for teeth that have previously undergone traditional dentistry. These are the teeth whose enamel webbing or the structural rim around the biting surface have already been destroyed and the tooth has broken down as a result.

Clean Air/Clean Water

Another dirty dental secret: your mouth is not the only place biofilms exist. Biofilms form everywhere there is water. Many dental office water lines are highly contaminated, even if the staff uses dispensing bottles with sterilized water and flushes the lines nightly. Recolonization can occur in twenty minutes. Contamination is measured in terms of “colony forming units” or CFUs. The ADA suggests a goal of 200/ml of water. Boil water alerts go out when CFUs exceed 500. Many dental unit lines have between half a million to five million CFUs/ml. Water contamination can occur from either end of the system: the source or the point-of-use. So even if an office uses dispensing bottles as is required, they must either ozonate their water or treat it with antimicrobials. I prefer ozonated water because it is alkalizing, it destroys cell wall deficient bacteria, and does not interfere with tissue reconnection, as chlorhexidine can. Dentists must also filter and dry their air source to keep it verifiably oil and contaminant-free. This keeps dental unit air lines from infecting water lines and does not re-contaminate teeth – either with new germs or with oils that contribute to resin filling failure. Clean air/clean water contributes to the quadruple bond strength MID/biomimetic dentists achieve with their resins. Obviously clean air/clean water also amplifies both surgical and non-surgical dental results.

Ozone

Ozone is one of the most exciting, versatile tools in the dental toolbox. Not a new idea in medicine, Germans successfully applied ozone to gaseous gangrene wounds during World War I. In use for more than 130 years, oxygen/ozone therapy is the current standard of care in over 20 countries. An inexpensive yet powerful antimicrobial, neither bacteria, nor viruses or fungi develop resistance to it. Ozone is a natural approach to infection control, wound management, and tissue repair. Oxygen/ozone therapy is fully recognized by the medical community in 14 states.

Could you benefit from dental ozone therapy? Ask yourself:

    • Do you like the idea of halting or reversing decay?

 

    • Unhappy with unsightly orthodontic bracket scars? Are you undergoing orthodontic care and want to avoid them?

 

    • Are you bothered by cold sores (herpes), oral ulcers, denture sores, or chronic sores at the corners of your mouth?

 

    • Are your teeth temperature sensitive?

 

    • Are you prone to oral yeast infections?

 

    • Do you want whiter teeth?

 

    • Do you have or intend to have implants?

 

    • Have you taken “bone-sparing” drugs like Boniva, Actonel, Aredia and suffered osteonecrosis?

 

  • Do you want to seriously boost gum disease therapy?

The Second Millennium

Before biomimetic dentistry I used to be a serial pulp killer. – Dr. Pascal Magne

The University of Geneva no longer teaches 100-year-old dentistry. No full crowns, no pins, no posts, no flat-bottomed, sharply angled filling preparations. They teach only MID and biomimetic dentistry.

In 2006, in the Journal of the California Dental Association, Dr. Richard Kao wrote, “Although the concept of evidence-based dentistry appears fundamentally simple and reasonable, clinicians have been slow to implement it… Perhaps as little as eight percent of dental care is justified by peer-reviewed, published and appropriately analyzed dental research.”

The faster research clarifies how things work, the further away we operate from a scientific basis. It is safe to say that many practitioners in all professions don’t keep up. Others are afraid to think beyond what they learned in school; they are comfortable or afraid to try new things, but weighing new research and acting on it is what defines a professional. None of us will ever know everything. We will not always be right. We must make our best treatment decisions based on current knowledge.

Dentistry has come far. Towards the end of World War I, the U.S. army had to lower its admission standards for army recruits. Early in the war, recruits had to have at least six sets of opposing teeth. By the end of the war, that standard was lowered to fill the army. We owe much to dentistry. In fact, all dental professionals put themselves at great daily health risk. Those who maintain the old ways are at highest risk. We should appreciate all they do for us. But we can and must do better.

Up until now decay has been:

    • poorly diagnosed

 

    • has involved tooth amputation with drills

 

    • have put children at risk for brain dysfunction if they undergo multiple episodes of general anesthesia

 

    • has been poorly accepted by the public

 

    • has been poorly executed

 

    • so that the average lifetime of a filling is low…

 

    • resulting in spiraling costs from ever larger and more complicated restorations…

 

  • often followed by either root canals or extractions, themselves a health risk.

We can do better. Today’s dentistry, based on the best science, is fast, pain-free, and affordable.

The days of “drill and fill” are numbered. Dental drills have had their day. They belong to another era. – Julian Holmes

The biggest impediment to new learning is old learning. – Albert Einstein

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