Dental Tribune Indian Edition

15Dental Tribune Indian Edition - April 2013 Trends & Applications appears to offer some promise, and while an oral surgeon may find it a nuisance to bother with placing them, a general dentist may be able to get them in place with little difficulty. Orthodontists often tremble at the thought of using a needle (like I did in dental school), so the price goes up as the patient heads to the oral surgeon. BIAS: A particular tendency or incli nation, especially one that prevents unprejudiced consideration of a que stion; prejudice. So this article is obviously biased towards expanded skills for the gene ral dentist, but I do respect the need to pick your battles in treatment and refer when the case demands it. I es sentially do not believe in putting up with any rubbish from specialists who want to dictate what a general dentist can and cannot do. If you do not like my ideas, tough luck because the ones you have may not stand up under clo se scrutiny. I do not want to waste my time justifying anything I choose to do and if I am taking a course beside an orthodontist who is snivelling that he will start doing fillings and extrac tions, that is awesome; I may have an opening for an associate. As excited as I am about STO, I think a twoday course is only a taste of what you need to know. It is like taking a twoday selfdefence class and then thinking you can enter mi xed martial arts. The problem is not what you learn, but the cases that you attempt that are actually much more complex than you realise (you will be defeated!). You MUST take a full orthodontic course such as the one taught by Dr Richard Litt, and you are insane not to take a series of oral rehabilitation courses from Dr Frank Spear or Dr John Kois. Adult orthodontics is fullmouth reconstruction, and the treatment of worn dentition is too important to overlook. In fact, orthodontists have a very difficult time trying to treat adults with worn dentition, so I consi der this a very good niche for doctors ready to invest in crosstraining. I have seen an orthodontist try to treat an advanced wear situation with full orthodontics, and the result was all wrong. Instead of allowing for the restorative material, the practitioner moved the short teeth into place as if they were full size, so when we wan ted to lengthen the worn incisors the result was a posterior open bite. The easier way to treat the case would have been to build up the teeth with composite prior to starting the ortho dontics. Cosmetic dentists have a tendency to veneer everything. They veneer te eth straight because they claim bra ces take three to four years. They ve neer teeth to get rid of wrinkles and headaches. They veneer teeth to whi ten and straighten them. They veneer teeth because the old veneers break. Exaggerated times in braces are of ten lies that need to be corrected as soon as possible to stop the abuse that is going on. Cosmetic dentists need to reprogramme to back off and get some air. And orthodontists need to give a little elbow room to their referring dentists who want to offer some orthodontics. The smart ones maintain a positive relationship and often see referrals from the primary care dentist increase. I know, NOT ALL cosmetic dentists are Veneer Nazis, and NOT ALL orthodontists tell patients that GP orthodontics causes root resorption. My suggestion for breaking an ae sthetic obsession is “cosmetic detox”, which is very difficult if you have focused your training on aesthetic dentistry. The easiest way to do this is to take porcelain veneers off the table in the treatment planning stage. Composite resin can be used conser vatively with orthodontics to provide a nearcomplete medium to long term solution. Any time you stick to a single se ries of training programmes, you start to pick up biases that warp your thinking. You will find that the ide as within the dental profession are as extreme as the religions and political beliefs around the world. The propo nents of the various philosophies can be very convincing, but I think each doctor needs to take a step back and make up an individual philosophy that puts the patient first. If you take the average patient, this means that you will offer fast, affor dable, reversible and conservative treatment. Millions has been spent to make people think veneers are better than real teeth; I challenge that idea. Porcelain is not as good as healthy enamel, not now and not ever. Of course, it is a material that serves a purpose but often it is used simply to line the dentist’s pockets. So to recap this approach to care, I suggest you take an STO course from one of the two 6month braces programmes, add a full orthodontic programme (ideally taught by an or thodontist who has taught orthodon tics grad students), take a fullmouth reconstruction programme (or at least a worn dentition component), then if you want you can take a composite technique course. I personally do not get fancy with composite, since my patients do not have loupes or want to pay double for advanced microscopic cosmetics. What patients do hate is composites that chip/stain. This brings me to use Clearfil APX PLT (Kuraray—no en dorsement money yet!). Freehand composite bonding is the best way to be able follow the contours of the te eth, so scrap the idea of using a wax up as an instant makeover if ortho dontics would be helpful. The Clearfil shade XL appears to have a chameleon effect that works for most shades of teeth. If a lighter shade is desired, then a cutback technique can be employed to mo dify the final appearance with ano ther shade/material like 3M Supreme (3M ESPE). From my review of the CRA/Cli nicians Report literature, this brand of composite is particularly strong in clinical use, and I have heavily resto red cases that are still holding up after five years of service. The composite does not polish very well, so I have started using GCoat as a final glaze, especially for smokers. I simply tell the patient that if he breaks the fil lings, there is a 50 per cent warranty for the first 12 months, regardless of how they were broken. With orthodontic treatment, you should, as mentioned earlier, try to rebuild any worn teeth before starting braces. Since you will be able to move teeth in three dimensions, you simply build up the teeth to full size and then you move directly into orthodontic records to get started. The occlusion should be left “high” and finalised with the braces. The change in vertical dimension (VDO) appears to be another handi cap that paralyses some dentists. If the patient does not have muscular problems and headaches, there may be no need to move into splint therapy to test a bite change. Simply by loo king at the effect enamel replacement would have on the bite and conside ring how orthodontics could manage the result may be sufficient without an articulator. A less deep overbite and a less trap ped mandible appear to be desirable within most schools of training. The cosmetic training really will begin to come into play with incisal di splays, tooth proportions and fuller ar ches. The arch form after orthodontics usually is very pleasing and mimics the technique of overlaying ceramic on the facial surfaces of the upper bicu spids. The term for this has faded from my memory because I tend to avoid courses that push the use of porcelain. When I attended the UCLA Aes thetic Continuum, Dr Jimmy Eubank took a few moments to talk about a case in which a young teen had had her teeth disfigured with bulky ve neers. He was forced to retreat her teeth but she had been compromised for life. As dentists, we are subject to many sales presentations disguised as courses and we rarely get the truth. The truth is dentistry is not easy and taking one weekend course will not be nearly enough. No guru is going to tell you all that you need to know. At a recent course on anterior aesthetics taught by Dr Gerald Chi che at the Seattle Study Club, I was forced to prepare a number of ve neers on plastic teeth. The burning smell reminded me of dental scho ol, which brought back mixed emo tions. I took away the idea of addi tive cosmetic strategies and the use of minimal reduction if choosing to use ceramic. Bonding to enamel in stead of dentine still seems to be the better plan. (I also gave Dr Chiche a few photographs of John Lennon’s decayed molar and he shared the fact that he had an original photo of the Beatle that was lost in Katrina— I hope he finds the copy sometime soon!) As one of the first dentists to com bine STO concepts with advanced treatment planning of the worn denti tion, I can honestly say that if you can set aside the use of porcelain veneers and substitute some of the treatment modalities mentioned in this article, you will eventually find a way back to ceramic usage with a better empathy for patient care. The public is beco ming wiser and the market is shifting towards dentists who are ready to mix up their training. As my UK dentist colleague Dr Martin Kelleher, who lectures on “ve neerial” disease, would say, use the daughter test before you do anything irreversible. I would add that you owe it to your patients to learn from the best in the profession, and crosstraining in con tinuing education may be the best investment you can make in dental practice.DT “I know, NOT ALL cosmetic dentists are Veneer Nazis...” “...the market is shifting towards dentists who are ready to mix up their training.” Dr Michael Zuk is the author of the book Con fessions of a Former Cosmetic Dentist. As a consultant to several marketing program mes, including HighSpeedBraces. org and KillerToothache.com, the dentist has cultivated unique niches as alternatives to the veneerbased practice model. He can be contacted at drz@bowerdental.com. Contact Info Daniel Zimmermann DTI MEMPHIS & COLUMBIA, USA: Human trials on a revolutionary me thod to prepare dental cavities are ex pected to commence soon in the US. In collaboration with Nanova Inc., a Columbiabased startup, a research team from the University of Missouri (MU) will test a device that is said to improve longevity of fillings through treatment with streams of lowtempe rature ionized gas. The “plasma brush” first received recognition in 2009 when the Small Business Innovation Research pro gram of the US government awarded US$157,000 to Nanova for the deve lopment of the device. According to company representative Meng Chen, the first lab test using the method was successful and produced no side effects. The technology exploits the pro perties of nonthermal plasma, also known as cold plasma owing to its low temperature, which has been used in other industrial sectors such as the food industry to sanitize fragile sur faces like those of fruit permanently. Through a similar process, the MU research team found that it also hel ped to disinfect oral cavities by pro ducing oxygenfree radicals that are able to destroy biological microorga nisms like bacteria by disrupting their cellular membranes. In addition, cold plasma enhances the bond between the natural tooth surface and different filling materials by changing the surface of dentine through a chemical reaction. “Our studies indicate that fillings are 60 percent stronger with the plasma brush, which would increase the fil ling’s lifespan,” Hao Li, professor in the University of Missouri College of Engineering said. Chen said that if the trials produce clinical data that confirm the initial findings, the device could be available to dentists by the end of next year, de pending on regulatory approval.DT Cold plasma ‘a blast’ for teeth (DTI/Photo University of Missouri) ← DT page 14