As a dentist, completing restorations is a regular part of your practice. But restorations that maintain their longevity and strength over time can be difficult to create — and if you've invested time and expenses into restoring a patient's teeth, it's disheartening to watch those restorations crumble.
There are three helpful strategies when it comes to managing dental caries: prevention, restorative management and non-restorative management. Understanding the importance of these three strategies, and helping your patients recognize their role in the process, is crucial to ensuring that restorations last.
To prevent caries disease from forming or progressing, it's essential to complete a caries risk assessment on each patient. This assessment evaluates disease factors, risk factors and protective factors.
Disease factors include visible cavitations or cavities in the last few years. To assess risk factors, start by conducting an examination, paying close attention to salivary flow or exposed roots. It's also important to ask patients about their lifestyle habits. For example, do they drink regular sodas? Do they snack between meals? Do they use recreational drugs? Ask about whether they maintain regular dental cleanings and if they're exposed to fluoride in their drinking water. These are helpful details to know.
Finally, calculate protective factors into your assessment. Protective factors are anything a dentist or patient regularly partakes in that helps level the scale. Fluoride, calcium, xylitol and bacteria management, for example, prevent caries disease from taking hold. Once you've completed the full assessment, place each patient at high, moderate or low risk for caries disease and outline your strategy from there.
The first step to restorative management of caries — the process involved in restoring damaged tooth structure — is preventing the disease from spreading. Glass ionomers (GIs) are an excellent yet underused option as a triage material in dentistry. Restorations done using GIs last longer than those using amalgam (fillings made with mercury and silver) or composite (fillings made of quartz added to a resin), as amalgam has the potential to cause the tooth to crack, and composite easily breaks or chips. In addition, GIs are easier to apply for temporary restorations.
Options for good GIs include 3M™ Ketac™ Universal Aplicap™, GC Fuji IX GP® or IonoStar® Plus. One study, cited in the September/October 2021 issue of Special Care in Dentistry, the official journal of the Special Care Dentistry Association, showed that GIs and silver diamine fluoride (SDF) curbed disease by 90% in a patient population. Based on this evidence, GIs can help transition a patient toward a full mouth reconstruction by eradicating as many caries as possible and helping the patient get the disease under control.
GIs are effective because they release fluoride in the presence of acid. When you place a GI in a patient with a high rate of caries, fluoride will be released when the acid attack is occurring — in other words, exactly when you need it. This gives GIs a leg up over options such as composites for patients with high caries risk or high disease rate.
Non-restorative management of caries and disease looks different than restorative management. This type of disease management is not invasive. It manages the disease process at a lesion level. Stabilizing the oral flora and controlling the pH are two of the most important steps to begin with, and good hygiene, fluoride varnishes, sealants, high concentration fluoride and xylitol products are vital to the process.
One meta-analysis conducted by the Journal of Restorative Dentistry looked at three strategies: 5% sodium fluoride varnishes, resin infiltration and sodium fluoride varnishes, as well as high concentration fluoride. The analysis discovered that these three strategies were the most effective at arresting or reverting non-cavitated lesions and cavitated root lesions.
Lesions are caused by a variety of factors. Some patients lose tooth structure through an acidic process. A study performed by Dr. Marc Geissberger, Dr. Terry Donovan and Dr. Ward Noble, printed in the Journal of the California Dental Association, looked at the buffering time of sports drinks — how much time is needed to neutralize every sip you take of a drink. The study discovered that Red Bull is the most erosive sports drink due to the time it takes to buffer. Red Bull takes 22 minutes, while Coca-Cola takes just two-and-a-half. Acidic drinks wear tooth structure very quickly.
To address disease through non-restorative management, the first strategy suggested is fluoride varnishes. This includes applying fluoride varnish on a regular basis — every three to four months at minimum, if not more often. This is simple, but a game changer.
Next is sealant. Sealants decrease the areas where plaque and bacteria can accumulate on the occlusal surfaces of teeth, making them an easy way to decrease a patient's bacteria load.
The third is prescribing high concentration fluoride. These products contain ingredients that are essential for re-mineralization.
And finally, the fourth is xylitol, a naturally occurring sugar alcohol often used as a sugar substitute in sugar-free products. There is some good supporting evidence that xylitol in adults can help curb the disease through the interruption of bacterial reproduction. Patients need a therapeutic dose from products such as 3M™ TheraMints™ 100% xylitol sweetened mints or the xylitol found in certain store-bought mints and chewing gum.
Ultimately, the best way to create restorations that last is to get your patients on board. Talk to them about the importance of staying on top of their oral health through proper care and regular maintenance. Together, you can ensure their teeth remain as healthy and protected as possible — and that your hard work doing restorations doesn't fall by the wayside.
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