Transcribed by ______________Date of the Lecture

Transcribed by Jacqueline Heath

* please note that the podcast slides were behind, so I did my best to match up the content of the lecture with the content of the slides, but as Dr. Wolff kind of hops around and tends to skip a lot of slides, its probably not perfect. Thanks for understanding! - Jac

DOD [Lecture 31] Caries and the Newest Methods for Minimal Intervention by Dr. Wolff September 9th, 2014

[1] Title slide: Changing Concepts in Restoring Teeth[Wolff] How light do we want it? Can you still see with this much light? Yeah, youre okay? Otherwise we can make it darker and you can sleep easier. Ok, everybody seems happy where it is. So, you know this is kind of interesting. Im giving a variation of this lecture, literally I guess its Thursday, already tomorrow in India, so its Thursday in India, and Ill be back to give you a lecture on Friday, so its an interesting routine that were actually talking about very much the same subject, the concept that our management of the carious lesion is changing. And in that particular lecture, I actually lead off with the comment that GV Black is dead. And I need you to understand where this changing concept comes in restoring teeth. There is no doubt that at NYU 4 or 5 years ago that this lesion represented: pick up a handpiece and drill this tooth. Whats the implication of us doing that? Weve had this discussion before. What does it mean when we choose to do that? [student response] Whats that? [student response] It weakens the tooth, thats very accurate. Well, weve certainly lost a good part of that battle, yes. Were now winding up restoring tooth. 5 years from today, 8 years from today, 10 years from today, what else happens? See, the rationale why every faculty in good conscience looked at these areas and said they need to be restored, is look at the amount of decay in this patients mouth. Wed better get to this before it gets worse. I can do a small restoration. And in fact we know the longevity of a restoration is directly related to its bucco-lingual width, as well as the strength of the tooth. Once we go from the bucco-lingual width between the cusps to 1/3 the width between the cusps, we weaken the tooth by 50%. As long as we stay within less than 1/3 that distance between the buccal and lingual cusps, on a premolar is where the studies were done, the strength of that tooth is almost identical to the virgin tooth. The minute we go from 1/3, Im sorry, to 1/3 the width, a very small change: 25% to 33%, the tooth now gets weakened by 50%. And this was done by very simple experiments just cutting out a hole between the groove of known depth, putting a ball bearing between the two cusps and looking at where the tooth fractured when youre loading. So if the same depth, if we stay 25% of the width, the tooth is just as strong, but if you make it 1/3 the width, its now only 50% as strong as the native tooth. Thats number one. So we make things more likely to fracture, we have longevity issues, we lose the battle on here. What else? How long is that restoration going to last? [student response] Whats that? [student response] You know we wish that it would last 15. The average life expectancy of a Class II restoration in the United States, according to the insurance companies is less than 8 years. And then weve already talked about the things that vary that. You know its... if I see her restoration, and start looking, uuhhhh ohhh. When I look at MY restorations, I go, yeah that has a little bit more legs, it can go a little bit longer. But dentists tend to be a little more critical of OTHER peoples work than of their own. So we look at our own work and go hm, ok, not bad for 8 years, its holding up, maybe we can get a few more years. But when I look at her work, I go psh, if thats the type of work you want to walk around in your mouth, thats ok with me. So a few things occur. We know that the restoration were placing, theres no such thing as lifetime restorations. Done. No such thing as that. The next thing we know is that when we place the restoration, particularly if we make it too wide, we destroy the tooth structure. But the thing that was most important that we learned was that in placing that restoration, we did not decrease the caries. We did not decrease the disease that person has. Because decreasing the disease goes to etiology, not to outcomes. This demineralization is an outcome. So here it was very clear that we restore this. And Im going to say to you we can just see it leaking into the DEJ here. And today we use this as the NYU threshold. A couple of schools are still using thresholds that are up there [if I remember correctly he pointed at the E lesions on the maxillary premolars] but even the Northeast regional board has abandoned that threshold. But Im telling you that 95% of the teeth that have surfaces that just touch the DEJ like this, even though the demineralization extends into the dentin, still have an intact external surface, or a nearly intact external surface, and that could be remineralized. So the debate is starting to be whether or not we should be restoring when it hits the DEJ or whether when the demineralization is very clearly into the outer 1/3 of the dentin. Actually moving it further and further in. So this was considered state of the art restoration to go ahead and treat that restoration, that lesion that was there,

[3-5] Picture of a slot prep on a premolar

it did not necessarily break facial or lingual contact. How far gingivally does it go? [student response] Whats that? It breaks the contact gingivally, why? Thats where the tooth decay is. Why not buccal and lingually? [student response] If the decay isnt there, it doesnt matter. Whats the ideal composite restoration for a Class II look like? Remember even that term doesnt apply anymore. For an aproximal lesion on a posterior tooth. Whats the ideal preparation look like? Person in the very last row, who gets a freebie, you can say anything you want! Whats the ideal preparation look [like]? Describe how you prepare this tooth today. Is this a good preparation? [student response] Whats that? Well, its a nice slot prep. Did I have to make it square? Absolutely not. There is no rationale for making it square. So there is excessive tooth destruction there. What is the every prep today has the same identical ideal preparation. What is it? [student response] Remove the caries and [student response] break the contacts, we already have said remove the caries is the critical item. We break gingival contact because as he said, the decay is below the gingiva. So we break the contact at the gingival because thats where the decay is. We remove the decay and [student response] we remove unsupported enamel. Why? [student response] Its not the leakage. When we go ahead and put a bonded restoration on, one of the things you see with unsupported enamel particularly, or thermocycling afterwards, is that the breakage of the lesion of the restoration isnt at the bond to the enamel, but rather at the unsupported enamel to the tooth. So weve created an area that as you see, causes microleakage, but it causes microleakage not because we bonded to unsupported enamel, but rather because that unsupported enamel easily shears away from the tooth. So you want to get a hefty enamel that can bond to the tooth. Exacavate the decay, remove unsupported enamel. The concepts of breaking contact are just not necessary. So in 1981, a dental student wrote an article in Dental Student Magazine, [he drops his clicker] if you could get that for me, in Dental Student Magazine, that said why are we doing preparations that look like GV Blacks to place amalgam? Composite, posterior composites hadnt been invented yet. And when I wrote that, it got rejected the first three times it was submitted, until it was finally read by someone that today is considered a fairly clairvoyant person about dental restorations and where we are going. Then it was a very revolutionary concept. Today, thats the new modicum. Excavate the decay, get nice, clean surfaces and place a restoration in there. Lets look at what GV Black had to say about this. Hopefully. There we go. So its etched, its bonded. We look at this and we think its a nice restoration. Comment by Elise Heath:

[6] By restoring this tooth

But by restoring this, weve already said that we didnt treat the disease.

[7] Hypothetical Example

So we need to go back and look at oh. This is, this is from Dr. [Desananake?]. He probably gave you this one already. Have you seen this? Really great discussion. Only dentists you know, you shouldnt throw these things on the floor, they dont work as well afterwards. [referring to the clicker he dropped] Um, only dentists think about opening up a tooth, cutting something out, and treating it as if it were a real disease that we cured. Speak to your dentist. If your parents are dentists, speak to them. It changes this mindset. We actually looked at it as if we were curing the disease. If you dont finish at the end of this virgin restoration by doing a fluoride on this patient and talk to the patient about doing home fluoride home care, youve done nothing to treat the disease. So you know, we do the wrong things by, by surgically removing the tooth [I think he might have meant by removing the caries?] without doing all sorts of items along with it. And I have to tell you, encouraging brushing and flossing to remove plaque is not amongst them. We have to look at products and the rationale and why the patients are actually getting decay. Blame it on the patient. I really like that mode.

[9] What is minimal intervention dentistry?

So minimal intervention is based on assessing the patients caries risk, and youre going to get this from Dr. Allen coming up. You need to be able to look at certain things in the patient and say, why are they likely to get decay again? the number one predictor of whos going to get decay in the future is [student response]... who got decay in the past. Do you remember this? We did this in the clinic, right? Did you guys work with me? Right over there. I know youre writing notes because Dr. Wolff didnt give you the lecture slides to take before, or youre ordering shoes, or furniture, or.. youre ordering lunch? No. You remember doing this caries risk assessment in the clinic with Dr. Meeker last year? We sat down, we talked about caries risk assessment. Looking at areas of demineralization. New demineralization. Active caries in the mouth. Those are the number one indicators that youre likely to get disease again in the next 3 years. It sounds stupid. Now there are a series of other conditions that make you more likely to get disease. Name a few. [Student response] High sugar intake, but more than high sugar intake [student: frequency] High frequency sugar intake. How about something from that back corner over there? Just give me something that makes the patient more likely to get disease again! [student: xerostomia]. Xerostomia, lack of saliva because saliva does what? [student: buffer] it helps buffer the acids. This is your review for your exam. These are the questions that could show up. Why is saliva important? Whats that? [student response] We already said that. Say it louder. [student response] Washing away, its an actual toileting of the area, removing both food and the acids. [student response] That goes along with the washing and dilute. Placing calcium and phosphate at the surface. There is another big one that Im a real believer in. Whats that? [student response] No, it doesnt lower the pH, it raises the pH, the opposite direction. Raises the pH, it brings it brings, what ion is the, it brings bicarbonate, not what ion, what moiety, it brings bicarbonate and hydroxide ions to the plaque and helps raise the pH, it brings calcium into the plaque which helps remineralize. It brings phosphate into the plaque. What else does it bring into the plaque to feed the good bacteria? [inaudible response] It happens to be, I used the demonstration of Arginine, but there are a series of amino acids that help raise the plaque [I think he meant raise the pH of the plaque] by feeding base-forming bacteria appropriate foods. So, recognizing that we need to do this each time we see caries is actually the treatment of the disease, not the surgical treatment; not the excision. If you were smoking cigarettes and had lung cancer, and I didnt say to you, you know, you should really quit. Anyone have a parent or family member that has gone to the dermatologist that takes something off their skin? What is their first thing the dermatologist says to the person even before they cut it off? You better use sunscreen, right. So thats looking at the risk and looking at the management. Nobody gets put on high blood pressure medications without being told to exercise and lose weight and cut down on salts! History of dentists is the exact opposite. Lets drill out this cavity and Ill see you in six moths. Its an annuity. We just never manage the disease. So were looking at a medical model now for treating caries and thats really important to you. The disease is not linear or one way. In the time of GV Black, if you started getting caries and we noted it on that radiograph, remember, GV Black was 1890, not 1990, we saw it on the radiograph, the only treatment this man had, there was no fluoride, there was no understanding that sugar was causing caries, there was no management strategy for patients, was to get in there early and remove the caries! So for his time, what he wrote was quite accurate. Unfortunately, [hes blocking someone from seeing the screen] you should have seen me when I was bigger, I could block more people. In his time, he was very, very accurate. He was clairvoyant actually in what he was seeing.

[11] Millers Acid Decalcification Theory

And this was the Millers theory. If we take mineral, you get acids in one direction, Im sorry, and that would make the demineralization. If you have alkalinity, it runs it in the other direction. This is the change so the disease [doesnt finish sentence]

[12] Bitewing radiograph

So lets talk about that carious margin. And Im not talking about the day you take the boards, because the boards are still a little old fashioned in how we approach this. If you were to see, how many of you are getting in the clinic and actually seeing tooth preparations? How many of you have been in there and seen this? What you have to do is knock over the upper classmen and take the mirror and physically look into the preparation as theyre taking caries out. Physically look at the caries and start deciding where the decay is located and how far demineralization has extended. So chalky, unsupported, weak enamel has to go. But the theory that you have to take everything away, today has disappeared. We can get good bonds to reasonable dentin, and retain it over a long period of time, that restoration. So not only, today, is this in question about treatment, but all those other surfaces, we need to think about. So risk assessment falls in first. Remineralization of all of those early lesions, not saying to the patient.. You know what the dentist says to this particular lesion here? Anybody dental assisted for a dentist? Nobody? And you all decided to be dentists? Youre lying, you just dont want to be called upon. Youre lying, I know, I can tell by your smile there. Youre lying. So what does your dentist call that lesion? What did he tell you to put in the chart? No, you didnt, but she did. Oh no, its a DO, but did he restore that tooth? Oh, he would, oh okay thats even worse, Im sorry. But he drives a Mercedes, its okay. No. But what did he say about this lesion? Watch it! W. Thank you for helping me, Ive been looking for someone to play the straight man out of this! But actually, yours was even better, I like that answer. So the W is a stupid thing to put in the chart. And its stupid because you should never watch it. You have to treat it. Observation of that is just benign neglect, moving that patient towards your next payment on the car. And its actually not moral!

[13] Tenants of Minimal Intervention Dentistry?

So what you need to do is risk assess the patient, work on remineralizing all of these, and then we start, were working on methods of reducing the amount of cariogenic bacteria by managing the frequency of this sugar, brushing the teeth better, using toothpaste and mouthwashes that alter the bacterial content, and then work with the plaque to try to remineralize and make the tooth more resistant. And then when all else fails, we use a minimal surgical intervention on the lesion that is lesion specific. A student cant tell me that Im going to use an amalgam here, Im going to use a composite here. They cannot tell me that it needs to be an MOD unless its an obvious its what size is the lesion, I have to excavate the decay, I believe this is going to wind up being a mesio-occlusal composite, but it may be that I can just reach it from the straight mesial. Maybe I can reach it from only the occlusal, but I have to remove the decay. And then, I will design the restoration such When you take the boards, tell them what surface. [14] Picture of GV Black

Um GV Black was not a bad person. He was genius. And in envy of a man that wasnt a scientist that actually understood a disease so thoroughly that he gave us the tenants to improve oral health, literally for decades. Almost for a century, what he taught us brought improvements to oral health.

[15] picture of old dental chair

[16] Blacks Classification of Carious Lesions

He gave us the classification, but this classification system is rapidly dying. Its being replaced right now by the international caries management system. A different dialogue of what decay looks like, that describes its location, its activity, um, and it gives us the ability to start measuring early demineralizations.

[17] Blacks Cavity Preparation

Um, he gave us the design of the preparation, and that was incredible. We still use these terms about outline and resistance form today. He wrote about extension for prevention. Extension for prevention is not what most people today refer to it. Most of our faculty think that extension for prevention refers to taking out the entire groove. And well even address that in a few moments. Taking out the entire groove is not necessary, the fissure is not necessary. Removing diseased fissure is necessary, probably. There is a lot of literature saying you can seal it and do just as well as going in and surgically treating. But removing that carious fissure, the caries to the dentin, is one thing. But extending through the groove is what GV Black said and the thought was that he wanted to get it up into a cleansable area.

[18] So what are some things Black wrote about tooth preparations?

[19] Picture of amalgam restoration

But what he was actually referring to was not this massive amalgam. And remember what I said? 1/3 the buccolingual width? That would take that cusp there, and this cusp tip there, and measure the distance between this one, is somewhere close to the width. Up in this area, its much more than the width. This tooth is gravely weakened and likely to fracture. And in fact, anyone who has been in practice has seen these cusps fracturing off in 50, 60, 70 year olds all the time. That preparation was never necessary and doomed this tooth to probably an endo, post and crown sometime in the future. And thats just very sad.

[20] Wrote about tooth preparations?

But this actually turns out, its not extension for prevention. Thats not what GV Black was writing. GV Black as referring to moving the cavity preparation, so this is when, this was his writings in 1915, that he moved the occluding surface of the molar, you prepare the filling with the idea that the fissure and part of the enamel has favored the occurrence of caries.

[21] So what are some of the things Black wrote about tooth preparations?

For this reason, the fissures and grooves are joining the cavity, even though not decayed, are cut away to such a point to seemingly give a smooth, even finish at the margins. So his goal was to carry it up into the groove pattern up here, so that it was on an incline that you couldnt accumulate food at the margin. There are a couple of things that you need to recognize. His amalgams did not contain high copper. They contain very low copper. They corroded rapidly and broke down at the margins. They have a life expectancy of less than five years. Putting the margins where you could look at them and inspect when they were breaking down resulted in smaller restorations on the redo of the tooth. So you wanted to see all of these margins so you knew when they started to break down. He didnt have any adhesive dentistry. Adhesive dentistry changed the game. Adhesive dentistry says lets do the same thing GV Black says: take out the caries, then lets get the groove to be protected. How do we do that? Very simple. How do you protect the groove after youve taken out a little bit of caries on the distal, for instance? Somebody up here whispered it to me, but I want to hear it from somebody in the front row section over there. You looked up, its too late! Thats right, were contacting. [inaudible response] No idea? If I have a fissure, and I dont want it to get decay. Its deep, its disgusting. If I took an explorer and stuck it, it actually sticks. How do I prevent that from getting caries? [student response] Sealant! So you actually did know the answer. And thats what you do in a restoration. So even though Dr. Bucklan taught you a very conservative MO box slot prep, what occurs after the slot prep is, if the fissure is deep, seal it! Close it off so it meets the GV Black criteria of not being likely to get caries!

[22] Blacks restorations pictures

Now, he would take one of these aproximal lesions and cut a restoration that brought it out to the lingual because A, he wanted to get the toothbrush in there, and B because he couldnt look at the margins that would break down rapidly. He wanted to get them where he could see them.

[23] Figures 18 and 19

So he made these giant preparations that really destroyed large chunks of tooth. Literally bringing out these margins to the facial areas, like you see here in Figure 19, these are actually out of his textbook. So you can actually pull these margins all the way out here. The problem was that these break down more rapidly, they weaken the tooth, but he was able to see them and prevent decay on them.

[24] amalgam photo

So this is a modern alloy, it contains high copper, and it doesnt tarnish or corrode at the margin. This restoration happens to be 15 years old! A little ratty at the edges, it has been polished by the way, to bring back that luster. But it still stands up well.

[25] So what changed?

So what changed was we actually changed the amalgam composition in two ways. First, we went ahead and used a technique that put less mercury into it. The way GV Black described triturating, A, he didnt use a magic machine, they put the powder into a pestel, they put excess mercury, they took the mordor[?] and pestel and smushed it all around, and then they put that mixture in a cloth and squeezed out the extra mercury and let it fall on the floor so you could call Dean Marris down and have him quarantine the building because of.. well actually its bad, you dont want to get Mad Hatter Syndrome, which is what you get out of that. [26] Blacks dental amalgam?[27] amalgam restoration photo

[28] Eames Technique

Um. Eames technique says measure exactly the amount of mercury you need to wet the amalgam, and no more. Condense it, place, and suction off any excess. the norm.

[29] photo

[30] high copper dental amalgams

Conservative preparations, adhesive dentistry. Um and the increased in copper made a real big difference in, do you remember what phase? Did you get this? Have you learned about gamma 1 and gamma 2 in amalgam? Yeah, this was a big deal. So this was a gamma 1 causing amalgam. Its old, its broken down. And once we go ahead and change the mixture, and this is just a different brand, and raise the copper content up near 12 to 20%, we go ahead and decrease this gamma 2 phase and get better restorations. So the amalgams change, we learn to use them in a more conservative preparation. But to me, and this being the conservative preparation of one bur width, this restoration should never occur. Smaller restorations became the norm.

[34] Discovery of Adhesive Dentistry

Buonocore, in 1955, followed shortly after that by Bowen, who looked at methods of bonding. And this bonding was absolutely wonderful, and now gave us the ability to bond to tooth and actually make mechanical retention in the micro. This was only to enamel, not to dentin, and it never got fully perfected before we started to have the technique of dentin bonding.

[35] Bitewing radiograph

[36] Caries Assessment

So we needed to come up along at a new method of classifying these lesions so we could judge if they were getting better or worse in the process. So the classification system that has been adopted actually describes the depth of enamel, the depth of dentin penetration, with whichever is deeper taking the lead. And we wind up with initial caries. And initial caries depending on whether youre a European or American.. Americans are calling this initial caries, Europeans are actually calling this all initial caries, this being moderate and this this almost being extensive. So in this particular case, we typically talk to the patient about, um, about the fact that were going to have to do root canal on the tooth. Europe doesnt approach it that way, and they have really good data to say that the outcome of their teeth and the outcome of our endodontically treated teeth are identical. How did they treat it differently? They leave the caries. And lets talk about that. Because you know, if you want to give an old-time dentist a seizure. I mean absolutely drop them to the floor, tonic clonic, bouncing off the floor, throwing things at you, maybe even, if hes in TX, drawing a gun and shoot it at you, you say, Im going to leave caries in the preparation. Now this is an interesting discussion to have. Because that patient with decay practically touching the pulp, if this is a Medicaid patient, were extracting the tooth. Just about every dentist I know will look at that and say, you know, lets take out all the decay we can without going into the pulp, put some medication on top of it and see if we can get some remineralization and leave it alone. Every patient that has insurance and money, they go, the best way of saving this tooth is to go into the pulp, take out the nerve, do a root canal, and put a cap on top of the tooth when Im finished. Longevity of teeth, the literature is quite clear, is almost identical. Who got the better treatment? That means to say, I would rather avoid having a root canal when possible. Ive sucked up a few of my own, its not that I hate root canals. You have to get them when you have to get them. But you need to look at what goes on with these. So what do we need to look at on these teeth first? Not only the depth of the lesion. What else do I need to know? Youre going to make a decision, youre going to excavate this tooth. This is a big difference between old type dentistry and new type. [student comment] Well, the risk, like what? The risk of recurrent decay. Any patient that has decay, we already know the risk is high. So that doesnt count. [student response] Uhhh.. how long theyve had the caries. [student, long response]. Oh, okay, I agree, if its slowly progressing or not progressing, thats a really good prognosis. But there are other things you want to know right away. Whats that? Uh, having many root canal therapies is probably a function of how many dentists theyve seen. [student talking]. Whats that? [student]. Ah! Tell me about the pain on the tooth. If this tooth hurts when I tap on it, what does that tell me? [student] Well, it tells me not that root canal. Root canal is one of the things that its saying. Somebody tell me! Give me three cardinal signs that this tooth needs root canal!! [student] Sensitivity to.. [student] cold! Percussion! What about hot? Hot, cold, percussion, spontaneous pain, mobility, all of these things. Hot alone is not a sign that it needs endo. But when you have a patient that presents saying, my tooth is sensitive to hot, its sensitive to cold, its sensitive to percussion, it spontaneously painful, it has mobility, what else do you want to look at? [student] Why mobility? What does a patient tell you as a tooth has started to become infected? One of the very, very common presentations. I cant bite on the tooth. Why? There is inflammation, the tooth is rising inside the socket, and you start to see the tooth actually developing an increased mobility. Its not periodontally induced mobility, but rather the tooth is now inflamed, its rising, its not in the bite properly and when you move it side to side, there is motion on the tooth. And when you tap on the tooth, it hurts the patient. So this tooth, when you look at it, before you anesthetize the patient, you have to assess this patient, whether or not its likely this tooth will need endodontic therapy. There is one other thing we use in this assessment. Somebody said it. What is it? Radiograph! I mean, look at this, there is a periapical area, you look at this, there is a draining fistula, any of the above tell me, I dont care how deep the decay is, Im heading toward endodontic therapy on this tooth. But, if the tooth is asymptomatic, what if the tooth is sensitive to sweets? [student]. Differentiate a tooth that is sensitive to cold, that might just be dentin hypersensitivity or a tooth that has a large cavity in it, and a tooth that is sensitive to cold that has a pulp that is starting to become heavily inflamed? [student] Well, sensitivity lingering sensitivity could be an indicator, but you know, when we did our dentin hypersensitivity patients, about 1/3 of them had pain that lingered after the air was removed. And we looked at those patients and they were no more likely at the end product to have, to have teeth that were non-vital over a 10 year period. [student] Hot, cold, sensitivity to percussion, blow air into this tooth. But blow air into the cavity preparation, into the cavity and the tooth is sensitive, does that surprise us? No, if I stick a sharp instrument in it, if I put sugar in it, any of the above will elicit pain. But if I blow cold air on a nice cusp of the tooth and the tooth is sensitive, thats not a good sign. Thats a tooth that is sensitive to air that has a, an inflammatory process going on in the nerve, likely to be a vital tooth or a non-vital tooth? I mean is it reversible or irreversible? Were blowing cold air on it and we get a sensitivity. It doesnt actually mean its a fatal event, even though there are many that would go into the pulp on it. But we want to know the pulp status on all of these teeth before we go treat them.

[37] Diagnosis Caries by Severity and Activity

So this terminology turns out to be dead.

[38] Smooth surface caries

We know that with this surface, perfect, almost perfectly intact, we see demineralization deep inside. So when a dentist cuts it open and says see, its demineralized and soft in here, doesnt mean anything. Because I can take this same surface, work on it and remineralize it and make the tooth less sensitive and unlikely to get decay. When we do our preparations specific to the lesion, you dont have to rip everything open and make everything conjoined and attached to each other. You can do small lesions that function well.

[39] What else is new in our surgical approach?

[40] Posterior Composite Restorations

You do not need to break facial and lingual contact. We can maintain them depending on where the decay is. The preparations are no longer made by rote coming out into the middle of the tooth or the middle of a fissure. The preparation is actually made dependent on where the caries is. So if the caries in this one is way to the lingual, dont be making this preparation all the way out to the facial corner because thats what the prep looks like. Thats not appropriate.

[41] Class II composite

Gingival contact must be broken, we talked about that.

[42] Lesion specific restorations

Lesion specific restorations, we talked about it.

[45] sealants

Um. You know, these are ugly. Theyre stained, we need to look at other items to determine whether or not this tooth what was used to determine whether there is caries on this tooth? Air, drying it is nice. But ok it still looks ugly like this. Bright light, air, were going to look for demineralization around the groove. How about a radiograph. If you see caries looking at a radiograph under the occlusal, there is significant decay on that tooth. So you shouldnt just look for aproximal lesions on teeth, especially teeth that have ratty occlusal surfaces like these. These teeth are now rated based on what we see in the fissures as the severity. You see this area here would need to be restored, but it only needs to be restored in that one area, you dont need to be ripping everything open.

[43-60] photos

[48] photo of old and new prep areas on max molar

This is from a 1990 article that a Dr. Lou Ripa, a pediatric dentist, and I had written together. And this is a GV Black preparation for those two carious lesions. But what we still should be doing today is opening them up, sealing the grooves. Less likely to get decay, just like GV Black recommended, but with a totally different material, so that we can do these in small pieces, restore these teeth up, and bring them into a comfortable position that theyre less likely to get decay in the future.

[50] Conservative Occlusal Composite restoration

So even in a case like this, these teeth right here have exposure down to dentin, and though we open these teeth up very large and wide, we never had to open up this groove, we never actually had to open up this groove. You could have sealed those in place. Get rid of these caries deep down in here. This clearly was deep decay. This is just way too aggressive in treatment. You cannot possibly treat this area by taking all of the caries out of the gingival margins. This is all decay. You can restore this one area, work on managing a local lesion. This is a much more difficult example.

[61] Treatment Modalities

We use different series of materials. Well talk about these materials in our next lecture so I wont spend much time talking about it,

[62] Resin modified glass ionomers/compomers

but I need you to recognize that glass ionomers, [he is skipping over slides but I dont know which ones because the podcast slides are behind]

[63] So whats the evidence?[64] Longevity?

[65] We have the clinical studies about anti-caries effect?

which were two decades ago, thought to be the panacea because they released fluoride, never turned out to reduce decay rates. And thats a real big issue and well talk about this shortly. How do you prepare this tooth? First, how did that caries get there? There was another tooth next to it. Caries under it. What is the likelihood of these caries continuing and advancing? Very small because weve removed the etiology. But if you chose to treat it, what surfaces do you need to treat here? Direct access. Mesial preparation. No need to rip open the occlusal surface. So the description of a Class II that is an MO is just not an appropriate description here. We treated this with a DO on this tooth, but the real truth about this discussion is there is nothing O about this lesion! It was all D. And if you do notice it, this is almost a classic, and I wish I had washed it before I took a photo, this is almost a classic example of minimal opening, spreading to the dentin, its that classic this is why we have to open things up and take a lot of tooth structure away. This area is dying and its dying in part because a number of different treatments that become available.

[69] Conservative Class II

So weve placed sealants on the occlusal, and in fact, in this particular tooth, you would open up the mesial, you, you look at how far facial this mesial, both of these preparations are. Has nothing to do with where the groove is. If I took my bur and started here and ran across, this lesion, this preparation would be much more to the lingual. Its just not necessary. In addition, there is no preparation of this. This is kind of ugly here. Its ratty and lurky [?] its got some demineralization but were not ripping opening open that occlusal surface on this. So, we restore this with lesion specific. Theres still some unsupported enamel in there that needs to be cleaned out, but overall that lesion is managed with a much more conservative fashion.

[71] ICON DMG

We will spend more time talking about a sealant called ICON. Its actually designed for smooth surfaces, and its actually a pretty incredible product. Lets see if we can make this. [he plays a video:] DMGs ICON is the first veer caries infiltration product. Caries infiltration offers a totally new treatment method for early caries lesions with non-cavitated enamel and a maximum radiographic lesion depth of out to the outer third dentin. If an aproximal caries is suspected, a bitewing x-ray provides a reliable indication of the location and extent of a potential lesion. Papillary bleeding on probing also indicates the diagnosis of active, proximal caries, needing treatment. Tooth number 3 has a clearly visible cavitation of the mesial lesion. Lets take the same tooth, number [he stops the video].[Wolff:] Why is papillary bleeding an indication of activity of the lesion? We mentioned it last meeting. Im not taking an answer from the front row. I need something from the masses, over there! Masses: why is papillary bleeding related to caries risk and activity? Go ahead! Everyone conference together, come together! Give me the big answer! Dont embarrass me; Dr. Phelan just came in, youve got to come up with an answer. Come on! Somebody sounds like go ahead, shout something out. Anything! Please, Im dying up here, help me. [student response]. Plaque build-up. Thank you, why was that so hard? You all new; it was too obvious. See everybody else knew it already and you were just holding out as a secret. So this presence of plaque tells us that theres activity in that area and if weve seen radiographic lesion, you can go ahead go further. Oh I didnt want to do that, and didnt want to do that either. Were really near the end. Dr. Phelan hang tight, weve got you. Well get you[continues playing the video:] Here, we have x-rays. This confirms our clinical findings.[Wolff:] So theyre taking early D lesions.[video:] caries has progressed into the middle of the dentin. This, unfortunately indicates that a conventional restoration is required. The lesion on the left tooth has not progressed so far. In this case, it can clearly be seen that the caries extends through the enamel, just into the dentin. Experience has shown that caries at this stage progresses quickly, so that intervention and treatment is strongly recommended.[Wolff: ] Well spend some time actually going over the technique in the next, probably in the next lecture. But I believe that this is a new technique that you will actually be using routinely in the clinic before you graduate dental school. Its currently in clinical trials right now. Um, the outcomes on it, the person who invented it has spoken here a couple of times. He has incredible results right now and if they actually pan out to be true, this is going to alter how we deal with D1, D2 lesions. Radically alter how we deal with them. Ok so theres unemployment. Um, today, we recognize... [digresses back to the $ thing:] and not really, youre going to be putting this stuff on there, its less painful, your patients will be happier to see you, youll see more patients, itll be a joy, everything will be wonderful, there will be peace on earth, good will to men, cats and dogs, living together. What movie is that from? Nevermind. Ghostbusters. You guys are terrible, youre just making me feel terribly old, and you should just not graduate dental school ever. These materials have changed where we treat dentistry, and whats interesting is back to GV Black, you know, GV Black felt that the longer we can make the filling last, the more likely we are to get good restorations out of a lifetime of a patient. And he also believe that eventually, and thats not formatted properly, sorry, he also believe that we had the possibility of actually using fluorides and other materials to help prevent tooth decay and change things. He just didnt know they even existed at the time. And that a fairly scary thing that a guy at his stage actually recognized all this and its taken dentists over 120 years to move away from GV Black. Your dentist practiced like GV Black. I dont know your dentist. The reason why I know it is that nobody in the 80s, 90s, into 2000 was practicing the theories we are teaching today about how to manage caries. Thats it. Any questions? I will send you the presentation shortly after leaving the room. I will see you on Friday for another, I think I have you for two hours. We are talking about aging and caries, and dental materials and caries, if I recall correctly.

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