perio handout

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9/24/2014 1 The Perio Tray is an FDA cleared, prescription medical device to place solutions of the dentist’s choice into the gingival sulcus or periodontal pocket. Flexible comfortable material for non-invasive delivery. The Perio Tray differs from other trays or mouth guards in that the flexible material is custom formed with specialized seals and extensions for the shape and depth of each pocket so that a gasket-like seal directs and maintains medication in the pocket long enough for medication to have therapeutic effect.

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Page 1: Perio handout

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The Perio Tray is an FDA cleared, prescription medical device to place solutions of the dentist’s

choice into the gingival sulcus or periodontal pocket. Flexible comfortable material for non-invasive

delivery.

The Perio Tray differs from other trays or mouth guards in that the flexible material is custom formed with

specialized seals and extensions for the shape and depth of each pocket so that a gasket-like seal directs

and maintains medication in the pocket long enough for medication to have therapeutic effect.

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Crevicular flow cleans out the pocket area 40 times per hour under healthy conditions and even more so when the pocket becomes infected

With the biofilms attached to the tooth and tissue, these areas become even more resistant to being flushed out

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In Vitro PEROXIDE GEL EXPERIMENT

Confocal micrograph, untreated control, 3 days in vitro Streptococcus mutans(S. mutans, strain UA 159) biofilm.

Confocal micrograph, 3 day in vitro S. mutans biofilm treated for 5 minutes with 1.7% hydrogen peroxide gel.

REPORT ON PEROXIDE GEL EXPERIMENT

Confocal microscope, S. mutans biofilm treated for 10 minutes with 1.7% hydrogen peroxide.

Confocal microscope, S. mutans treated with placebo gel without hydrogen peroxide.

10 minutes BID as maintenance….TID during treatmentSo When?

We recommend place them in prior to your am shower Then brush and do your regimen afterEvening time is easy but it can be when you watch TV or really when you wantClean with your toothbrush and waterClean with your toothbrush and water

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Fluoride gels with high cariesMI Paste with high caries patients or sensitivityVibramycin for antibiotic usage in the trays when you want alternatives or patient wants alternatives to systemicyTruly what you want in customized trays

An explorer….a probe….traditional x-rays

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Tell me, and I will forget.

Show me, and I will remember.

Involve me, and I will understand.

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It has been suggested that the majority of all plans that go untreated are a direct result of the patient’s lack of

understanding.

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15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

45 year old… 1 implant crown, 1 crown, 2 restorations on 3 and 14

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Visual diagnosis can be highly subjective, Kefley and Holt 1993Dentin involvement can occur under an intact enamel layer Pitts, 1997On X-ray, detecting occlusal decay is only when there is dentin penetration by 2-3mm due to the thickness of the x-ray having to penetrate buccal/lingually the thickest portion of the tooth. Bite Wing x-rays can identify inter-proximal lesions earlier because x-rays pass through a narrower part of th t th t th i iti it i till t ll tthe tooth yet their sensitivity is still not excellent

40-60% demineralization required to produce image

Underestimates size or depth

Insufficient to determine activity level

Low sensitivity39% occlusal50% interproximal

Bader et al 2001

70% of overall adolescents experience tooth decay, and far more in lower income families90% of caries in pit and fissures, and most are in molarsPit and fissures account for 12.5% of the surface area of a tooth and yet this is where 88% of caries occur

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The overall annual attack rate for caries for all occlusal first permanent molar surfaces is 5.9% per year, while the approximal surfaces is 1.3% in a representative

group of children, seven to fifteen years of age.

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Transference of infective S mutans to other sites?

62% sensitivity / low reliability

False positives & false negatives

Di i f l li i i i l f

Loesche et al, J Dent Res 1979Hujoel et al, Caries Res 1995

Lussi, Caries Res 1991

Disrupts intact surface layer, eliminating potential for reversal

Al-Sehaibany showed tug back by an explorer was only 24% diagnostic, meaning that 76% of the time that tug back was present, there was no caries!Ekstrand showed that a sharp explorer tip can damage an early de-mineralized white spot lesion of the enamel by cavitating the surface

.

15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

15 and 31 slight sticks…18 no stick…Do you Drill?What is the patient’s caries risk?What is the patient s caries risk?

What does the patient want?

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15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

6431 38

Yes…dark stained pits, DRILL or NOTYes…dark stained pits, DRILL or NOT to Drill?

Beginning EnamelC i

Deep Enamel CariesDentin Caries

Deep Dentin CariesSound Enamel1.5 2.0 2.51.0 > 3.0

“Doppler Radar” for Caries Detection

Analysis of Spectra images Color Scale and Diagnostic Value

Caries

A Picture is Worth a Thousand Words

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D0 – sound fissuresystem

D1‐D2 – EnamelCaries

D3‐D4 – Dentin Caries

Histological Clinical Analysis

Diss. Madani, 2004 Uni Jena

Caries Caries

Nomenclature of Dental Lesions

15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

Color Mapping with Air Techniques andColor Mapping with Air Techniques and Spectra

15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

I f d T h l C i i AdInfrared Technology…..Continuing to Advance

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15 Distal Occlusal Pit 31 Occlusal 18 Occlusal

Minimal preparations…well into enamel patient preferred to treat early and avoid shots and future work

Treatment with Equia or Low stress bulk fills or Activa

•Non stress bearing Class I & II restorations

•Deciduous teeth restorations

•Geriatric restorations

•Base / dentine replacement

•Cervical (Class V) restorations

•Core build up

•Temporary fillings

•ART (Atraumatic Restorative Technique)

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4137

No stick

Class 1’sInto DentinWithout major occlusal function

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Application of EQUIA Coat…

...30-50 µm of penetration in to EQUIA Fil to fill up porosities

…increases fracture toughness by 212%

…increases flexural strength by 72%

…increases flexural fatigue resistance

…protects from acid erosion

…improves aesthetics

…takes long to wear off (6 months or more)

EQUIA Fil

EQUIA CoatNo delamination layer at the interphase

EQUIA Coat filling up porosities

Depth of penetraition 30-50µm

EQUIA FilEQUIA Fil

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0,00

0,05

0,10

0,15

0,20

Fuji IX GP EXTRA Fuji IX GP EXTRA + G-COATPLUS

Aci

d e

rosi

on /

mm

Extra Protection

EQUIA Fil EQUIA Fil +

EQUIA Coat

199199

EQUIA Coat protects from acid erosion, important in High Caries Risk patients…

What happenswhen Coatingwhen Coatingwears off?

What happens when EQUIA Coat Wears off?The EQUIA restoration undergoes a unique maturation effect attributed to

saliva…

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0

500

1000

1500

0 20 40 60 80 100

Fluor

ide

rele

ase

/ μg

cm-2

Fuji Triage

Fuji II LC improve

Fuji IX GP FAST

Fuji Filling LC

EQUIA Fil

202

Once coating wears off, fluoride recharge cycle is initiated...

0 20 40 60 80 100days

0

20

40

60

80

100

120

1day 4 days 7 days 30 days 90 daysµm

GIC have high early wear ……… however due to maturation a long term wear similar to composite

Fuji IX Fuji IX GP Fast

I Pl d i 1984 I Placed in 1984

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207

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Chew the enclosed wax, thenspit to the A line

Add 1 drop of Reagent 1:Tap the container 15 timesp

Add 4 drops of Reagent 2:Shake until saliva sample turns green

Now Dispense 3 scales of saliva into the sample window and wait 15 minutes

The red arrow shows the pipetThe yellow arrow shows the plastic vehicle we use to mix Drops from Solutions 1 and 2 to mix prior to testingThe white plastic testing piece is h l S M how we evaluate Strep Mutans results

1. Identification of Antigenic Epitopes in an Alanine-Rich Repeating Region of a Surface Protein Antigen of Streptococcus mutans. N. Okahashi, I. Takahashi, M. Nakai, H. Senpuku, T. Nisizawa and T. Koga. Infection and Immunity, Apr. 1993, vol. 61, N°4:p.1301-13062. Rapid and quantitative detection of Streptococcus mutans with species specific monoclonal antibodies. W. Shi, A. Jewett, W.R. Hume. Hybridoma 1998;17:365-371.3. Simple and Rapid Immunoassay for the Estimation of Streptococcus mutans in Human Saliva. Y Matsumoto, N. Sugihara, M. Koseki, Y. Maki. Abstract –50th ORCA Congress, July 2-6, 2003, Konstanz, Germany4 Evaluation of Rapid Screening Test for S mutans Using Species specific 4. Evaluation of Rapid Screening Test for S. mutans Using Species-specific Monoclonal Antibodies. Y. Maki, N. Sugihara and M. Koseki. Abstract 2077–81st General Session of IADR, June 25-28, 2003, Goteborg, Sweden

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After placing Reagent 1 and taping the container 15 times4 Drops of Reagent 2 are then added to the solution and again mixed until the saliva turns greenThe solution is THEN placed into the orifice via the pipet and you wait 15 minutes

How do you customize their therapy?

Positive result - Either a faint or clear red line appearing means

there are over 500,000 cfu/ml of S. MUTANS.

Cariogenic biofilms thrive in acidic environments. These environments are partially created by eating and drinking certain foods.In order to fight mouth bacteria we need to work on the saliva as well as the surface of the teeth. By working on both aspects we can win the war of caries management.g

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Real time (Real time (15 15 second ) second ) inexpensive screening test inexpensive screening test for separating at risk from for separating at risk from low risk individualslow risk individuals

Cariscreen- Meter that when a swab with pellicle is placed inside , it can read the degree of cariogenicity of the patients biofilm.Depending on the reading, patient can be treated with their proprietary series of rinses.PH of the rinses are in the 8,9, and 10 range. Very basic to change the environment in the oral cavity.

(“Measurement of ATP Bioluminescence from Oral Bacteria Contained in Dental Plaque: Basic Sciences and Clinical Assessments for Testing of Caries Risk” by Drs. R. Sauerwein, J. Kimmell, T. Finlayson, S. Fazilat, P. Pellegrini, I. Kasimi, D. Covell, P. Gagneja, J. Engle, K. Kutsch, T. Maier, and C.A. Machida , representing [not in corresponding order], Department of Integrative Biosciences, Academic DMD Program and OCTRI Research Fellowship Program, Department of Pediatric Dentistry, and Department of Orthodontics, School of Dentistry, Oregon Health & Science University, Portland, and Oral Biotech)

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Systemic antibiotics

What will affect the population of a biofilm

What will not affect the population of a biofilm

Intense heat = 175 degrees FComplete mechanical debrasionChemotherapeutics

BrushingFlossing

Introduction and ScienceWhat is Dental Caries: The New Paradigm

pH Neutralization: Reduces growth and acid production of cariogenic bacteria, supports healthy oral bacteria growth

Antibacterial: Significantly reduces total bacteria levels when high levels are identified

Fluoride: Aids in remineralization and inhibits acid production of cariogenic bacteria

Xylitol: Reduces growth and acid production of cariogenic bacteria

Nano HA (Ca PO4): Aids in remineralization with nano particles of hydroxyapatite

Targeted TherapyWhat is CTx?

How the CTx Guide Applies to Products

Number of agents equals CTx Score

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CTx4 Treatment RinsepH NeutralizationAntibacterial (.2% sodium hypochlorite)Fluoride (0.05%)Xylitol (Greater than 10%)y ( )

3 Main Products

CTx4 Gel 5000pH NeutralizationFluoride (1.1% NeutralSodium Fluoride)HA Nano (Ca PO4)Xylitol (Greater than y10%)

CTx3 RinsepH NeutralizationFluoride (0.05%)Xylitol (Greater than 10%)

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Distributed exclusively by dental professionals Extra-strength blend of ProBiora3® crowds out harmful bacteria around teeth and gumsUse once daily for 90 days after a professional cleaning

ProBiora3 – Ingredient in branded products

professional cleaningExtends the benefits of a dental prophy

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For companion petsFreshens breath, cleans and whitens teethTasteless, odorless powderStrains weighted for gum healthhealth

ProBiora3 is the most comprehensive oral care probiotic technology available

Developed from research into dental caries and periodontal diseaseBlend of 3 naturally occurring Streptococcal strains – S. oralis, S. uberis,

S. rattus

ProBiora3 promotes:dental and periodontal healthwhiter teethfresher breath

Probiora3: Product Overview

ProBiora3 Marketed as Food IngredientSelf-affirmed GRAS status

ProBiora3 is safe and effective15 peer-reviewed publicationsProBiora3p p

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Competitive AdvantageStrong scientific basis for safety and efficacy

ProBiora3 is the first and only comprehensive oral care probiotic on the market

ProBiora3 – Competitive Advantage

The ProBiora3 contains a formulation of beneficial bacteria, found in naturally healthy human mouths.

S. oralis KJ3

S. uberis KJ2

S. rattus JH145S.rattus JH145 is a unique strain of streptococcus that does not produce lactic acid, and has been shown to successfully compete for nutrients and space on tooth surfaces withthe native strain of streptococcus that produces lactic acid.

ProBiora3 – How it worksA spontaneous lactacte dehydrogenase deficient mutant of Streptococcus rattus for use as a probiotic in the prevention of dental caries. Hillman JD, McDonell E, Cramm T, Hillman CH, Zahradnik RT. Journal of Applied Microbiology 2009 Nov;107(5):1551-8. Epub 2009 Apr 24)

ProBiora3 – How it works

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ProBiora3 – How it works

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Remin Pro supports remineralization.Remin Pro strengthens teeth.Remin Pro smooths tooth surfaces.Remin Pro neutralizes acids.Remin Pro desensitizes.Remin Pro tastes good.

Contains all ingredients ofnatural tooth substance...

Calcium ionsPh h i

hydroxyapatite- Phosphate ions

- Water/fluorides

y y p[Ca5(PO4)3OH]

• Remin Pro is ideal for

protective tooth care

Three Key Ingredients:

- Fluoride (1450 ppm) - Hydroxyapatite (Calcium and Phosphate) = natural tooth substance

X lit l ( t ith i t ti ff t)- Xylitol (non-sugar sweetener with cariostatic effect)

Natural tooth substance consists largely of hydroxyapatite (calcium and

phosphate).

It fills superficial enamel lesions and the tiniest irregularities that arise from

erosion.

Remin Pro adheres to the tooth substance and protects the tooth against

demineralization and erosion.

Smooths the surface by sealing dentin tubules.

A smooth surface impairs

the adhesion of bacterial plaque.

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Reduction of caries formation Sealing of tooth surfaces, desensitization Repair of incipient caries (remineralization) Delay of plaque formation and smoother surfaces Teeth whitening and gloss increase

Kani T, Kani M, Isozaki A, Kato H, Fukuoka Y, Ohashi T, Tokumoto T: The effect of apatitecontaining dentifrices on artificial caries lesions. I Dent Health 38, 364–366 (1988).

Okashi T, Kani T, Isozaki A, Nishida A, Shintani H, Tokumoto T, Ishizu E, Kuwahara Y, Kani, M: Remineralization of artificial caries lesions by Hydroxyapatite. I Dent Health 41, 214 – 223 (1991).

Nishio M, Kawamata H, Fujita K, Ishizaki T, Hayman R, Ikemi T: A new enamel restoring agent for use after PMTC Posterpresentation 82nd General Sessionrestoring agent for use after PMTC. Posterpresentation 82nd General Session & Exhibition of the IADR / March 2004.

Kawamata H, Nishio M, Fujita K, Ishizaki T, Hayman R, Ikemi T: Posterpresentation 82nd General Session & Exhibition of the IADR / March 2004.

Yamagishi K, Onuma K, Suzuki T, Okada F, Tagami J, Otsuki M, SenawangseP: Materials chemistry: A synthetic enamel for rapid tooth repair. Nature. 2005 Feb 24; 433 (7028): 819.

Sugar substitute comes from the Xylitol portion of a plant.Cannot be metabolized by acid producing cariogenic bacteria.Excreted as whole molecule. Natural population shift to helpful bacteria.6- 10 grams per day.Potentially toxic to dogs.Xlear, Dr. John’s candies, Xylitol USA

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The Glucose is absorbed by the Strep Mutan the Glucose then goes through a metabolic breakdown and ultimately gets excreted as acids and thus the pathway to caries

Xylitol gets absorbed by the Strep Mutans, occupies or keeps the Strep Mutans busy but DOES NOT get broken down, and is excreted in whole…

After short and long-term use, xylitol significantly reduces the amount of Strep Mutans in plaque and saliva. The growth of lactobacilli is reduced during long-term use of xylitol. Xylitol shows effects which promote tooth remineralization.Xylitol actively prevents acid production in dental plaque (enamel dissolves when the pH decreases below 5.7). Regular xylitol consumption reduces the adhesive property of plaque, making it easier to brush off.

http://www.ncbi.nlm.nih.gov/pubmed/12693818 An overview of studies about xylitol and dental caries Mäkinen K.K. The rocky road of xylitol to its clinical application. J. Dent. Res. 2000; 79: 1352. Lynch H, Milgrom P. Department of Dental Public Health Sciences, Northwest/Alaska Center to Reduce Oral Health Disparities, University of Washington, Seattle 98195-7475, USA. Xylitol and dental caries: an overview for clinicians. J Calif Dent Assoc. 2003 Mar;31(3):205-9. K.K. Mäkinen, K.P.Isotupa, T. Kivilompolo, P.L. Mäkinen, J.Toivanen, E. Söderling. Comparison of Erythritol and Xylitol Saliva Stimulants in the Control of Dental Plaque and Mutans Streptococci. Caries Research 2001;35:129-135. Kandelman D., Gagnon G. A 24-month clinical study of the incidence and progression of dental caries in relation to consumption of chewing gum containing xylitol in school preventive programs. J. Dent. Res. 1990; 69: 1771. Kauko K. Mäkinen, MS, Phd, Kauko P. Isotupa, DDS, Taina Kivilompolo, RDH, Pirkko-Liisa Mäkinen, MS, PhD, Satu Murtomaa, DDS, Juhani Petäjä, DDS, Jukka Toivanen, DDS, Eva Söderling, MS, PhD. The effect of polyol-combinant saliva stimulants on S. mutans levels in the plaque and saliva of patients with mental retardation. Special Care Dentistry 2002; 22(5): 187-193. Isotupa K.P., Gunn S., Chen C.Y., Lopatin D., Mäkinen K.K. Effect of polyol gums on dental plaque in orthodontic patients Am. J. Orthod. Dentofac. Orthop. 1995; 107: 497. Mäkinen K.K., Bennett C.A., Hujoel P.P., Isokangas P., Isotupa K.P., Pape H.R. Jr., Mäkinen P.-L. Xylitol gums and caries rates: A 40-month cohort study. J. Dent. Res. 1995; 74: 1904. Autio J.T., Courts F.J. Acceptance of the xylitol chewing gum regiment by preschool children and teachers in a Head Start program: a pilot study. Pediatr. Dent. 2001; 23:71. Autio J.T. Effect of xylitol chewing gum on salivary streptococcus mutans in preschool children. ASDC J. Dent. Child. 2002; 69: 81-6, 13. Alanen, P., Holsti, M.-L., Pienihäkkinen, K. (2000) Sealants and xylitol chewing gum are equal in caries prevention. Acta Odontol. Scand. 58:279-284 284. Caufield, P.W., Cutter, G.R., Dasanayake, A.P. (1993) Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J. Dent. Res. 72:37-45. Trahan, L. (1995) Xylitol: a review of its action on mutans streptococci and dental plaque – its significance. Int. Dent. J. 45:77-92. Scheinin, A., Mäkinen, K.K. (1971) The effect of various sugars on the formation and chemical composition of dental plaque. Int. Dent. J. 21:302-321. Scheinin, A., Mäkinen, K.K. (1972) Effect of sugars and sugar mixtures on dental plaque. Acta Odontol. Scand. 30:235-257. Scheinin, A., Mäkinen, K.K. (1975) Turku Sugar Studies I-XXI. Acta Odontol. Scand. 33 (Suppl. 70):1-349. Isokangas, P. (1987) Xylitol chewing gum in caries prevention. Academic Dissertation, University of Turku. Isokangas, P., Mäkinen, K.K., Tiekso, J., Alanen, P. (1993) Long-term effect of xylitol chewing gum in the prevention of dental caries: a follow-up 5 years after termination of a prevention program. Caries Res. 27:495-498. Mäkinen, K.K., Bennett, C.A., Hujoel, P.P., Isokangas, P.J., Isotupa, K.P., Pape, H.R., Jr., Mäkinen, P.-L. (1995) Xylitol chewing gums and caries rates: a 40-month cohort study. J. Dent. Res. 74:1904-1913. Hujoel, P.P., Mäkinen, K.K., Bennett, C.A., Isotupa, K.P., Isokangas, P.J., Allen, P., Mäkinen, P.-L. (1999) The optimum time to initiate habitual xylitol gum-chewing for obtaining long-term caries prevention. J. Dent. Res. 78:797-803.

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• With the finger

• Using a soft toothbrush

• Plaed in a tray

Recaldent- Casein phosphopeptide (CPP)- amorphous calcium phosphate (ACP)Unique chemical in that it is substantive with a 3 hour half lifeMI Paste +----5 Calcium,3 phosphate,1 Fluoride—Ideal biochemical ratio to drive remineralization. Made from a milk protein, so contraindicated in patients with true milk allergy.OK for patients who are lactose intolerant OK for patients who are lactose intolerant Caution with young children.

• Two Components1. ACP:Amorphous Calcium Phosphate2. CPP: Casein Phosphopeptide – natural

occurring molecule• Milk Protein• Protects the ACP component• Delivery vehicle• Very sticky

Functions:

CPP-ACP attached to strep mutansmaking them non-viable

252

– Remineralization– Desensitization

What is RecaldentTM (CPP-ACP)?

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Molecular model of the CPP-ACP complex. Casein phosphopeptide (CPP) is a milk derived protein able to bind calcium and phosphate ions and stabilize them as Amorphous Calcium Phosphate (ACP).

ACP alone does not remain stable enough for effectivelong-term remineralization*

253

g

*Cross KJ, Huq NL, Reynolds EC. Casein phosphopeptides in oral health—chemistry and clinical applications. Curr Pharm Des. 2007;13:793-800.

CPP-ACP is added to the oral cavity.The ‘sticky’ CPP part binds readily to enamel, pellicle, plaque and soft tissue

254

H+

H+

H+H+

Under acidic conditions, RecaldentTM is able to release Calcium and Phosphate ions

255

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256

The free Ca and P ions move out of the CPP, enter the enamel rods and reform into apatite crystals

• Helps to maintain a state of super-saturation of Calcium and Phosphate ions on the tooth surface

• Depressing enamel demineralization• Buffers plaque pH• The longer CPP-ACP is maintained in the mouth, the more effective the

result

RecaldentTM is the ‘fluid enamel’which restores mineral balance

257

Improved Plaque Uptake and Enamel Remineralization by Fluoride with CPP-ACPE C Reynolds, N.J. COCHRANE, P. SHEN, F. CAI, G.D. WALKER, M.V. MORGAN, and C. REYNOLDS, Cooperative Research Centre for Oral Health Science, School of Dental Science, The University of Melbourne, Victoria, Australia Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has been shown to slow the progression of caries and to remineralize enamel subsurface lesions. Objectives: The aim of the studies was to determine the ability of CPP-ACP to increase the incorporation of fluoride into supragingival plaque and to promote enamel remineralization in situ with acid resistant mineral. Methods: Randomized, double-blind cross-over studies were designed involving three mouthrinses and five toothpastes as follows: Mouthrinses (i) 2% CPP-ACP, (ii) 2% CPP-ACP plus 450 ppm F and (iii) 450 ppm F; and Toothpastes: (i) placebo, (ii) 1100 ppm F, (iii) 2800 ppm F, (iv) 2% CPP-ACP and (v) 2% CPP-ACP plus 1100 ppm F. The mouthrinses (15 ml) were used for 60 s, three times per day for 5 d and supragingival plaque collected and analyzed for F content. The toothpastes (1 g) were added to 4 ml water to form a slurry and used for 60 s four times per day for 14 days in an in situ remineralization model. Results: The addition of 2% CPP-ACP to the 450 ppm F rinse significantly increased the incorporation of fluoride ions into plaque where the plaque fluoride level (33.0±17.6 nmol/mg dry wt) was over double that obtained with the fluoride-only rinse (14.4±6.7 nmol/mg dry wt). Fluoride in the toothpaste slurry produced a dose-response related remineralization of subsurface enamel lesions. The toothpaste containing 2% CPP-ACP produced a level of remineralization (13.5%±1.5%) similar to the 2800 ppm F paste (15.5%±2.4%) and the paste containing 2% CPP-ACP plus 1100 ppm F was superior (21.0%±5.9%) to all other formulations in enamel lesion remineralization. Acid challenge of the remineralized lesions showed that the CPP-ACP/F mineralized lesions were relatively acid resistant.

Conclusion: CPP-ACP promotes the incorporation of fluoride Conclusion: CPP-ACP promotes the incorporation of fluoride into plaque and sub-surface enamel producing effects superior to fluoride alone.

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Reduces sensitivityDecreases or eliminates white spotsAssists in Caries management

Children with cavitations and positive caries tests Children undergoing orthodontics.Adults with positive caries tests and cavitationsPeople with sensitive teethPeople taking medications that alter quantity and quality of salivaPeople undergoing a lot of restorative Dentistry.p g g y

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262

Documentation and progession control.

263

Before treatment (cleaning) After treatment (cleaning)

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HCL Acid etch of all the teeth.Prema- PremierOpalustre- Ultradent

Brown & white enamel demineralization

PREMA® is applied using 10:1 reduction angle – slow speed

After a 14-day take home whitening treatment

Immediately after PREMA® treatment

Approximately 15 seconds per tooth- open the enamel pores.

Following this a 37% phosphoric acid is applied to the teeth for 30 seconds.After rinsing it off, Remin Pro( MI Paste), is applied in the office for 5 minutes.This can be achieved with a gloved finger and leaving the cream in place or with a gloved finger and then placing the tray over the cream.Patient is sent home and told to wear the trays as much as possible daily with the cream in place.

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37% Phosphoric acid for 30 seconds followed by 5 minutes of therapeutic cream.This is done weekly till 50-60% remineralization is seen.Now Pola Night (10% for kids or Pola Day CP 35% for adults) is added to the protocol daily for ten days.Continue etch/cream protocol till desired result is / pachieved

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Futurabond® U

The Dual-Cure Universal Adhesive!

.

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self-etch

selective-etch total-etch

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MI Paste in a bleaching tray for as long as she can wear it everyday. (Homework)

Pola night — 15% started at week 8 for 2 weeks.

Continued with MI Paste

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