Online Continuing Education / Course Details

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Technique Guide to Basic Layering with an Omnichromatic Universal Composite

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this course, the reader should be able to:

•  Discuss how and when to use an omnichromatic composite

•  Explain the importance and uses of block out with traditional and omnichromatic composite

•  Describe the traditional concepts of composite shade selection.

Abstract

For decades, dentistry has recognized the need to block out (cosmetically mask) deep stains and lingual deficiencies in tooth structure to prevent unsightly show-through. This paper describes past and present concepts in composite resin in general and blocking out in particular. In addition, the paper reviews both the historic and current literature regarding shade selection and multiple shade composite resin systems are described. Use of an omnichromatic composite is detailed, with case reports focusing on its use with its associated blocker. We conclude that in many instances in cosmetic restorative dentistry it is possible to eliminate multiple shades of composite, replacing them with just one omnichromatic shade and, when needed, its associated blocker. 

COMMERCIAL SUPPORT This educational activity is made possible through an unrestricted educational grant from Tokuyama

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 108 of 109

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10 Factors In Avoiding Damage to Dental Handpieces

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Date: 06-24-2020 08:32:26 am

Tired of Handpiece Breakage? Here Are 10 Helpful Tips...                            





10 Factors

In Avoiding Damage to
Dental Handpieces​

 
 
 
 

1

Never use chemicals of any sort unless specifically indicated

 

2

Never use soaps during cleaning unless indicated,and if soap is indicated, don’t use one containing chloride

3

Never use pre-soak or immerse in any liquid, including water, holding solutions, or liquid chemical sterilant-disinfectant

 

4

Never leave the low-speed attachment and motor attached to each other when reprocessing

       

5

Never leave a bur in the attachment during cleaning

6

Never have a bur/dummy bur in  the attachment during autoclaving unless specifically indicated in the instructions for reprocessing

7

Never autoclave motors and  attachments at higher reprocessing temperatures or different cycles than recommended by the manufacturer

8

Never use a dry heat sterilizer as the higher temperatures will degrade resins and plastics

 

       
 

9

Never

use a chemiclave

10

Never skip indicated
lubrication

 
       


 

 

Article 24 of 24

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

State of the Art of Universal Adhesives

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this webinar, participants will be able to:
» Assess which bonding technique is better (total-etch, self-etch or selective-etch) and why
 
» Apply a universal bonding agent in any of the above mentioned bonding techniques
 
» Answer the questions, "Are all universal adhesives truly universal?" and "Are all universal adhesives designed to bond to all surfaces?"

Abstract

The dental market has a vast array of adhesive systems available for the clinician, which can seem overwhelming at times. This CE webinar will cover the benefits of switching to a universal bonding agent and the clinical impact that this change will have on all bonding protocols to the tooth structure as well as other restorative surfaces.

Supported through an unrestricted educational grant from BISCO

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 102 of 109

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Super, Gorilla, or Elmer’s? Which Glue for Zirconia Adhesive Cementation – Why and When?

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

View Video

Educational Objectives

After completing this webinar, participants will be able to:
»     Perform enhancing zirconia preparations for crowns and bridges 

»     Identify when to use self-adhesive regenerative resin cementation 

»     Maximize adhesion for zirconia and when to use it

Abstract

Clinicians most often choose materials that are aesthetic, durable, and comfortable with zirconia a large percentage of indirect restorations today. Proper preparation and cementation techniques are undeniably related to long term restoration success. When the preparation is less than ideal or functional stresses high, there has been a substantial amount of dentist who have had zirconia restorations become un-cemented or broken. There has been considerable confusion about how to improve the bond and retention with zirconia. This course will discuss the best techniques for routine cementation and for those times when maximum adhesion is necessary.

Supported through an unrestricted educational grant from BISCO

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 98 of 109

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Bioactive Materials A Clinical Perspective

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this course, participants will be able to understand the concepts of bioactive materials, as well as be able to:
1. Define bioactivity and how it relates to dentistry
2. Understand the history of bioactivity related to dentistry
3. Understand the science behind various bioactive approaches and experimental research
4. Identify the potential benefits of bioactive materials
5. Incorporate bioactive therapy in a clinical restorative setting.

Abstract

Modern bioactive dental materials are pushing the science and art of dentistry to new heights. Techniques and materials are evolving, and the paradigms of treatment have shifted from replacement of tooth and bone structures to actively inducing the human body to work in conjunction with engineered materials to deliver better health outcomes. This article will review the history and development of bioactive materials and include some of the exciting new treatment modalities of modern clinical practice.

COMMERCIAL SUPPORT This educational activity is made possible through an unrestricted educational grant from Apex Dental Materials.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 94 of 109

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Bioactivity in the Field of Dentistry

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Date: 05-07-2020 14:24:58 pm

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Bioactive materials have long been used in medicine. Since the invention of 45S5 Bioglass by Dr. Larry Hench, they have evolved and taken on many applications. Before the invention of Bioglass, biomaterials were generally meant to be inert when in contact with body fluids and anatomical structures; however, 45S5 Bioglass changed the game by providing an alternative to graft materials that was active and bonded to bone and released biologically active ions to promote osteogenesis.1 Since then, biocompatibility has evolved to include second-generation materials that can elicit a controlled action/reaction in a biological setting and third-generation materials that stimulate a cellular response at a microbiological level.2 Fourth-generation biomaterials are aiming to use bioelectricity to alter signals to regenerate tissue, monitor cellular responses, and allow for communication with host tissues.3

After its creation in the late 1960s, 45S5 Bioglass found an array of applications in medicine and dentistry. Its first clinical implant application in the United States was to replace bones in the middle of the ear to treat hearing loss and was marketed under the names “Bioglass Ossicular Reconstruction Prosthesis” or “Middle Ear Prosthesis.”1 Not long after, Bioglass found its way into dentistry. Its first commercial dental application was the endosseous ridge maintenance implant. This device, marketed in 1988, was used to replace the roots of teeth after extraction and provide support for prosthetic replacements such as dentures.1 This advancement eventually led to the development of products such as PerioGlas (used to repair bone defects in the jaw and help regenerate bone around a tooth root) and NovaBone (used not only to repair bone defects in the jaw, but also for orthopedic applications in certain sites).1 Over the past decades, these materials have found more acceptance in both fields. Medical applications included everything from skeletal muscle repairs to aiding in cancer treatments; dental use expanded from bone regeneration to remineralization of tooth structures, decreased dental hypersensitivity, and improved cements.

Since its Food and Drug Administration approval in 1985 until 2016, Hench’s original 45S5 Bioglass is estimated to have been implanted in 1.5 million patients to restore bone and repair dental defects.1
This article will focus on dental use of bioactive glasses (and bioactive materials in general) and how these products can positively impact patient care.

Fluoride-releasing Materials

The concept of bioactivity in dentistry has been around for decades. One of the earliest forms can be found in ion-releasing compounds to aid enamel remineralization and prevent primary and secondary caries. One ion shown to have this effect is fluoride. When fermentable sugars are found in the mouth, bacteria in plaque metabolize these sugars, resulting in byproducts (particularly lactic acid) that can break down hydroxyapatite and increase demineralization.4 This throws off the balance of demineralization/remineralization in favor of the former, resulting in tooth decay. Fluoride induces remineralization and promotes the mineral phase of the tooth, inhibiting tooth decay.4 It is no wonder this ion has found its place in various dental products and is the focus of many clinical trials and studies.

One application in which fluoride-releasing materials have been extensively investigated is sealants and their contribution to dental caries prevention, with many studies showing promising results. For example, in a study by Lobo et al, investigators evaluated sealants and their effect on enamel demineralization, with a focus on physical protection by the sealant and the effects of fluoride on neighboring enamel. This study, conducted at the Piracicaba School of Dentistry in São Paulo, Brazil, consisted of taking 48 impacted, caries-free human third molars and randomly allocating them into four groups: no sealant (control), resin modified glass ionomer (RMGI) sealant, fluoride-releasing composite sealant (FRCS), and nonfluoridated composite sealant (NFCS).5 An area of the occlusal surface 3 mm long x 4 mm wide (with the central groove in the center) and a square window 4 mm x 4 mm on the buccal were outlined on each tooth. Each sealant group was then subjected to a five-day pH cycling regimen to mimic a high caries environment, while the control group was kept in a stable, moist environment at 37° C. The following variables were then evaluated: fluoride uptake in the buccal window, fluoride release by the sealant, and cross-sectional microhardness.

This study found that the RMGI sealant group exhibited higher levels of fluoride release, greater uptake by neighboring enamel, and diminished demineralization, while the FRCS group showed reduced demineralization on unsealed enamel and delivered fluoride uptake in areas of enamel away from the sealant.5 The authors postulate that the lack of demineralization on sealed enamel, regardless of material used, was a testament to the protection created by the “physical barrier” provided by the sealant, while demineralization reduction in areas of enamel surrounding RMGI was a result of its superior fluoride-releasing capability.5

Despite findings showing the effectiveness of fluoride-releasing sealants, several studies have shown conflicting results. For example, a systematic review and meta-analysis conducted by Alirezaei, Bagherian, and Sarraf Shirazi failed to show this purported benefit. In this review, the investigators performed a search of PubMed, Scopus, Embase, the Cochrane Library, and the Scientific Information Web of Knowledge using the same key search words. They performed their final search on September 20, 2017, and did not have time or language exclusions. Two investigators, both in the field of pediatric dentistry, independently reviewed/selected articles, and in the case of a disagreement, a third-party reviewer was brought in if necessary. After initially finding 2,411 studies, the authors removed studies that did not fit the desired criteria and ultimately included 31 studies—16 with a low risk of bias and the remaining 15 with a medium risk.6 The investigators completed two independent analyses of the included studies and found no difference in the percentage of caries formation when using glass ionomer cements (fluoride-releasing) compared to resin-based sealants (nonfluoride-releasing); however, they did find a higher retention rate favoring resin-based sealants.6

The use of fluoride-releasing materials in dentistry is not exclusive to sealants; they are commonly used as cements, buildup materials, and permanent restorations (cervical restorations in particular). For instance, glass ionomers can be used as restorations, particularly in pediatric dentistry and when employing the atraumatic restorative treatment technique.4 These materials are calcium or strontium fluoro aluminosilicate glass powder–based and can release ions such as fluoride, calcium, and phosphate.4 Fluoride release by these materials is not only immediate, but also has been shown to last for up to several years. In fact, these compounds can undergo “fluoride recharge” and take up fluoride ions under certain conditions, such as by exposure to other fluoridated substances, which may contribute to their long-term effectiveness.7 The ions released by glass ionomers form sturdy bonds with tooth structure; however, these types of restorations generally are not as esthetic as other available restorative materials, and thus are not commonly used for restoring permanent dentition.4

RMGIs combine the bioactive properties of glass ionomer with a more esthetic restorative result. They are similar to glass ionomer in that they form adhesive bonds to enamel and dentin while releasing fluoride, but possess the organic monomer 2-hydroxyethyl methacrylate (HEMA),8 which allows for greater strength of the set material. However, if not cured properly, RMGIs release increased amounts of unpolymerized HEMA and negatively impact biocompatibility by diffusing through dentin and potentially adversely affecting the pulp. Clinicians should always follow manufacturer curing time guidelines.Dental professionals also should be careful when handling materials with HEMA because exposure to unprotected skin can lead to allergic reactions.8 However, when Nicholson and Czarnecka reviewed the biocompatibility of RMGI cements for dentistry, they found that despite the potential hazard to dental personnel, “no reports” appear in the available literature (as of the date of publication) of “acrylate allergy” linked to the specific use of RMGIs.<span class=">8 Giomers are another material option with ion-releasing abilities. These materials are similar to flowable composite but contain prereacted glass ionomer as part of their filler.4,9 As with glass ionomers and RMGIs, giomers contain both fluoride-release and recharge capabilities, but also have the added advantages of superior esthetics, strength comparable to resin, and improved polishability.9 Giomer fluoride release also has been linked to antibacterial properties.4 These materials release ions such as sodium, borate, and aluminum; however, they do not release calcium or phosphate ions and are unable to form hydroxyapatite to assist in tooth structure regeneration.

Regardless of the often-ambiguous findings on the extent of fluoride release and reuptake by varying bioactive materials, fluoride can aid enamel remineralization and prevent caries. More studies are needed to assess the true effectiveness of ion-releasing biomaterials on dentition. As the physical attributes and capabilities of materials improve, the desired results may become more evident. For example, the use of RMGIs and even fluoride-releasing composites have helped address retention shortcomings experienced by previously used sealants while adding the purported benefit of fluoride release.5

Calcium-based Materials

Various dental biomaterials use different compounds as the basis for their respective bioactivity. For instance, many bioactive materials are either calcium silicate– or calcium aluminate– based. Calcium silicate cements came on the dental scene as a root restoration material used

in endodontic therapy, the first of which was mineral trioxide aggregate (MTA).10 This material is similar to Portland cement, which is a common type of cement and a basic ingredient of concrete and stucco. MTA consists of tricalcium and dicalcium silicates and was seen as an attractive dental material because of its hydraulic nature; endodontic restorative materials need to be effective in a wet environment.10 Bismuth oxide was added to MTA to provide radiopacity, allowing clinicians to see it in radiographs.

MTA has been shown to exhibit antifungal and antibacterial activity (purportedly due to its alkaline pH), and some studies have found that calcium hydroxide formation and deposition of a hydroxyapatite-like substance contribute to its biocompatibility.10 Due to these favorable attributes, MTA has found dental applications other than root end replacement. It has been used as a root canal sealer, pulp capping material, pulpotomy dressing, and during apexification of developing teeth.10 Other variations of calcium silicate–based biomaterials (for example,

BioAggregate) lack calcium aluminate, have added components such as hydroxyapatite, and show antibacterial characteristics similar to MTA.10 Tricalcium silicate–based materials (for example, Biodentine) offer the biocompatibility of MTA but have a faster set time that allows for more clinical indications, such as restoring large coronal or cervical caries, in addition to typical MTA indications.10

Calcium aluminate-based biomaterials also have been used in dentistry due to their bioactive properties. Examples of such materials include a hybrid luting cement, direct restorative cement,and use in endodontic treatment similar to MTA.11 Like its calcium silicate-based counterparts, this material mainly is used in construction but has gained popularity in dentistry, and some research has found that it possesses physical properties, such as microhardness and compressive strengths, that may be superior to MTA.11 Evidence exists demonstrating its ability to form hydroxyapatite. Lööf et al. conducted an in vitro study to compare the bioactivity of two calcium aluminate cements (one in which calcium was the only active substance; the other a hybrid with a glass ionomer) with a traditional glass ionomer cement.12 In this study, the three materials were submerged in a phosphate-buffered saline at 37° C for the following amounts of time: 1 hour, 1 day, 7 days, and 4 weeks. The saline was changed on a weekly basis, and samples were removed from the solution at their designated time, at which point they were rinsed with distilled water and stored in a desiccator for at least 7 days before analysis. The samples were then analyzed by grazing incidence x-ray diffraction, a transmission electron microscope, a scanning electron microscope, and energy dispersive spectroscopy. The investigators found that the calcium-based cement demonstrated bioactivity by formation of hydroxyapatite on its surface, with its detection taking only 24 hours. The hybrid cement also displayed bioactivity, but hydroxyapatite formation was detected after 7 days. No bioactivity was detected with the glass ionomer control.12

Bioactive Glasses in Restorations

At the beginning of this article some potential dental applications of Bioglass and other bioactive glasses were discussed. It should be no surprise that modern restorative dentistry is seeing a trend of incorporating bioactive glass into its restorations and cements as well. Although different compositions and structures of glass result in varying properties, bioactive glasses generally exhibit bioactivity by not only forming bone-like apatite layers in physiologic environments, but also by stimulating bone formation.13 Bioactive glasses are known to cause calcium phosphate precipitations, and studies have suggested that they can be used to remineralize damaged dentin.13 For instance, in a study by Prabhakar et al., investigators added bioactive glass to glass ionomer and RMGI cements to examine its effect on demineralized dentin. Eighty caries- and restoration-free permanent mandibular premolars were obtained, and standardized Class V preparations were made on the buccal and lingual surfaces of each tooth. The teeth were then split into 4 groups of 20 teeth each and exposed to pH cycling to mimic carious conditions. The teeth were then sectioned, prepared, and restored with their respective materials. The remineralization and microhardness were evaluated by means of an imaging system (as described for demineralization) and a microhardness tester, respectively.13 The results of this study showed that adding bioactive glass to the glass ionomer and RMGI cements resulted in “significant remineralization,” with the RMGI hybrid not only showing the highest bioactivity and remineralization, but also a calcium phosphate–like precipitation on the specimen surface.13 Although the addition of bioactive glass to the glass ionomer cement had a positive effect in the form of remineralization, it compromised the surface hardness, but only to a limited extent.

Materials that contribute to remineralization can have broad dental applications. For instance, in addition to their proposed use as restorative materials, bioactive glasses are being investigated to battle white spot lesions during orthodontic treatment because of their remineralization capabilities. In addition, bioactive glasses have demonstrated antimicrobial characteristics (presumably due to their alkalinity), with no discovered resistance.14 Also, bioactive glasses have the potential to aid in reducing tooth sensitivity by occluding dentinal tubules via hydroxyapatite deposition and binding to collagen fibers.14 These capabilities make bioactive glass materials particularly interesting not only as a restorative option, but also for their potential in everything from teeth whitening to endodontic treatment to implant dentistry.

Conclusion

The concept of bioactivity has been present in healthcare for decades and does not appear to be going anywhere soon. In fact, its presence will likely be felt more as time goes on. As technology advances, so do biomaterials. Clinical studies and research will lead the way in creating products that will not only integrate with anatomical structures but also help them further regenerate. From fluoride release to the development and evolution of bioactive glasses, the field of dentistry seems poised to benefit from this expansion and growth. With indications in nearly every dental specialty, bioactive materials may in fact become the new norm in modern dentistry.

 References

1.    Baino F, Hamzehlou S, Kargozar S. Bioactive glasses: Where are we and where are we going? J Funct Biomater. 2018;9(1):25.

2.    Hench LL, Polak JM. Third-generation biomedical materials. Science. 2002;295(5557):1014-17.

3.    Ning C, Zhou L, Tan G. Fourth-generation biomedical materials. Materials Today. 2016;19(1):2-3.

4.    Nicholson J. Fluoride-releasing dental restorative materials: An update. Balk J Dent Med. 2014;18(2):60-9.

5.    Lobo MM, Pecharki GD, Tengan C, et al. Fluoride-releasing capacity and cariostatic effect provided by sealants. J Oral Sci. 2005;47(1):35-41.

6.    Alirezaei M, Bagherian A, Sarraf Shirazi A. Glass ionomer cements as fissure sealing materials: Yes or no? A systematic review and meta-analysis. J Am Dent Assoc. 2018;149(7):640-9.

7.    Bayrak S, Tunc ES, Aksoy A, et al. Fluoride release and recharge from different material used as fissure sealants. Eur J Dent. 2010;4(3):245-50.

8.    Nicholson JW, Czarnecka B. The biocompatibility of resin-modified glass-ionomer cements for dentistry. Dent Mater. 2008;24(12):1702-8.

9.    Kimyai S, Savadi Oskoee S, Ajami AA, Sadr A, Asdagh S. Effect of three prophylaxis methods on surface roughness of giomer. Med Oral Patol Oral Cir Bucal. 2011;16(1):e110-4.

10.  Jefferies SR. Bioactive and biomimetic restorative materials: A comprehensive review. Part 1. J Esthet Restor Dent. 2014;26(1):14-26.

11.  Garcia L. Calcium aluminate based-cements for endodontic application. JJ Dent Res. 2014;1(2):008.

12.  Lööf J, Svahn F, Jarmar T, et al. A comparative study of the bioactivity of three materials for dental applications. Dent Mater. 2008;24(5):653-9.

13.  Prabhakar AR, Jibi Paul M, Basappa N. Comparative evaluation of the remineralizing effects and surface microhardness of glass ionomer cements containing bioactive glass (S53P4): An in vitro study. Int J Clin Pediatr Dent. 2010;3(2):69-77.

14.  Skallevold HE, Rokaya D, Khurshid Z, Zafar MS. Bioactive glass applications in dentistry. Int J Mol Sci. 2019;20(23):5960.

 

About the Author

Christopher Canizares, DMD

Christopher Canizares is currently practicing orthodontics in Rome, New York. He completed his specialty training at NYU Langone Health’s Advanced Education Program in Orthodontics and Dentofacial Orthopedics. He received his DMD from Boston University Henry M. Goldman School of Dental Medicine and completed a General Practice Residency at Montefiore Medical Center before practicing general dentistry for 5 years.

 

Dr. Canizares can be reached at canizares.christopher@gmail.com

Whitepapers 2 of 2

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

FLUORESCENCE-ENHANCED “THERAGNOSIS” for Minimally Invasive Caries Management

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Email

Educational Objectives

The overall goal of this course is to provide an introduction to fluorescence-enhanced therapy and diagnosis for minimally invasive caries management to maximize hard tissue preservation in the patients’ best interest. The tool, called Reveal, which visualizes the phases of caries, is a loupe and light combination that shines fluorescent light onto teeth under a specified magnification so probing and radiography no longer need to be the only methods of diagnosis. At the conclusion of this course, participants will be able to:
 

  1. Understand the difference between “classic” caries lesion diagnosis and fluorescence-enhanced therapy and diagnosis
  2. Conceptualize minimally invasive caries management and caries therapy combined with diagnosis (theragnosis)
  3. Visually differentiate various phases of active caries lesions
  4. Identify hard tissue worth preserving during minimally invasive caries management
  5. Follow a step-by-step protocol for diagnosis, subsequent differential diagnosis, and then treatment option selection.

 

Abstract

Diagnosis of caries is the prerequisite for treatment choice selection. Management of caries lesions adopted the concept of minimal invasiveness with the goal to conserve as much dental tissue as possible. Classic caries removal does not support the actual concept of minimal invasiveness. New, proven, and evidence-based devices have stepped in, ensuring that the diagnostic process is able to gather all needed information related to any given caries lesion in question to grant a minimally invasive treatment option, leaving as much tooth structure intact as possible and, thereby, facilitating restorative material choice in accordance with the diagnosed caries specifi city. “Theragnosis” combines therapy and diagnosis through fl uorescence-enhanced magnification, making true minimally invasive caries management possible.

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Designs for Visions, Inc

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 84 of 109

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Indirect Pulp Treatment in First Primary Molar & Restoration With Zirconia Crown

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Date: 03-23-2020 12:09:31 pm

The American Academy of Pediatric Dentistry (AAPD) supports the preservation of primary teeth until natural exfoliation to maintain appropriate oral function and facial growth. There-fore, the maintenance of sound tooth structure and its supporting tissues remains a leading objective of pulp therapy in teeth that have been affected by caries or other injuries.
Currently, pulpotomy followed by a full-coverage stainless steel crown is the most frequently used treatment for carious lesions approximating a vital pulp in primary teeth. However, existing research has shown that an alternative technique, indirect pulp treatment, is a suitable option and results in similar or greater success rates than pulpotomy. A study conducted by Rosenberg and colleagues at New York University College of Dentistry demonstrates the efficacy of indirect pulp treatment in primary molars when using 2% chlorhexidine gluconate disinfecting solution and resin-modified glass ionomer liner. Additionally, the use of pediatric zirconia crowns provides an obvious esthetic advantage over stainless steel crowns.
Indirect pulp treatment is indicated for treating large carious lesions that approximate the pulp and do not demonstrate signs or symptoms of irreversible pulpitis. Indirect pulp treatment involves removing the first layer of the infected dentin of a carious lesion, while leaving behind a thin layer of affected dentin to prevent pulp exposure. Next, a biocompatible liner is applied over the remaining affected dentin to stimulate healing at the dentin-pulp interface. Finally, the tooth is restored to form an adequate seal and prevent microleakage.
Zirconia is a biocompatible material used widely for crown and bridge, implant, and endodontic procedures in adult dental patients. However, the use of zirconia for pediatric crowns was not available until recently. Zirconia crowns provide superior esthetics over preveneered and stainless steel crown options and they do not stain or chip.
One important disadvantage to consider when using zirconia crowns, however, is that saliva and blood contamination can weaken the bond strength between the tooth and the crown. Some manufacturers have overcome this problem by developing try-in crowns to verify proper fit before the final crown is cemented. Furthermore, zirconia crowns may not be suitable in cases with significant crowding or space loss, as their size, shape, and fit cannot be altered.
The following case presents a 6-year-old healthy patient with a large carious lesion on the lower left first primary molar. Indirect pulp treatment was completed after caries removal, and the tooth was restored with a zirconia crown.

Article 18 of 24

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Following an Indirect Restoration Workflow for Long-Term Success

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Date: 03-20-2020 11:41:49 am



The workflow of all indirect restorations should be dictated by what the tooth requires for a long-term, successful restoration. Not every crown needs to be bonded in, because clinically that may not increase the long-term success of the restoration. On the contrary, bonding the crown to the tooth could be the essential element for increased longevity and predictability among many restorations. Therefore, this decision is made by classifying all preparations into 1 of 2 categories: retentive and nonretentive. When preparation design dictates the decision pattern, cement selection will be definitive and clear, leading to the ultimate step of how to prepare the ceramic for the type of cement selected.


Case Presentation

In this case, a 57-year-old male presented with severe recurrent decay on tooth No. 20. A lithium disilicate indirect restoration (IPS e.max, Ivoclar Vivadent) was agreed upon by the dentist and the patient as the treatment of choice, given the force of the opposing dentition, as well as the esthetics and position of the tooth. After adequate reduction (ELECTROmatic Premium, MASTERmatic LUX M25 L high-speed, and MASTERmatic LUX M20 L lowspeed, KaVo Kerr) and an effort to retain proper resistance/retention form, a polyvinyl siloxane (PVS) impression was captured and sent to the laboratory for fabrication. Upon return from the laboratory, the preparation was evaluated. The tooth appeared to have appropriate resistance/retention form following all of the gingival contours (Figure 1). Considering the retentive nature of the preparation, I determined that the preparation would fall under the retentive preparation category, which made available a broad selection of cements for the seating procedure. In this case, we chose to use a self-adhesive resin cement (Maxcem Elite Chroma, KaVo Kerr). Self-adhesive resin cements are appropriate when some bond is desired, but the preparation also provides retention.These situations include areas of esthetic concern,when other luting agents are too opaque and certain translucent or colored cements are desired.The provisional was removed by the dental assistant, and I cleaned the preparation with air-abrasion (PROPHYflex, KaVo Kerr) (Figure 2). After try-in to verify appropriate occlusal and interproximal contacts, the e.max restoration was etched with phosphoric acid (H3PO4) for 30 seconds and washed thoroughly to remove all contamination from the patient’s saliva. The tooth was isolated using the Isolite system (Zyris). Since the restoration had proper resistance and retention form, it was not necessary to use a bonding agent on the tooth or a primer on the restoration. The self-adhesive resin cement filled the intaglio surface of the restoration (Figure 3). The restoration was firmly seated and a 3-second tack-cure was performed (Figure 4). Excess cement was easily removed, and floss was passed through the mesial and distal contacts. I held the restoration firmly in place for the next minute while the polymerization of the cement continued to progress. The restoration was allowed to fully polymerize for 4 minutes while still maintaining a dry field with the Isolite in place. The restoration was light-cured (Demi Plus, KaVo Kerr) around the margins for 20 seconds to ensure the maximum possible polymerization. With all cements, it is imperative that the full polymerization time is provided for the cement to set before any manipulation or occlusal adjustments are made. Afterward, an x-ray was obtained (DEXIS Titanium, KaVo) to make certain no extra cement had been left below the tissue that could affect the periodontal health of the surrounding bone and tissue (Figure 5). Final verification of occlusal contacts and excursive movements was evaluated, and the patient was discharged (Figure 6).

Conclusion

With all indirect restorations, the correct cementation can be achieved and implemented as part of a standardized thought progression followed by every team member. Evaluation of the prepared tooth for appropriate resistance/retention form is first determined and categorized as retentive or nonretentive. The front office staff is informed and allots the appropriate length of time for the crown seat appointment. Assistants are empowered to play an important role in the procedure, particularly when executing the cleaning of the preparation and the indirect restoration. We, as clinicians, move forward with confidence that we will have fewer crowns that loosen and fall off, reducing levels of stress and ensuring the longevity of all indirect restorations.


 
Article 16 of 24

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

The Cutting Edge: Reprocessing and Maintenance

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

The overall goal of this article is to provide information on the care of low-speed handpieces and burs. After completing this article, the reader should be able to:
 

  1. Review the current Centers for Disease Control and Prevention (CDC) recommendations on the reprocessing of handpieces/attachments and motors
  2. List tips and know how to avoid common errors in handpiece/attachment and motor reprocessing
  3. Describe the CDC recommendations for stand-alone
    (cordless) devices
  4. Review considerations in selecting burs and their role in efficiency, safety, and the functioning of handpieces/attachments.

Abstract

Instrument reprocessing is a key component of infection control. Core steps in instrument reprocessing for handpieces, motors, and other attachments are similar to other instruments and devices; however, there are also specific steps that differ and vary by type and manufacturer. All such devices that attach to and detach from the dental unit air and waterlines should be cleaned and heat sterilized (autoclaved) following the manufacturer’s instructions for reprocessing. In addition, device maintenance is essential for proper functioning, safety, and longevity of these devices. Consideration should also be given to burs and their role in effective, efficient, and safe patient care.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 82 of 109