xxJanuary 2008Irish Dentist

When I graduated from dentalschool and got my licence, I waseager to go out into the worldand display all the skills I hadlearned. Yet after more than ayear of actually dealing withdental insurance and patients inmy Puerto Rico private practice,I became a little discouraged. Irepeatedly asked myself, howdid the profession allowinsurance to take over dentistry?I was frustrated with the ‘drill,fill and bill’ aspect of dentistry; Iwanted to stick out like a sorethumb!

Later on that year, theAmerican Academy of CosmeticDentistry held its annualmeeting in Puerto Rico. Arepresentative for an air abrasioncompany at that meetingcontacted me with such a greatoffer that I could not refuse totry air abrasion in my practice.My first patient following my airabrasion training convinced methat this was my way out ofstandard dentistry.

You see, that first patientneeded two defective, ratherlarge, amalgam restorationsremoved. Never one to hesitate,I proceeded to offer this patientdrill-free removal of heramalgams with air abrasionfollowed by tooth-colouredrestoration replacements. Nowbear in mind that patients inPuerto Rico usually complain ofthe $5-25 deductible peramalgam restoration and shewould need to pay an

approximate $65 deductible forthe tooth-coloured restorations.She not only accepted thetreatment plan, but had noproblem paying the higher fee!What a concept.

Needless to say, I havelearned much about theprocedure since that day.However, that first lessonremains true. Patients will paythe extra euro or drive the extramile to receive the treatmentthat they want, performed in themanner that they prefer. Tofollow a similar path out of the‘drill, fill and bill’ routine, youmust decide which tools toemploy in your practice. This iscertainly no easy task since thereare so many gadgets and gizmosavailable – each of whichproclaim to be ‘the best’.

The way forwardWhat is minimally invasivedentistry? It is the dentistry thatwe can practise today. Thematerials we now have indentistry work for us instead ofus working for the materials.

Amalgam requires aminimum thickness for strengthand undercuts for mechanicalretention. This results in a largeamount of preparation done atthe expense of healthy enamel

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Minimally invasive dentistryDo you want to separate yourself from other dental practices? David Silber clarifies what minimallyinvasive dentistry means to him and how its implementation can benefit you and your patients

Dr David Silber is committedto providing the highest levelsof patient care, dentaltechnology and innovativetreatments at his privatepractice in Texas. Hespecialises in cosmeticdentistry, composite fillings,air abrasion techniques anddental office management.

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January 2008Irish Dentistxx

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and dentine. Understandingmodern adhesive dentistry, wecan now remove only that partof the tooth that is diseased andreplace it with a tooth-colouredrestoration that is aestheticallypleasing and conserves healthytooth structure. Adhesivedentistry works for us, notagainst us.

There are a multitude of toysto help us in our diagnosis ofintra-oral decay. I haveincorporated two into my dailypractice. The first one is KaVo’sDIAGNOdent. This is not onlyan accurate laser caries detector,but when used in the rightmanner can also lead to a lot ofconservative dentistry. It is agreat tool to help the patientunderstand where diseasedtissue is present. My hygienistuses it to compare diseasedtooth structure with solid toothstructure. Then when I arrive inthe room, the patient is eager forme to begin the restoration.

The second tool I use iscaries detect stain. This intra-oral dye shows me exactlywhere the decay is present. It isa great visual for the patient andthe dentist. Studies havedemonstrated that detection ofdecay with the explorer aloneshows only 24% of the decaythat is present. Manyrestorations with beautifulmargins eventually fail becauseof ‘recurrent decay’. Recurrentdecay, I would argue, is diseasedtissue that was left behind at thepreparation stage. We restore it,after visual and tactileexamination. By using cariesdetect stain, you can be surethat the surface is disease-freeand thus create a longer-lastingrestoration.

These tools partner togetherin a useful way. With the use ofthe DIAGNOdent you canidentify decay. With the use ofcaries detect stain you canconfirm absence of disease.

Air abrasionOnce the patient acceptstreatment, you must decide howto prepare the occlusal surface.You can numb the patient, grabyour electric handpiece and bur,and proceed to finalise thecavity preparation.

I have been clinicallyconvinced that tooth surfaces

can be successfully cleaned ofdecay without having to subjectthe patient to a needle or theintense sounds of thehandpiece. How? The greatestconcept of minimally invasivedentistry – air abrasion.

You may hesitate because airabrasion was not part of yourdental school curriculum. Well,let me tell you how easydentistry can be with the use ofair abrasion. If an occlusal pithas decay, either visual or tactile,you were likely taught to use thefollowing phrase: ‘Let’s observethat tooth’. May I ask, whatexactly are we waiting for? Forthe decay to get deeper so thatwe feel comfortable in ourdecision to prepare that toothwith our handpiece and bur, sothat the removal of the disease isdeeper and more grandiose?

Let’s consider the otheroption – air abrasion. Airabrasion has been around sincethe advent of the Borden airturbine in the early 1950s. Theturbines were cheaper than allthe equipment needed to makethese air abrasion units, so youcan understand why one wasmass produced and the otherwent back to the drawing board.However, thanks totechnological advancements, airabrasion came back with a solidbang in the late 1990s and iseven better now.

What is air abrasion? As I tellthe patients, it is like going tothe beach. An instrument thatcombines air and sand is usedto remove the decay from thetooth. Basically, it is aninstrument to remove decay.

The biggest concern withdecay is having a comfortablepatient. With air abrasion youcan optimise patient comfort byadjusting the air pressure atdifferent stages of the procedure.For instance, as you approachthe dento-enamel junction(DEJ), where the patient is moresensitive, you should lower theair pressure. Patients will notunderstand the steps you aretaking, but they will certainlyappreciate the fact that you careand do not cause them pain.What a practice builder!Imagine the effect of yourpatient telling friends andfamily, ‘I just went to the dentistand he filled four teeth without

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FFiigguurree 66:: TThhee CCrryyssttaallmmaarrkk aaiirr aabbrraassiioonn uunniitt ccaann uussee aaiirr oorr hheelliiuumm..TThhee llaatttteerr wwiillll pprreepp ttwwiiccee aass ffaasstt aass aaiirr wwiitthh nnoo iinnccrreeaassee iinn ppaattiieennttsseennssiittiivviittyy

giving me an injection or usinga drill’!

The air abrasion technique isnot limited to use only onenamel. It can also effectivelyroughen the porcelain surface ofexisting crowns and bridges.Wondering why you might wantto accomplish such a thing?Doing so allows you to bondthin porcelain veneers to theexisting porcelain restorationsand create a ‘new’ appearancewithout the need to remake thecrown or bridge. TheLUMINEERS BY CERINATEsystem, utilising Ultra-Bondresin bonding restorative, is theonly porcelain veneer systemthat has clinically demonstratedthis use. Patients get veryexcited about this much less

invasive method of improvingthe appearance of their oldrestorations. Tally up thenumber of crowns and bridgesyou see in your practice that arefunctional but perhaps revealmetal due to gingival recessionor no longer match the shade ofthe smile – you will be amazedat the enormity of thisopportunity to help yourpatients’ smiles withLUMINEERS.

Air abrasion combines analuminium oxide powder withair. The manufacture of thepowder may vary slightly,however it is generally availablein two sizes. The diameter of thealuminium oxide particles maybe either 27 micron or 50micron. The 50 micron particle

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is for gross removal of decayand is much messier than the27 micron particle. I prefer the27 micron particle because it iscleaner and more conservative.An air cleaning unit can ensurethat the excess powder isabsorbed by the cleaning unit,minimising the mess associatedwith air abrasion.

You may choose a simple airabrasion unit like the one fromKaVo that connects to yourstandard high-speed handpieceadaptor or a stand-alone unit.Some stand-alones include anindependent air source, whileothers connect to the air sourcethat is available in your dentalunit.

The latest air abrasion unitemploys a combination of airand helium for even lowerpressure to remove disease.Personally, I prefer thehelium/air combination unitfrom Crystalmark. It is a free-standing unit that is very easy touse and maintain. Some of theseunits can be very difficult tomaintain, requiring (among

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other things) that the pinchvalves be replaced wheneveryou fill the chamber withpowder.

RestorationYou have already identifieddecay with the DIAGNOdent,confirmed disease with thevisual aid of the caries detectstain, and removed the decaywith air abrasion. The tooth isready to be restored.

To begin the adhesionprocess, the tooth is etchedand treated with a bondingagent. For the restorative, Iprefer to use a flowablecomposite because it ensuresthat every irregularity from thepreparation will be filled. As itflows, it restores. Some ofthese materials flow too much– moving all over the placebefore you can put yourcuring light to it. Based on mypersonal experience, I chooseDen-Mat’s Virtuoso Flowable.This material has enough flowto it while, at the same time, itstays in place without flowing

all over the adjacent teeth.The selection of curing lights

is quite vast: a standard light, anLED, a plasma arc. I personallybelieve in the need for speed. Ifyou use an LED, it may take upto 20 seconds to cure; using astandard halogen it may take 10seconds. I like Den-Mat’sSapphire Supreme plasma arclight because I can cure thecomposite down to 6.5mm inthree seconds. When youconsider a curing light, realisethat the composite must absorbabout 10 to 12 joules of energyto reach your restorativematerial’s maximum hardness. If

The multiple uses of air abrasion

Air abrasion can be used on many

surfaces and in a multitude of ways

to expand your treatment options:

• Enamel – conservatively remove

decay

• Porcelain – roughen the porcelain

surface of existing restorations to

bond LUMINEERS porcelain veneers

for pain-free cosmetic enhancement

• Metal – reduce and roughen the

metal margin on porcelain fused-to-

metal restorations to allow direct

bonding of LUMINEERS and to mask

the dark metal effectively. Using

GoldLink and Infinity, crowns may

also be placed

• Composite and acrylic –

conservatively remove to update or

roughen for direct bonding of

LUMINEERS.

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the light you are using does notemit the amount of energyrequired, your composite willnot absorb the energy and it willtake longer to achieve maximumhardness of the composite.

I have made my life verysimple when it comes to

polishing. I adjust the occlusionusing carbide polishing burs.When the occlusion isfunctional, I use an amalgampolisher, brownies and greeniesof the high-speed handpiece,with lots of water. This will giveyou the best possible polish of

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your composite restoration.In conclusion, air abrasion

furthers your ability to practiseminimally invasive dentistry –both general and cosmetic.Minimally invasive dentistryleads to referrals from yourexisting patients, who in turn

tell their friends what a fantastic,caring, non-painful dentist youare. Remember, word of mouthis what gets new patientsthrough the door. The morereferrals you get, the morechances you have to grow as aclinician.

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