Fools Rush In

Paul Feuerstein, DMD


There are patients who have low caries susceptibility. Commonly, there are small lesions found on radiographs, especially interproximally, that started and then—for whatever reason—were arrested. There is no greater thrill for a hygienist to report on a newfound “stick.” With all patients, it behooves the practitioner to check the prior notes and images before rushing to the restoration. The digital radiographs and software allow for easy side-by-side comparisons to see the progression of a lesion. Years ago, there was actually a program that did x-ray comparison by “digital subtraction.” (If anyone knows what happened to this idea, let me know.) It is not harmful to watch something as long as there is follow-up. Even with minimally invasive dentistry, the preparation can be much larger than the caries. Caries detection using fluoroscopy (eg, Spectra [Air Techniques—Fig- ure 1], SoproLife/SoproCare [ACTEON]), laser reflection (eg, Diagnodent [KaVo]), transillumination (eg, CariVu [DEXIS]), laser photothermal and luminescence imaging (eg, The Canary System [Quantum Dental Technologies—Figure 2]), digital radiograph analysis (eg, Logicon [Carestream]), and others give us a quantitative method of “watching.” Other than myself, for teaching purposes, there is no reason to have many or all of these. Studying each of them will give you a sense of what system (or systems) fit into your practice style and philosophy. The start of the process is thinking about what you have been seeing and doing for many years of practice.

Figure 1. Air Techniques’ Spectra Caries Detection Aid.
Figure 2. Quantum Dental Technologies’ Canary System.

Looking at the clinical exam, it starts with physical examination, use of excellent lighting, and perhaps an intraoral camera and/or optical magnification. Once you start moving up the loupe chain, you will see more and more detail of what used to be determined by just the eyes and an explorer. (As an aside, Orascoptic recently introduced loupes that actually can zoom in: EyeZoom, which goes from 3x to 5x.) Radiography (hopefully digital) is the next step to determining a course of action. New 3-D imaging is also wonderful, although not necessary at this time for a routine exam. However, this will change as technology and current thinking evolves. When performing this exam, there is a buzzword: CAMBRA—Caries Management By Risk Assessment. It should really be called TAMBO—Think A Minute Before Operating. Don’t rush to pick up that handpiece. With these systems, there is a method to “watch” areas with more than just your judgement. The patient also can become directly involved in the discussion by seeing these results and not just told to “come back for a filling.” This leads to better rapport, better trust, and actually less nervous patients since they have a better understanding of what is about to happen instead of wondering. That’s not to say they will love it, by any means, but offices that follow this get a lot more patients saying “thank you” when they leave. And of course, there’s always the new patient who “hasn’t had a cavity in years, so why now?” He or she will not run out and say, “All this new dentist wants to do is make money on me!” This is something we all have seen and heard before.

You should all be aware that we are also entering an area of remineralization and chemical rebuilding of hydroxyapetite. Products like TCP (3M ESPE), MI Paste (GC America), Recaldent (VOCO), and others have the potential of slowing down or even reversing incipient damage. Some practitioners initiate this in the office and send the patient home with product for continuation. Compliance must be reinforced, especially if the areas are not completely visible. And if you are wary of the claims, the use of the technology products mentioned above can show the progress very clearly and validate this process to both the practitioner and the patient.

If restorations are recommended, keep in mind that the smaller (minimally invasive) lesions can be restored with bioactive products. Glass ionomers are well-known products to use in small lesions and even as sealants, and they excel in fluoride release as well as being recharged as additional fluoride is introduced in the oral cavity. A new set of restorative materials (Pulpdent’s Activa) and cements (Doxa’s Ceramir and NuSmile’s BioCem) claim to rebuild damaged enamel inside and at the margins of restorations. These are also helpful in larger restorations. Taking the idea beyond the scope of this discussion, we also have products such as Biodentine (Septodont), Theracal (BISCO), and Calcimol (VOCO) that are using this technology to rebuild the floor of deep restorations, doing what Dycal was supposed to do.

This is surely a lot of product information to absorb at this time. I feel like I took you up and down the aisles of a dental exhibit floor, and if so, this was my intent since this is what I do in my “spare” time. And as always, please feel free to stop me if you see me at a meeting or contact me through Dentistry Today.