Transcribed by Amit Amin September 15

th
, 2014

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[Diagnosis and Treatment of Oral Diseases] [33] [Medical and Surgical
Approaches to Dental] by [Dr. Allen]

[1] [No slides up yet. ]
[Dr. Allen] Good afternoon, I know youre really excited about medical and surgical
approaches to dental caries so lets try to get started and keep this a little bit
interesting so that you can understand whats going on and the points were trying
to make. I want to thank you for filling out that survey the last couple days and well
go over the results of that in just a few minutes. The important part of that and the
reason why I think thats probably something you guys should be interested in is
whats happening over the next 3 years. Youre going to be in the clinic, youll be
seeing patients, counseling patients, and treating patients. The big question, one of
the easiest and difficult things, will be deciding which approach to take? Medical
approach and surgical approach. Everyone knows the difference right? Surgical
approach is when we do the preparation. Medical approach is the complete
opposite. Its when we treat it w/o a hand piece. So this morning, afternoon, or this
evening you guys will be treating patient F Bee. You saw her X-rays, and you may
have noticed which caries risk did you place F Bee in? High-risk group. Meets all
those criteria for high risks. Fits all those guidelines. I was able get a copy of her X-
rays, I didnt have it up here. I just got it this morning. And I noticed that on looks
like tooth #20 and Im sure you dont have those X-rays in front of you there seems
to be what I would call an incipient lesion. An enamel lesion that had not extended
into the dentin. Considering everything you know about F Bee how would you treat
it? What are the choices? We can try to remineralize it. How would we do that?
Fluoride/ MI paste. Actually, Im glad you mentioned that. Well get to that. Fluoride
treated or surgically or treated medically. Whats the other choice? Theres no other
choice? Surgically, do a slot prep. W/ everything that you know about F Bee or
everything that youve read on the sheet that Dr. Glotzer sent out how many of you
would treat F Bee by doing a slot prep? No body. How many would you treat it
medically? A couple. Are the rest referring them to me? Thats great. I still practice a
day and a half a week. I appreciate the patients but you have to make a decision. So
lets start over again. How many would you treat it medically? Everyone knows F
Bees criteria? High risk. Why is he in that risk group? Current multiple carious
lesions, recent restorations in the last year. Any medications? Does Valium cause
xerostomia? Actually thats a great answer. I dont know. I have to go look it up.
When youre treating a patient how do you look it up? Yea thats basically right. You
look it up on an electronic device. Acceptable to look something up. Hi Im just
checking to see if your medication has some side effects that can effect your teeth.
No body except you guys can measure thousands of medications. Now that we know
whats going on w/ F Bee and considering the background you have to chose either
medically or surgically. If youre not going to chose one you have to tell me what
youre doing. Which one of you would treat it surgically? And medically? Can you
nudge the people to your right and see if they have an opinion? Which one? All
three. Surgical. Great answers. The problem we are coming up w/ now is that they
are all different. At this stage of the game Id like you all to have an unified answer.
Here we have F Bee. This patient who has an incipient lesion in the enamel only that
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were deciding to treat. Were deciding how to treat and were basing our decision
tree on lots of different factors. Some of them are not relevant for making this
decision. Patient is high risk for caries. What does that mean? It defines the protocol
that were prescribing. The home care we will do, the recall protocol, the protocol
for radiographs are all defined in that nice summary sheet thats posted on NYU
Classes and what you will use when you treat patients. Those are all predefined.
Youve got to make a decision on how to treat tooth #20. We have an incipient
lesion, regardless of the patients caries risk group, if this was somebody that never
had a restoration in their mouth who would treat it medically? Surgically? The rest
of you dont care. I would like you all to realize is that the way you treat this patient,
an incipient lesion, it should not differ based on their caries risk group. If its an
incipient lesion you treat it medically. Youre going to be seeing this patient,
motivating this patient, the day that they come in youre going to excavating all the
caries, reduce the bacterial load, and youre going to be prescribing the home care
regiments that are going to increase their fluoride use and help prevent caries in the
future. The best thing you can do for this patient is treat it medically and follow up.
Make sure they come back in for their recall, which would be sooner (4 months). We
dont automatically think high risk always treat it surgically if its an incipient lesion.
If there is one take away point that you should get out of today, is that incipient
lesion is treated medically regardless of the patients medical risk group. Anyone w/
a question or want to discuss it? One of your colleagues said, said something about
MI Paste. You said MI Paste right? You like MI Paste? Everyone else familiar w/ MI
Paste? Anyone knows MI means? No. Youre suggesting patients to use something
and you dont know what it is? Does anyone know what MI stands for? Its made by
the manufacturer. Not scientific. It means minimally invasive. MI paste comes in two
versions. Theres one version thats called MI Paste and one version thats called MI
Paste plus. Do you know which version youre prescribing. Im not going to take a
vote but why did you say regular one? B/c I dont know. Youre prescribing
something for your patient b/c you dont know. Thats not a good way to do it. The
difference is that MI Paste plus has fluoride. MI Paste does not. In our situation for
this high-risk patient I would go w/ the plus. How do I know one from another? You
read the label. You should check into things when you dont know.

Lets talk about the survey you guys did. The first slide, a good number of you
admitted to interproximal demineralization or one or more cavitated smooth
surface lesions. New smooth surface restoration due to caries within the past 12
months. This I believe is the number of people. Yes b/c there are 200 some people
who responded to the survey. Surprising numbers. I was pretty surprised by this.
What do you think the one critical factor I did not ask. What did I not ask that would
be important to know about this? Anything? What? Yea no, what would the one
thing in background information. Would age matter? No. How about gender? Would
that matter? Probably not. What could I have asked that would be important for you
guys to know? I know you know the answer. I discussed it w/ half of you in D1
seminars. Where did they grow up? Where did they live when their teeth were
forming? Were they exposed to systemic fluoride. Wouldnt that be an interesting
fact to know? Which group do you think would have more smooth surface
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demineralization. Fluoride group or non-fluoride group. Thats what we think but I
neglected to ask that question. So next year, if I do this survey again I will try to
remember and put in that question and ask did you grow up in an area w/ fluoride.
That would help us make some decisions. Ok.
[2] [Do you have white spots?]
[Dr. Allen] Ok. So lets see what the next question was. These are definitely raw
numbers. Very few of you had white spots or visible demineralization or admitted to
having them.
[3] [Risk factors]
[Dr. Allen] This was the most interesting part. Fortunately no one admitted to meth
use or severe xerostomia but I have the raw number theyre not on this slide. 80
some people admitted to frequent sugared beverages or snacks as evidenced by
what you are sitting here eating and drinking. Except for the water. Frequent
sugared beverages and snacks. This is the most common caries risk criterion that
Ive come across among students. What surprises me is that you guys started last
year w/ Health Promotions and you start this year w/ this course when you go into
the clinic what you going to tell your patient in high caries risk? Who said the reduce
word? Youre going to suggest that they reduce the intake of sugared beverages and
snacks. That makes me believe that everyone of you knows that you should reduce
your intake. I can be really difficult and ask if thats coffee? What? We wont go w/
how bad splenda is for you. Non-sugared beverage. I dont see what other people are
eating. Usually people are eating snacks, which are not low in sugar. I would like to
think that now that youre going into the clinic and youre working w/ colleagues
that you would listen to your own advice. Its hard to get people to change their
habits. I would like to think that if we did this same survey, when youre graduating
that the answers would be different. This number is way down here. Who thinks this
will happen? I think it will happen but it will be tough. Its like a marathon. You have
to train everyday. If I wasnt running so late I was going to ask you to try to come up
w/ some strategies for getting patients and you as a group to reduce your intake of
sugared beverages and snacks. I dont think Im going to go through that exercise
now. I would rather finish early. Im going to ask you separately/ individually to try
to think of a way to get your patients to reduce and at the same time you would
reduce your intake of sugared. The easiest method is substitution. Just like having
tea w/ splenda.
[4] [Which caries group?]
[Dr. Allen] So based upon your own self analysis you had about over 55 students
out of those who responded that put themselves in a high risk group. Thats terrible.
We should be examples for our patients. We should be better than that. Hopefully
you can be motivated to look at that caries risk chart, look at the criteria and reduce
your risk factors.
[5] [Protective Protocols]
[Dr. Allen] Last thing is what you guys do. Fluoride toothpaste, regular flossing,
mouthwash. Fluoride toothpaste is what everyone is doing. Regular flossing, come
on guys, youre telling your patients to do it, if you dont believe in floss use the
interdental brushes. Fluoride mouthwash. This is one of the things I think its easy
for patients to do. Easier than preivdent b/c of a prescription. Patients have to go to
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the pharmacy and renew them. Much easier to motivate patients to use a fluoride
mouthwash. Which mouthwashes have fluoride? Act. Its a big one. Listerine. Great
answer. There are, 12 different bottles of Listerine. Which one as fluoride? The
purple one and theres one white one that does now. If your patient you use
mouthwash switch to the fluoride version. The only way to know if it has fluoride is
the same way as the MI paste, you have to read the label. The manufacturers confuse
you and the public by having things looks similar. The Listerine bottles all look the
same. The one w/ fluoride is a different color. The come in different versions. W/
and w/o alcohol. Which one do we use? Alcohol free. Why? Patients w/ medication
will dry their mouth. The other big reason is patients who drink it. Oh absolutely. I
have the alcohol version in my office. I have patients who will sit there and drink
mouthwash. A good reason not to have the alcohol version.
[6] [Medical vs. Surgical.]
[Dr. Allen] Didnt I just talk about that? Medical vs. Surgical model. Maybe Im done.
[7] [Pictures of teeth w/ caries]
[Dr. Allen] We started off w/ what I described as a lesion thats in the enamel. I
think youve seen this slide before. If you happen to have a question on your exam
where it gave a complex history similar to F Bee and then described a lesion that
was in the enamel and asked you how to treat it you all know what the answer
would be. If it was in the dentin, any version, it would be treated differently. The
deciding factor is enamel vs. dentin. So the big question is what do you do w/ the
middle one? Its a toss up. Is this version extending into dentin? Anyone want to
guess? Its yes or no? If youre in a dental office, youll probably come back and say
its probably deeper than the radiograph. Thats not always true. The answer is that
if you dont see the lesion in dentin on a radiograph or clinically you dont treat it,
you treat it medically. Whats the worst that can happen? You treat it next time. You
always stick w/ being conservative.
[8] [Weve come a long way]
[Dr. Allen] Lets see what else we can talk about in relation to caries. So I put this in
for a bit of history. This is an ancient device use to drill. This is a hand-operated drill.
Dr. Bucklan still uses this. Only kidding but its one of the original hand operated
drill.
[9] [Or have we]
[Dr. Allen] This is a picture of some of the crowns I recently did. I havent done any
of these. But some tattoos on crowns.
[10] [No title]
[Dr. Allen] We have progressed a long way. Were also trying to be very scientific in
what we do. Cariology, study of tooth decay involves all different aspects of
dentistry. Its not just limited to whether a lesion is limited to enamel or dentin.
Everything is effected from microbiology to dental anatomy. I think I have some
examples of that.
[11] [No title]
[Dr. Allen] You know about the effect of bacteria from Dr. Caufields lectures. You
know about salivary pH. Behavioral sciences. Patient motivation. If a patient wont
brush or floss, whatever we do the chances of success are going to be significantly
reduced. We need radiology to make an accurate diagnosis at times. Biomaterials
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play an important role in what we do. Im sure that youll have lectures on different
materials that have anti-carcinogenicity properties incorporated w/the material
youre using. We use oral diagnosis to evaluate caries risk. We use epidemiological
approach to study the other risk factors. How I would modify that survey I did when
you first walked in to find out if any of you filled out the survey lived in areas w/
fluoride or not fluoride. Physiology would effect the salivary flow, which is tied in to
pharmacology, which defines the medications we use which can reduce salivary
flow. Restorative we have the medical or decision tree b/w the medical and surgical
approach. Dental anatomy we all know from Dr. Bucklans course that the size,
shape, contour of the tooth determines the way we restore teeth and the ability to
restore them. The classic stories about the mesial concavity on what tooth is that?
Thats the one. Thank you. The mesial concavity on tooth #5 or #12 b/c of the
difficulty in restoring that and making sure you dont have an overhang.
[12] [Same tooth?]
[Dr. Allen] I mentioned that radiographic evidence is critical to help diagnose.
Heres an example where you have two radiographs of the same tooth and it looks
like there is caries on one and not on the other. There it looks like an incipient lesion
and here it looks deep. They are definitely the same tooth. Which is correct? I would
agree. I think on this one you have some moderate overlapping so youre artificially
seeing caries when there is not. Why is this a problem? If you only took this one X-
ray and never took this one you may do a restoration here w/o think there is an
overlap and maybe I should take it at a different angle. All the diagnostic materials/
criteria you have dont work unless you think about it and use the knowledge you
have. Im using a X-ray but am I using it correctly? Just b/c I have a tool doesnt
mean you have an answer.
[13] [Caries activity]
[Dr. Allen] This is something that we all know and I think Ive heard you guys
mention it in lectures when Dr. Wolff has asked you questions, the difference b/w
active and not active is wet/dry, chaulky/ shiny, cavitated/ non-cavitated. On your
right there is a lesion here, which is really not active. I have seen many cases where
people have left this alone and not restored it and it has stayed fine over many
years. Whats the only way you can tell if this is going to develop into a cavity? I
hope this is the right slide.
[14] [The only way]
[Dr. Allen] The only way youre going to be able to tell if its an arrested lesion is to
moderate it over time radiographically or visually.
[15] [New Terms]
[Dr. Allen] So were going to come up w/ new terms. Well be treating things
differently then dentist have in the past. Were not going to replace everything.
Were not going to take every restoration out. Some of you have office exposure
where the first thing they pick up is the evil instrument w/ a hook. I forget what its
called since we dont use it anymore and stick it really firmly and say you need a
filling. We dont do that. Just b/c you have a little space b/c a tooth and an existing
restoration doesnt mean it cant be refurbished, refinished, repaired, resurfaced,
reglazed, or repolished. They do that upstairs. If that happens tell Dr. Wolff. It
shouldnt happen. I will be the first to admit that we have a large number of faculty.
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Some of them may have not gotten this message that we are treating things
medically. If thats happening its important that we know that. If you do run across
that in the clinic tell Dr. Wolff. It wont be held against you. It never is held against
you. Its important for us to know that. The only way we can get better is by
knowing whats going on. We dont use explorers and we dont immediately restore
a tooth just b/c it has a rough margin. If it has caries yes. Not if it cant repaired,
resurfaced, etc.
[16] [Caries imbalance]
[Dr. Allen] Any questions about that? Excellent. I think this is something youve
seen before. It was part of an article by people you know. The basic premise is that
we want to push everything over to the right side. We want to end up w/ no caries
as opposed to caries. We know what the indicators are and the risk factors. We want
to increase the preventive factors. We know the protective factors: saliva, sealants,
antibacterial, fluoride, and an effective diet. Which of these do you have control
over? You have control over fluoride. Lots of control. Especially as a dentist what
can you do? Fluoride varnish. Counsel your patients to use fluoride
mouthwash/toothpaste. You can place sealants. Can we control the saliva? What?
Yea whats one way we can effect saliva. We can recommend someone to chew
sugarless gum to stimulate saliva. We can give out xylitol lollipops to help change
the imbalance.
[17] [No title]
[Dr. Allen] This is great slide, it is basically something we dont want to happen. We
dont want to start w/a Class 1 and 30 years later end up w/ a missing tooth. If we
can stop at stage 1 and avoid the disease, the patient is much better off. If you get all
your young patients and apply sealants youre one step ahead of the game. Theres
no down side. Its clinically shown to reduce caries.
[18] [Disease indicators vs. Risk factors]
[Dr. Allen] Have you seen this slide before? Disease indicators vs. risk factors.
Sometimes theres confusion what the difference is. Which is the disease indicator
and which is a risk factor? This would be a risk factor. Once its in there is a. How do
you repair this disease? Class 1 restoration.
[19] [Disease Indicator]
[Dr. Allen] By definition caries risk assessment, the chart that is at the end of the
presentation and the one I posted on NYU Classes is something you have to know for
our exam and all the components of it and what it says. Every school has caries risk
assessment form. It may be a little different but globally it does the same thing. One
or more disease indicators places the patient in a high-risk group.
[20] [Cavitated Smooth Surface Lesion]
[Dr. Allen] What are the indicators were talking about? Cavitated smooth surface
lesions, interproximal demineralization. Ill go over these quickly since you have
these on your slides (he speeds through the next slides w/ pictures). Root surface
caries, white spots.
[21] [Risk Factors]
[Dr. Allen] By definition low risk is less than 3, moderate is greater than or equal to
3, high risk is severe xerostomia, etc. Again, heavy visible plaque.
[22] [Frequent sugar]
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[Dr. Allen] Frequent sugar beverages. We talked about that before. I would expect
that the next time I come in here, whens your next lecture? Friday w/ Dr. Wolff. I
will expect that no one will walk in w/ a sugared beverage or chips right? Its going
to be carrots, celery, and non-sugared beverages.
[23] [Exposed Roots]
[Dr. Allen] Exposed roots. How do we deal w/ exposed roots. Can we deal w/ this?
No. This is a healthy mouth. Those gums look great. They have some exposed root
surfaces maybe due to toothbrush embrasures or aging. What we are going to do for
these? Use fluoride on there. Unlikely they will get decay there. You want to reduce
the risk by prescribing fluoride.
[24] [Mechanical]
[Dr. Allen] This is one of my favorite slides. Again one of Dr. Glotzers patients.
Gross overhang and a nice carious lesion. What do you think will get caught there?
Everything. That has to be removed since its a mechanical interference.
[26] [Fluoride toothpaste]
[Dr. Allen] Fluoride toothpaste many different versions. I know Dr. Wolff has gone
over.
[25] [Oral hygiene. ]
[Dr. Allen] Oral hygiene. Lots of different ways to teach patients to floss, brush, and
clean their teeth. Based on the patients age, medical history, and physical
limitations you have to adjust how you treat the patients. The patient who has
Parkinsons disease will handle a toothbrush and floss differently than someone
young like you.
[25] [Dietary Guidance and education.]
[Dr. Allen] My favorite is dietary guidance and education. I think that some of you
think its an hopeless cause. Id like to think that its not. Especially since on Friday
youre going to show me that youve transformed and you learned how to make
substitutions.
[25] [Fluoride Rinses]
[Dr. Allen] The purple Listerine has fluoride. This just list all the different kinds of
Act. W/in Act there can be a bunch of versions. If you ask your patient if they are
using mouthwash ask them to bring in the bottle. The only way to tell is to read the
level. There are generic brands of mouthwash, CVS, Durane Reade. You know to
know what they are taking.
[25] [MI Paste]
[Dr. Allen] MI Paste. We use custom trays. Its pretty easy to use. This is a picture of
MI Paste plus. The plus version is what we want to use since it has fluoride in it.
There is one situation where you cannot use MI paste. Does anyone know when?
Allergy to milk or milk products. You have to have a good medical history and you
have to look at it. Having a good medical history is no good if you dont refer to it
and look at it every time you see a patient. I cannot remember all of my patients
medical histories. Before you do anything you have to look at it.
[26] [Recare Intervals]
[Dr. Allen] Recare intervals are outlined on the caries risk assessment sheet. You
should know these. They are different for low, moderate, and high. The other thing
that goes on is when you prescribe the X-rays the number and type of X-rays you
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take are made after you examine the patient and not before. Just b/c they are high
risk they may not have certain restorations in certain areas. You may not need
bitewings of the whole mouth. Only prescribe the x-rays that are needed and where
they are needed. Appropriate bitewings, not always anterior/ periapicals are
needed. Going by the AAOMR principles.
[25] [No title]
[Dr. Allen] Last but not least, the caries risk assessment form. This form changes.
We have not updated it in a year. It can easily change this year. That does not mean
the last one was wrong. It means that based upon the evidence we are using a new
more, evidence-based version. The important things to outline just the way you did
on that survey, what the risk factors are, the disease indicators, and come up w/ a
caries risk group and to make sure that patient is compliant to all those criteria
youve placed in that risk group for that group. Please look at the caries risk chart,
look over the slides so you know the materials weve discussed. If you have
questions, feel free to ask me Friday. I anticipate you will not be drinking sugared
beverages and not bring evil snacks into Septodont. Thats a great question. Why
does Listerine? I have no idea. I cant understand why and its the same price. They
may taste a little different. Idk why the purple one has a fluoride version.
Remineralizes, you may have white spots and not have high caries. The calcium and
phosphates. I actually asked Dr. Wolff if we can get samples of mouthwash for the
clinic. Hes trying to get some b/c any time you can give patient they can duplicate
and they can buy it its better than just saying it. Thank you very much.