John Jameson, DDS
Dr. John Jameson recently with spoke with Dr. Stewart Rosenberg, an international authority on microdentistry. Dr. Rosenberg is a pioneer and innovator in the use of dental lasers, micro-air abrasion, and other high-tech dental instruments and applications. He is a founder, Diplomat, and President of the World Congress of Microdentistry, as well as founder, master, and past president of the Academy of Laser Dentistry. Dr. Rosenberg is a recipient of the Academy's Distinguished Service Award, and is a fellow of the International Society of Laser Dentistry, the American Society of Laser Medicine and Surgery, the International College of Craniomandibular Orthopedics, The Academy of General Dentistry, and the Academy of Stress and Chronic Disease. While maintaining a busy private practice emphasizing cosmetic and advanced dentistry, he serves as an attending doctor at Johns Hopkins Hospital.
As Director of Clinical Technologies for Experdent Centers of Dental Excellence, he lectures frequently throughout the world on the integration and marketing of new technologies. He is a regular contributor to many dental publications.
Dr. Jameson: Let's talk about the evolution of miocrodentistry, and how doctors can effectively utilize microdentistry in their practices.
Dr. Rosenberg: It's funny - I've always believed in being as minimally invasive with my patients as possible, and in trying to conserve as much tooth structure as possible. This issue really came to the forefront in the early 1990s with the introduction of air abrasion into dentistry. Our concept then was to just make smaller holes and eliminate "over-preparing" teeth. This involves not just caries removal, but using veneers or mini-crowns instead of full crowns, or taking off a millimeter of tooth structure instead of a millimeter and a half.
My definition of microdentistry was to remove only enough tooth structure and tissue to get rid of pathology and then replace it as conservatively and aesthetically as possible. And that was our original concept that we tried to promote around the country and around the world - to get dentists to stop taking off more tooth than they needed to. Adhesive dentistry made this concept much easier to accomplish; it allowed us to do more minimally invasive preparations.
Despite all of the incredible advances in technology, no tooth restoration will ever be as good as what God put there to begin with. Why take it away needlessly? It's not in the patient's best interest! Anytime we go into a tooth, we pretty much mandate that the tooth will have to be restored again in its lifetime - nothing is forever. The more we save initially, the more we have to work with when the tooth needs a second or third restoration.
This is another reason why we're seeing doctors go back to feldspathic crowns and veneers. With these, you only have to reduce a half a millimeter or in some cases even three-tenths of a millimeter of tooth structure and still get a nice, aesthetic result - rather than the greater reduction needed for pressed ceramics.
Amazingly, we've come farther along than we ever imagined when we first coined the term "microdentistry." This is largely attributable to the World Congress of Microdentistry, an organization that was formed 21/2 years ago by a group of dentists from around the world who shared a passion for minimally invasive dentistry.
We realized that we each were practicing in our own little vacuum, each thinking he had the answer. We discovered we had much to gain by sharing and comparing ideas and formulating an entire philosophy of minimally invasive dentistry for all of the various disciplines. We formed an organization made up of clinicians, academics, cariologists, and researchers - you name it - anyone who shares this philosophy of minimally invasive dentistry. It's the first organization of its kind. Our next meeting is in Newport Beach Calif. August 21-24. It's open to everybody. Our first meeting was held in upstate New York; last years meeting was in Australia.
Over the first two years, I completely revamped and re-thought the way I embraced microdentistry - to the extent that I now no longer think about just making smaller holes, but in terms of preventive dentistry. This is where the future of microdentistry lies, and it's very exciting.
Dr. Jameson: Many doctors, when considering this type of dentistry, believe the only way to profit is to provide a restoration that has an established insurance code. Dentists are going to have to shift their thinking, and perhaps begin billing for their services the way physicians bill for their clinical judgment - making a determination and providing direction to the patient - minus anesthesia or treatment, and yet still have a billable service.
Dr. Rosenberg: I couldn't agree more. One of the things that has come out of the World Congress is that we must start thinking like "physicians of the mouth" rather than as traditional dentists. By this I mean we must start thinking about the disease process. Dental caries and periodontal disease are bacterial infections that we must treat, rather than merely wait for a hole to form.
In my practice, we've started doing caries risk assessments. Very few doctors in the United States are doing this, but I think it will become increasingly more popular. How many times have we done a quality restoration for a patient with reasonably good if not excellent oral hygiene, only to see that patient return every few years with carious lesions or failing crowns? This happens because we don't address the original problem - bacterial infection.
We've been using the CRTRegistered bacteria caries risk test from Ivoclar Vivadent. It comes with agar plates and all the things dentists need to culture bacteria. We have the patient chew on a sterile piece of wax for five minutes and spit saliva into a plastic cup that measures accumulation in milliliters. The normal salivary flow for a patient is at least one milliliter per minute. Anything less than that indicates a dry mouth and susceptibility to caries. Dry mouth can come from disease process, radiation and chemotherapy, or due to different types of medication that patients may be taking. After assessing salivary flow, we culture the saliva for 48 hours in a small incubator, and then compare the results with a chart provided with the kit. This tells us the lactobacillus or streptococcus mutans count by which we can determine if the patient is at a high, medium, or low risk for caries. We then do a diet analysis, and, coupled with the caries analysis, put patients on a program of proper home care such as fluoride rinses, gum with Xylitol, and changes in their diet.
We've seen remarkable results with this regimen. It's not only wonderful from a clinical standpoint, but has been a real practice-builder as well. Patients love it and appreciate that we're providing them with better preventive care, and, because of this, refer their friends and family. We also utilize a hard tissue/soft tissue laser as part of our minimally invasive approach. The BIOLASE Water lasetrademark allows us to do class 1 through class 6 restorations without anesthesia, and it's an excellent tool for microdentistry.
The concept of microdentistry has also wrought significant, positive change to how my practice performs adhesive restorations, especially posteriorly. This change is largely due to the influence of the World Congress of Microdentistry, specifically from several "Down Under" colleagues of mine from Australia and New Zealand, Dr. Geoffrey Knight and Dr. Graehm Melisich. These doctors have developed new techniques for restorations involving glass ionomers to replace dentin, and then composites to replace the enamel. These are the best restorations we can give our patients in terms of caries control, marginal adaptation, aesthetics, and, most importantly, long-term, predictable success without post-op sensitivity. The future of microdentistry is very bright, and impacts everything we do in the profession today.
Most important to the practice of microdentistry is to treat decay as a bacterial infection, and get rid of it before it becomes carious. If caries are present, we must diagnose and treat the condition as early in the disease process as possible.
This involves using a caries detection device like the DIAGNOdent, which is proven to be 90 percent accurate in finding occlusal decay (as opposed to X-rays and explorers, which are only about 25 percent accurate). We need these devices in our practice so that we can detect problems in their early stages, then treat them with minimally invasive procedures that are more comfortable and less time consuming for the patients.
Microdentistry is a tremendous profit center. I can do as many as six or seven minimally invasive occlusal restorations in the same amount of time - and far more profitably - than a crown prep. We're doing better dentistry for our patients; they know it, and consequently refer their family and friends, expanding our profits even more.
Dr Rosenberg can be reached at (301) 776-3300, by fax (301) 725-1372 or email him at srosenberg8@com cast.net
Dr. John Jameson is chairman of the board of Jameson Management, Inc., an international consulting firm. Dr. Jameson lectures internationally on high-tech dentistry and its integration into the dental practice. He provides research for manufacturers and marketing companies. Dr. jameson may be reached at (580) 369-5555 or by email at firstname.lastname@example.org.