Air abrasion`s overall impact on the dental industry
Angel Sanchez-Figueras Jr., DDS
Over the past decade, air abrasion has slowly made its way into the armamentarium of an increasingly larger number of dentists. Clinically, air abrasion offers numerous benefits, such as:
* reduction of enamel without microfracturing
* cavity outline with rounded internal and external line angles
* kindness to pulpal tissues, and
* reduced need for anesthesia.
All of these attributes, combined with professional in-office patient education, work synergistically to greatly enhance patient referral and the practice`s public image.
Many doctors have expressed to me that the claims for air abrasion`s lack of pain during treatment are not well-grounded in reality; that these are nothing more than marketing gimmicks. Most doctors who have run into the "sensitivity wall" don`t realize that there are two dominating parameters that govern the existence of this pain/no pain phenomenon. One pivotal parameter that relates to this issue is the equipment`s ability to reduce dentin at air pressures as low as 10 to 40 PSI. If your equipment lacks the capacity to do this, you will run into many sensitivity issues that cannot be resolved. There is a direct relationship between the incidence of sensitivity and the air pressure used.
Changing to smaller-sized nozzles will allow the dentist to finish a procedure 4 mm to 5 mm into dentin without anesthesia. Independent adjustment of powder flow and air pressures allows the doctor to compensate for specific treatment scenarios and to finish treatment without anesthesia. Without the capacity to do that, your hands are tied and you end up reaching for the syringe.
The issue of powder mess in the operatory is something that dentists routinely tell me is one of their principal concerns. It was once the case that a powder mess in the operatory was an accepted evil if you used air abrasion.
A properly designed air-abrasion device accurately meters only the absolute minimum quantity of powder necessary; the end result is minimal powder consumption and no powder mess. Powder volume-use figures that range from .5 gm/minute minimum to 6 gm/minute at the maximum setting are what the modern dental air abrasion equipment should demonstrate.
The average dental procedure using this type of machine would generate an average, total powder-consumption figure of between 1 gm to 2.5 gm per procedure. When you consider that the majority (approximately 85 to 90 percent) of the powder is being eliminated via the high velocity chairside suction, the quantity of remaining powder is almost insignificant. A machine must be designed to utilize the minimum amount of powder necessary, while being capable of reducing tooth structure efficiently and consistently.
When the modality made its resurgence in the late 1980s, most dentists were basically set loose on the world with minimal advice or training. Properly written training manuals and clinical guides greatly enhance the shortening of your learning curve as a clinician.
You will find that once the preliminary basics are mastered, the actual clinical application in operative dentistry is very straight-forward and easy to control. Air abrasion`s cutting rate is about half that of the high-speed handpiece and is even more controllable. With air abrasion, a momentary deviation away from the intended path will reduce very little tooth structure. Try that with the high-speed turbine!
Applied practice on extracted teeth for a period of a couple of hours will hone your technique, so that you will feel comfortable with the modality when you treat your first patient.
We often have heard people say, "Aluminum-oxide powder can`t be very good for you," or "It must be toxic and cause some form of lung problems." Assuming we are using strictly the granular form of alumina in our dental procedures and that the smallest physical diameter of the powder does not stray below 10 to 11 microns, we are safe.
Any alumina of this type that is breathed in will be captured in the nares, nasopharynx, etc. (assuming you and your staff are not wearing masks) and be swept out. There should be no fibrous components to our dental alumina and the manufacturer should certify this to be the case. The reason I raise this issue is that fibrous alumina strands that have a diameter of 1 to 5 microns and lengths of 200 to 300 microns will behave aerodynamically as a granular particle of a below-threshold (10 to 11 micron) diameter. In other words, these long fibrous particles will penetrate well into the alveoli, where they cause tremendous damage.
The only reservation I would have in using air abrasion would center around a patient or staff member who suffered from asthmatic symptoms. Aluminum oxide which contacts the respiratory tract will act as an irritant (rhinitis, sneezing) and this is obviously a condition we wish to avoid with asthmatics. There are precautions one can take to reduce the patient`s exposure to the powder, such as the application of a nitrous hood, rubber dam, etc.
Plan to treat multiple quadrants in one visit, even when that dental appointment includes other disciplines of dentistry. A common example is as follows: The patient is treatment-planned for one crown in the lower left quadrant and three operative restorations, one per remaining quadrant.
The patient is anesthetized for the crown procedure in the lower left quadrant. Immediately after the injection, the treatment of the other three carious lesions can commence without anesthetizing the patient. While these procedures are being performed, anesthesia is being obtained in the lower left quadrant. Upon completion of the operative restorations, the crown preparation can commence. The patient is happy and you achieved your goal of reduced chair time for the patient and maximum production per unit time.
Another example of air abrasion`s practicality and flexibility is its use in the preparation of Class V and anterior incisal restorations in middle-aged and older individuals. I have placed many Class V composite restorations after carrying out the preparation of the cavity outline with air abrasion.
The procedure is performed without anesthesia, thereby saving tremendous amounts of time. Particular attention must be paid in this clinical application that the abrasive air stream is not directed into the sulcus; emphysema is a possible complication.
Incisal restorations in this same age group can be performed without anesthesia; the time savings, as well as the reduced exposure to local anesthetic and vasoconstricting agents are, I believe, two huge peripheral pluses for the modality. I have been extremely surprised to find the carious process extending along the DEJ in older patients, well into the lingual surface of maxillary and mandibular anteriors.
Early intervention of this process, followed by restoration with composite, saves these teeth from the eventual delamination of the lingual enamel and the ensuing restorative dilemma.
These are just a few of the beneficial aspects of air abrasion. I stress here that air abrasion is not intended strictly for incipient, occlusal pit, and fissure treatment; its uses are varied and flexible.
For more information about this article, contact the author at (888) 264-4337. A biography of the author appears on page 8.
Incorporation of air abrasion into your practice: the do`s
1. The practice`s implementation of air abrasion should be prefaced by the establishment of a clear and simple practice goal/mission, centering on the role of air abrasion in the diagnosis and treatment of dental decay. Once the treatment team is clear in its understanding of the use of air abrasion, an honest assessment of how to best present the technology to patients should be generated. It is important that patients understand why you have adopted this new technology and the value to them in terms of treatment.
2. Begin by explaining to the patient that in the interest of best serving them, your practice has incorporated this latest in clinical technological innovations. This new technology allows us not only to diagnose, but to treat decay without having to anesthetize the patient in the majority of cases. You will find that this is of tremendous interest to today`s patients with their hectic lifestyles. The advantages to the office when the doctor maximizes patient treatment per office visit in terms of cash flow are self-explanatory.
3. It is of vital importance that air abrasion`s diagnostic ability be demonstrated to the patient. An intraoral camera (IOC) facilitates the patient`s understanding of how hidden or "occult" decay is disclosed and uncovered by way of the air-abrasive procedure. The IOC`s use helps communicate to the patient the details of the entire procedure; intraoral cameras, in short, enhance the doctor`s credibility. There is no denying the severity of decay when it is shown to you on a 19-inch monitor. Although not indispensable, the combined use of an intraoral camera and air abrasion will ease case acceptance, as well as imprint upon the patient the "cutting edge" image of the practice.
4. The usual sequence of diagnostic events centers on the abrasive disclosing of teeth which are slated to be sealed or teeth which you suspect from their anatomy, the patient`s caries experience, and related oral hygiene are likely candidates for occlusal decay.
5. Patient education regarding the use of air abrasion (before treatment) is best done by combining audiovisual aids (patient-education tapes, pamphlets, handouts, posters) with an informed staff, willing and able to answer any questions the patient might have. An informed patient is more willing to accept treatment once the dentist enters the room. The treatment team is dealing with the immediate treatment of the patient; there is no need to reschedule the patient or to wait for anesthesia to be achieved. The average number of extra restorations is in the range of 3-4 per day in a typical air-abrasion practice. Apply whatever fees you use in your area and this will give you a good estimate of what financial return you can expect from the implementation of air abrasion in your practice.
6. We all know that there will be times when a conflict will arise between the performed procedure, the available radiographic evidence of the carious lesion, and the inevitable third-party-payment coordinator on the other end of the phone. It helps to have readily available documentation in the form of intraoral images (preferably with the caries-disclosing dye in place) and/or a standard, preprinted office form which informs both the patient and the insurance-claim representative of the nature of the modality, its role in diagnosis, and the extent of the decay that was removed that day.
7. Fee-structuring should be standardized for air-abrasion procedures. My philosophy for air-abrasion treatment and fee-structuring is what I call the "wall-limited" philosophy. As the occlusal fissure is explored (organic plug removed) and decay is pointed out to the patient, a continued and vigilant assessment is made of the depth of decay. My personal opinion - based on my own clinical experience, as well as that of many air abrasion clinicians - is that any enamel (minimal) removed by air-abrasive disclosure be restored with a flowable composite instead of a sealant. A properly adjusted and functioning air-abrasive machine should be capable of removing the organic plug at low pressures and high powder-flow volume, selectively over enamel. My personal reasons for selecting a flowable composite over a conventional sealant stem from its increased compressive strength and wear characteristics. The overall determinant as to how a fee is assessed is based on the depth of the preparation. If the defect/preparation extends short of the DEJ (the "wall"), I would recommend the placement of a highly filled flowable composite and charging a sealant fee. I cannot justify charging more for this procedure. I feel much better about placing this flowable composite as a sealant and my confidence level is much higher knowing that the underlying fissure is clean!
Not surprisingly, many times the extent of decay will go to the DEJ and beyond, yet the decay is not radiographically evident nor does the patient show signs or symptoms of active dental caries. In these instances, it stands to reason that the resulting restoration would be charged as a proper operative restoration. I personally have preferred Ray Bertolotti`s technique to restore this type of preparation and leave that for another article. As previously alluded to, an intraoral camera is invaluable in documenting the extent of decay. Show the patient!
8. Remember to inform the patient of the diagnostic nature of the technology. Patients must be reassured that the technology allows the treatment team to disclose, uncover, and treat decay that previously could not be detected. It allows us to intercept the disease process much earlier along its course. By intercepting and treating earlier, the "hole" we make in the tooth and the subsequent restoration is much smaller. This technique makes dentistry much more conservative. The patient must be made aware of the treatment team`s ultimate goal of making any restoration, if not unavoidable, as small as possible. By doing this, we increase the life of the tooth by conserving original tooth structure as much as possible. The end result is a much lower likelihood of that tooth ending up with a crown or root canal.