Fools rush in

Sept. 24, 2013
G. V. Black and amalgam restorations are haunting us. I am not talking about the spin regarding amalgam material safety.

by Paul Feuerstein, DMD

G. V. Black and amalgam restorations are haunting us. I am not talking about the spin regarding amalgam material safety. I look at patients who have giant silver fillings performed with extension for prevention and have less of their own biological material and more dental material. We restore and re-restore "mature" patients' mouths with an array of new, advanced composites and ceramics, as well as by rebuilding dentin.

When we look at a new young mouth and see a small spot on a radiograph or a catch in a pit or fissure, there is a new dynamic in diagnosis. We do not have to "wait until it gets big enough to fill." In many cases, we use a variety of chemical or biological processes to slow down, stop, or remineralize an area that was once doomed to an MOD restoration some 100 times larger than the lesion.

The acronym CAMBRA (Caries Management By Risk Assessment) has added more credence to putting that high-speed away. We even look at changing the biological balance of caries-causing bacteria with products such as EvoraPro from Oragenics that uses probiotics. Unique products such as DMG's Icon also present interesting alternate options to the drill.

These factors have forced us to rethink an initial diagnosis of what we should and should not treat mechanically. Too many practitioners are quick on the trigger to restore an occlusal catch or a slight breach of an old amalgam margin.

Digital radiography, one of many tools, has allowed us to see certain lesions more clearly. New devices using lasers, fluorescence, fiber optics, HD cameras, ultrasonics (S-Ray), tomography (OCT), and others help us accurately visualize what is under that explorer "stick." This helps determine whether that radiographic area has broken through the D-E junction, or if that decalcified area really needs to be removed and restored.

Carestream has software called Logicon that helps determine this breach. The system gives the clinician a graphical representation of interproximal decay based on a large database and sophisticated algorithms. Although many instruments are currently available, there are several new updates to existing products and a couple of new ones have hit the market.

Acteon has redesigned the SOPROLIFE into SOPROCARE. This is a combination intraoral camera and caries detection unit. The detection mode uses more of a black-and-white view of the area with the caries distinctly highlighted in orange. It is a bit easier to see than the former full-color view, due to the contrast.

Spectra from Air Techniques has upgraded the handpiece with some better ergonomic controls and enhanced visualization. Although Spectra is not a true intraoral camera, it can be bundled with the Polaris camera at competitive pricing.

Carestream has introduced the model CS1600 intraoral camera with a caries detection mode that uses a fluorescence/reflectance technology. The images are clear and are educational for the patient.

One product that has not had much change is DIAGNOdent. This product has been on the market for a long time, and it still seems to one to which others compare themselves. KaVo has decided to stick with this consistently well-received, small, portable product.

But the company has introduced another product in Europe called DIAGNOcam. This uses transillumination coupled with a camera that can display images on a computer/tablet screen to allow easy viewing of caries and fractures with simple white light. It should be available in the U.S. soon.

The newest and most interesting caries detection device is the Canary System. The system uses an array of technologies to give comprehensive information of carious and decalcified areas. It uses a laser with luminescence and thermal information to give the practitioner insight into the depth and range of caries and decalcification. It has a camera that allows easy marking of areas of the tooth.

Using various angles of viewing, interproximal as well as decayed areas around restorations can be identified. With extrapolation, the system can predict caries under restorations. Decalcifications can be easily monitored if the practitioner is using remineralizing products. This is the crux of this column -- when not to drill.

To the best of my knowledge, these are the newest models of devices that can help with early caries detection. It behooves dentists to take a hard look at the parameters being used to determine when to use the handpiece, laser, or air abrasion and "violate" the patient's enamel. To misquote Monty Python, every enamel rod is sacred. Don't step on that foot pedal just yet.

Paul Feuerstein, DMD, installed one of dentistry's first computers in 1978, teaching and writing about technology since then while practicing general dentistry in North Billerica, Mass. He maintains a website (, Facebook page (Paul-Feuerstein-DMD-Dental-Technology), is on Twitter (@drpaulf), and can be reached via email at [email protected].

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