Sunday, February 11, 2018

Bioactive dental materials

What are Bioactive dental materials?

Bioactive dental materials release compounds that help regenerate or maintain dental structures. In the past fluoride release was the only mineral that was in bioactive materials. Today we have materials that also release calcium and phosphate ions. Dentists use bioactive materials to remineralize dentin, repair bony defect, and maintain dental prosthetic margins

Another definition of bioactive dental materials

A bioactive dental material is something that forms a layer of hydroxyapatite or apatite like substance when immersed in saliva or a solution containing inorganic phosphate.  Bioactive refers to the materials ability to induce a response from a living cell.  It’s unclear if this definition excludes fluoride releasing dental materials, but I have fluoride releasing material on this page.

How do bioactive dental materials work?

Release of calcium from these materials, is what makes all of the non-flouride only bioactive materials work. This calcium works to help pulpal healing, promote immediate bonding and sealing, stimulate hydroxyl-apatite, and form secondary dentin. The material design often includes a biocompatible matrix material, bioactive molecules, or additive molecules and ions.

Classifications of bioactive dental materials

Primarily we have calcium silicates and calcium aluminates but the bioactive dental materials often contain some mixture of both. This only refers to the calcium releasing bioactive materials not the fluoride only materials.

  • Calcium silicate materials similar to MTA (Portland cement)
  • Calcium silicate with phosphate and without aluminum
  • The calcium silicates with mostly tricalcium silicate
  • Calcium aluminate
  • Calcium aluminate and glass ionomer

 

List of bioactive dental materials

Specific bioactive dental materials by trade name

Many of these materials are very similar. I am not including those materials in the table above.

  • ACTIVA (Pulpdent) comes as both a filling and liner
  • Beautifil  (ShofuDental) comes as restorative filling material
  • BioCem  (NuSmile) this is the exact same as ACTIVA cement and I heard just repackaged for NuSmile.
  • TheraCal LC (BISCO) is a dental liner

Why do dentists use bioactive materials?

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MTA mineral trioxide aggregate

MTA was the bioactive dental material that jump-started the interest in the field. It consists of portland cement 75%, bismuth oxide 20%, and gypsum 5% and trace amounts of silicon dioxide, calcium oxide, magnesium oxide, potassium sulfate, and sodium sulfate.  Portland cement is tricalcium aluminate, dicalcium silicate, tricalcium silicate, and tetracalcium aluminoferrite.  The removal of tetracalcium aluminoferrite removes the gray color and creates White MTA.

Information about some bioactive dental materials

TheraCal is in a new class of materials called resin-modified calcium silicate RMCS.

MTA Fillapex is resin base endodontic sealer and is similar to Fillapex MTA cement.

Biodentine by Septodent is a calcium silicate product. It is very similar to MTA with some improvements. Biodentine is made of tricalcium silicate, dicalcium silicate, calcium carbonate, calcium oxide, iron oxide, and zirconium dioxide as a radiopacifier. The liquid portion is calcium chloride and a polymer.

Activa Bioactive by Pulpdent is a bioactive cements that releases flouride, calcium and phosphate.  I have been told that BioCem by NuSmile is actually made by someone else and the only other product availabe is Activa so….

MTA research

MTA beats biodentine in furcation perforation repair. Assed Bezerra Silva JOE 2017

Ceramir cement by Doxa

Ceramir is a hybrid material consisting of calcium aluminate and glass-ionomer components. It’s new and I’ve seen conflicting reports on whether or not it’s actually better in any way. Pameijer shows that micro-leakage of Ceramir is the same as Rely x luting plus in the short term. Ceramir does test higher than other cements for antibacterial properties. Unosson  Of course the main reason we have interest in Ceramir is due to it’s ability to remineralize at the margin. Alhuwayrini It is testing as acceptable retention.  Jefferies J Clin Dent 2009 Jefferies 3 year test

Bioactive dental liners

TheraCal LV by Bisco, Activa BioActive Base/Liner and Biodentine.

Giomer products

Giomer products have been around for a long time but Shofu’s new line of Beutifil products are nice and like all giomers release fluoride.

Bioactive dental material articles

Dental today article is very nice and so is this review article.

Other similar topics to bioactive dental materials

Bioceramic dental materials are under the umbrella of bioactive dental materials.

Bioceramic materials include alumina, zirconia, bioactive glass, hydroxyapatite, and resorbable calcium phosphates. They are chemically and dimentionally stable, biocompatible, and osteoconductive. Biocermic materials are non-corrosive, bioinert, bioactive, and biodegradable, soluble or resorbable.

Bioactive molecule delivery systems should be in own post since this is tissue engineering

Bioactive molecules are active signaling molecules that both initiate and maintain cellular responses. They are one of the basic principles of tissue engineering triad; those three being stem cells, scaffolds, and bioactive molecules. The challenges dentistry has in using bioactive molecules is that high concentrations can be toxic to cells, bioactive molecules have may have a short half-life, and maintaining a high enough concentration for the therapeutic time period.

Dentistry uses bone morphogenic protein BMP for bone grafting, well technically we use rh-BMP2.

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Friday, February 9, 2018

Implant assisted partial denture

What is an implant assisted partial denture?

Implant assisted partial denture is a partial denture that has one or more dental implants helping it out.

What does an implant assisted partial denture look like?

If you know what a partial denture looks like then you know what an implant assisted partial denture looks like. The only difference would be there are what appear to be buttons, which we call attachments on the tissue side of the partial denture. There will be an female attachment for each dental implant inside the partial denture.

Image of an implant assisted partial denture

What are the benefits of supporting a partial denture with implants?

  • The partial denture will hold up longer because it has more support.
  • The remaining teeth will hold up longer because they have extra help supporting the partial denture.
  • The partial denture will fit more tightly because it is snapping onto a dental implant or dental implants.
  • The bone where the dental implant is at will be stronger and will hold up longer.

What is the cost of an implant assisted partial denture?

That depends on the number of implants one has to help support the partial. If only one dental implant the cost in our office in 2018 is around $4,000. That cost includes the partial denture, the dental implant, and the attachment parts that connect the two.

What are some of the complications and issues with implant supported partials?

Parts wear out and break down at higher rates than most other things we do in dentistry. This of course depends on the individual and the parts we use but eventually things break.

 

Tips and tricks for dentists that have an interest in providing implant assisted partial dentures.

    • Pick up the metal housing in a processed baseplate or metal mesh baseplate. This tip comes from Dr. Sharifi and I love the idea!
    • Do not hang the partial off of an implant crown and plate the terminal abutment. However, these rules are also useful in regular partial dentures too.

What type of attachments are available for implant supported partial dentures?

The most common are ERA and locators but the list is extensive. The ERA is vertically resilient so use for any anterior implant positions and use the locator for posteriors.

What are the ADA dental codes?

  • 5862 = precision attachment (one male and female component)
  • 6054 = implant/abutment supported removable denture for partially edentulous arch

 

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Tuesday, January 30, 2018

Oral dysesthesia

Oral dysesthesia – What is it?

Oral dysesthesia is a challenging condition for both doctors and patients. It is a painful or unpleasant abnormal sensation that is classified into 2 categories of spontaneous or evoked. The pain is what differentiates this condition from paresthesia.

Oral dysesthesia Etiology and Symptoms

The symptoms or oral dysesthesia can vary greatly from patient to patient. The symptoms can consist of a large number of things.

  • Feelings of a foreign body
  • Exudation
  • Squeezing or pulling
  • Movement
  • Misalignment
  • Pain
  • Spontaneous thermal sensation or taste
  • Feelings of slickness
  • Excessive saliva or bubbles
  • Dryness

List of oral dysesthesia symptoms

This is likely a combination of neurological and psychological causes with a combination of neurosensory hyper-awareness and psychological effect. The spontaneous types occur for no apparent reason. The evoked types occur after some sort of peripheral nerve trauma. This can be almost any dental procedure, systemic illness, medication side effect, or exposure to chemicals.

The most common type or oral dysesthesia is phantom bite syndrome. Numb chin syndrome is similar to oral dysesthesia but is not under this umbrella.

Oral dysesthesia treatment

A diagnosis of either peripheral or CNS is made by injection of local anesthetic. The treatment consists of behavioral and pharmacological treatments. Cognitive behavioral therapy of coping or distraction skills. Medication we use is neuroleptics or low does antidepressants. Local medical treatments may also be effective. Treatment needs to be with an oral facial pain expert typically found in University settings. The University of Illinois has an orofacial pain clinic and that is were I send any patients that call our office looking for care. The article by Spencer is excellent.

Many patients with this condition end up getting at least some dental treatment that was likely never needed. Unfortunately, this is almost impossible to avoid due to the wide range of symptoms.

Other difficult conditions in dentistry that may be similar to oral dysesthesia.

This is the 7th in a series of 8 posts about orofacial pain with difficult to diagnosis or unusual origin.

  1. Cracked tooth syndrome
  2. Trigeminal neuralgia
  3. Atypical odontalgia     JADA article Marbach Feb 96 JADA      Great lit review
  4. Neuralgia-inducing cavitational osteonecrosis or NICO
  5. Referred pain
  6. Myofascial pain 
  7. Burning Mouth Syndrome 
  8. Oral dysesthesia

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Tuesday, January 23, 2018

Crown vs filling

Crown vs filling – when do we do crown and when do we do a filling?

Crown vs filling is a very tough thing to decide. Nearly every dentist has their own criteria and that criteria is highly subjective. The same dentist may not even have the same recommendations from year to year and forget about dentist to dentist. The variability between professionals is enormous. No one really knows who is “right”.

Factors dentists consider when deciding crown vs filling.

There are many factors a dentist must think about when deciding whether or not a tooth needs a crown or a filling. Most evolve around how much tooth structure is left and what the patient habits are.

  1. How much tooth structure is left.
  2. Did the tooth have a root canal?
  3. How much functional abuse the patient is applying to the tooth/teeth.
  4. Dental history of the patient.
  5. The decay risk of the patient.
  6. The condition of the rest of the teeth.
  7. The financials of the patient.
  8. Variable patient specific issues.
  9. Variable dentist specific issues.
  10. Others?

Crown v filling – How much tooth structure is left?

Definitely the most important factor in deciding whether or not a tooth needs a crown or a filling will suffice. There is no hard and set rule for this or else crown vs filling would not be a debatable topic.

Did the tooth have a root canal?

Basically back teeth with a root canal should have a crown and front teeth should not. I have another post on this topic as there are some exceptions as to where you need a crown after a root canal.

Functional abuse, decay risk, and patient history factors when deciding crown or filling.

All three of these are patient specific so they vary from person to person. The more functional abuse, grinding and clenching, the more one would lean toward a crown. Cracks and wear facets are good indicators of functional abuse. The more decay, well the more tricky. Do you just do a cheaper filling knowing they will need a crown later or do a crown and hope you limit the area of the tooth that can decay? Are they so bad that you are just buying time so what the cheaper filling? Patient history is basically how well are crowns and fillings holding up in that person.

Image of crown vs filling

The above photo shows a tooth with cracks and wear facets. The wear facets are circled in black and the black arrows are pointing to the cracks.

Iamge of crown v filling

The same tooth as above right before we bond it and take an impression for the dental crown. The arrows point to the crack that was under the metal filling.

The condition of the rest of the teeth and the financials of the patient factors help decide crown or filling.

When thinking about crown v filling, the rest of the mouth may come into play. If only dealing with one tooth then this is not an issue, however, if you have a mouth full of decay the long term plan must be thought about. The long term plan will need to include a discussion about finances. It costs a lot to fix a mouth full of decay and if the person doesn’t change their diet and oral hygiene habits then it can be a waste of money.

Image or crown or filling?

Crown or filling on these teeth? To me these teeth require knowledge of the the rest of the mouth. I am more conservative and none are crowns for sure in my eye, but I will use transillumination and patient history to decide when to pull the trigger. I also consider insurance issues, so teeth like this will get done in the end of the insurance year if nothing else was done.

The variable factors of crown v filling include the odd things.

Patients may not like crowns or fillings for some personal reasons. Dentists may not like doing a dental filling in certain areas of the mouth or in certain people as they are too difficult to do well. A large filling on a back upper molar of an obese individual with a gag reflex can be very challenging to do well and the dentist may be better able to provide a crown.

Crown vs filling the website

A website the helps determine crown v filling from the literature is crownorfill.com.

Still in it’s infancy as of 2018, this site really can be the evidence based site to help us decide crown or filling.

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Saturday, January 13, 2018

All on 4 broke

Is your All on 4 broke?

All on 4 broke and you need a repair or replacement? If so check out some of the issues and options to fix the problem. You may also find out find out why your all on 4 broke and what if anything you can do to prevent it from occurring again. The term all on 4, hybrid denture, AO4 are interchangeable. The issues on this page occur with many implant supported dentures.

Well what specifically about the all on 4 broke?

There are many things that can break or fail on an all on 4. Starting at the very base a denatl implant can fail and need removal. Implants or the abutments attaching the implant to the all on 4 denture part can break. Screws of the all on 4 can break or come loose. The metal support can break. Finally the teeth or acrylic can break of fall off. Each problem has a specific solution to fix and also should possibly change how your dentist and you maintain your all on 4 going forward. I will discuss each type of breakage individually with tips on how to fix and how to avoid in the future.

Teeth and acrylic of the all on 4 can break

This is by far the most common issue we see. Studies show that half of acrylic all on 4 prosthesis will have a tooth or acrylic fracture @ the 10 year mark. In my personal experience once a patient has this occur once it seems to be a recurring theme for them.

The simplest fracture is when an individual tooth comes out. This is fairly easy to fix and we often just fix it in the office. A more sever fracture of acrylic may require the whole thing be sent to the lab. This is a pretty big inconvenience for a patient.

 

Image all on 4 broke tooth

Solution – The dentist or the dental lab can replace the tooth, teeth, or acrylic at a cost of several hundred to maybe a thousand or so depending on severity.

Prevention – Wear a night-guard to protect your investment and be careful what you are eating.

The teeth on an all on 4 can wear down.

It is my belief that the percentages we see of wear correlate directly with the percentage of patients that suffer from sleep bruxism. The exact percentage of the population that suffer from sleep bruxism is not well known.  A questionnaire study from 1981 shows the number of sleep bruxers to be 13% but I personally don’t trust a questionnaire study on bruxism at all. About 1/3 of prosthesis will show signs of wear at the 10 year mark.

Solution – Replace the teeth at a cost of perhaps a thousand or two.

Prevention – Wear a night-guard to protect your investment.

Failure of a dental implant on the all on 4.

This is pretty rare but it does happen. Typically if the dental implant survives the first year it’s chances of long term survival are very high. When a dental implant fails, it needs removal. However, if we catch a dental implant that is just failing, there are things we can do to help ensure that you keep the implant. There are procedures such as LANIP that can sometimes save a failing dental implant but that is the exception not the rule.

If the dental implant fails and needs removal this can be a major issue. However, if your mouth was over-engineered and you have extra implant then we can remove the implant and it will not impact the prosthesis on top. If you have only 4 implants and one fails your prosthesis can be in serious trouble of complete failure. I have seen an individuals take off the prosthesis, place a new dental implant, and laser weld to the existing prosthesis to save the day. That is a fantastic save and is something that most labs can accomplish these days.

Below is this case about 1 year after delivery. The area had an infection that would not go away and we could place the probe into the infection site. After awhile the infection ate up enough bone to cause the loss of a dental implant. Fortunately we we over-engineered the aces and had 6 total implants so the loss of one middle one didn’t impact the case at all.

Solution – If have enough implants do nothing. If not add an implant at a cost of around 2k plus costs to attach to prosthesis, which can be hefty.

Prevention – Not much one can do other than maintain excellent hygiene, however many failures happen for unknown reasons.

Implant or the abutments attaching the implant to the all on 4 breaking is pretty rare.

I am sure this can occur but I have not ever seen it personally or heard about it happening. However, I have seen individual implants break and we must remove them. This seems less likely when we attach 4 or more dental implants together because we can distribute the forces out more.  I have never seen a metal abutment break, but the zirconia ones are notorious for this. I do not think anyone uses zirconia for their all on 4 dentures and I have never seen or heard of an all on 4 abutment breaking ever. Depending on how many implants you have this type of breakage could be irrelevant or very damaging.

Since I have not seen this type of breakage I will include a photo of what a single abutment breakage looks like.

Solution – Dentist replaces the screw which should cost hundreds to maybe a thousand or so.

Prevention – Nothing you can do to prevent.

All on 4 screws can break or come loose.

This is also rare. Typically if this happens it is not that difficult to remove them and replace. Around 10% of prosthesis have a screw come loose by the 10 year mark and about half that number have a screw break.

Pushing the limits on what is possible is a sure way to increase the chances of this happening. We have one patient with an all on 2 and both screws have broken.

Solution – Replace the screws at a cost of a few hundred dollars.

Prevention – Not much. Have dentist check design of the bite, in other words how the teeth come together.

 

The all on 4 framework can break

This is also rare but if it happens it can be a major issue, perhaps even ruining the entire prosthesis. A fracture of a zirconia framework requires a remake. A fracture of a metal framework can have a laser weld to repair it. Under 10% of frames will fracture by the 15 year mark.

Solution – Big issue if breaks somewhere that you need a repair. If you have a metal framework we can laser weld it back together but that is not cheap, couple thousand at least. If zirconia you are out of luck and are going to have to get a new one.

Prevention – Not much you can do. Dentist can limit cantilevers or in layman’s terms not add so many teeth to the the back.

 

All on 4 broke and you need help?

If your all on 4 broke, we can help you with any issue dealing with your dental implant prosthesis. Whether it is a surgical dental implant issue or a prosthesis complication, just give us a call and we can try to find a solution for you.

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Tuesday, January 9, 2018

White kids crown

Are you looking for a white kids crown alternative?

White kids crown alternative to the metal kids crown is available and our Board Certified Pediatric Dentist, Dr. Briney is providing this service to kids across the Midwest.

What are the benefits of the white kids crown?

The only real benefit is the esthetic benefit. One complaint we hear is that a child is socially aware of the black metal crown. Kids picking on each other is a part of life and a metal crown sometimes makes a child a target. Few parents are aware that there is a even a choice for a white kids crown, which is a shame.

What does a white kids crown look like?

There is no way to explain it other than to show it, so below you will see a photo of 4 white pediatric crowns.

Image of a white kids crown alternative

Why aren’t all kids crowns white?

Well they cost more for one. The cost is that much more in terms of the actual material cost but it takes more skill to do the white kids crown well. Basically it is harder to do and thus it costs more to do. We can bend metal kids crowns to fit a tooth whereas a white kids crown has to have the tooth fit it perfectly. It takes some skill and experience to prepare the tooth so that it is a perfect fit for the preformed white crown.

Why wasn’t I made aware of the option for a white pediatric crown?

The stainless steel crown alternative is not available everywhere and it is very likely your dentist does not provide this service or they do it very rarely. It’s simply not possible to always let everyone know every possible alternative available in the whole world. We provide the options for the services we are aware of and feel are appropriate for a given situation. The is also the fact that stainless steel crowns have a long history and thus lots of research behind them. Whereas, the stainless steel crown alternative white crown is too new to have that data.

What do I do if I would like to have these white crowns for my child?

Give our office a call and we will happily review your insurance and answer any questions that you have. We see patient from across the Midwest so our staff can accommodate your family no matter where you live.

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Sunday, December 31, 2017

Tooth material options

What are your tooth material options for an all on 4?

Tooth material options vary depending on your particular situation. Typically if doing an all on 4 or any implant prosthesis There are many options available for tooth material section for the all on 4 or other types implant prosthesis. The options will certainly continue to increase. We are probably to a point where the lab technicians preference and experience is more important than the differences in material to some extent.

Tooth material options for your all on 4 or implant prosthesis.

There are several many categories for you to choose from when picking your teeth out for your prosthesis. Factors that you can use to help you deiced are found below. The most important decision is actually whether or not you want individual teeth or a single unit or block of teeth.

  1. Traditional acrylic denture teeth
  2. Modern nano composite denture teeth
  3. Porcelain teeth not including zirconia.
  4. Zirconia teeth.

Traditional acrylic denture teeth for the all on 4 or implant prosthesis.

This was once our only choice and works ok for people if they are not clenchers, grinders, or hard on their teeth in general.

Pros:

  • Cheapest materiel available
  • Easy to replace and fix
  • Standardized shapes and sizes to choice from
  • In use for decades so we know a lot about them, which means people have experience with them and we know their weaknesses and strengths

Cons:

  • Don’t look as nice
  • Don’t last as long (wear down faster)
  • Break out easier

Image of teeth material options acrylic teeth

Modern nano composite denture teeth for the all on four or implant prosthesis

These are the modern line of denture teeth and there is little reason not to be switching to these except cost. Phonares are one popular brand.

Pros:

  • Reasonably priced
  • Easy to replace and fix
  • Esthetically they are very nice in my opinion.
  • Standardized sizes
  • Can bond to it and fix in the mouth

Cons:

  • Break out easier

Image for tooth material options nano composite.

Porcelain teeth for all on four implant prosthesis

This is basically traditional crown and bridge dental work that happens to be on dental implants.

Pros:

  • Holds up extremely well
  • Can look beautiful
  • Can customize however want.

Cons:

  • Difficult and expensive to do well
  • If breaks, expensive and difficult to repair (unless do individual teeth)

Image for tooth material options porcelain

Zirconia teeth for your all on 4 implant prosthesis.

The newest porcelain in dentistry that is extremely strong.

Pros:

  • Strongest material we have that is tooth color.
  • Holds up extremely well
  • Can look beautiful but takes some skill
  • Can customize however want.

Cons:

  • If breaks, expensive and difficult to repair (unless do individual teeth)
  • Makes a loud clicking sound when you have top and bottom teeth same (this is the only reason that zirconia against zirconia may not be the absolute best)
  • Is the mode of failure now with the implants?

Images of tooth material options zirconia.

Factors in choosing tooth material for your all on 4

How hard you are on your teeth, what the opposite teeth are, how esthetic you want it to be and how much money you are willing to spend on the teeth are the main options I consider.

  • Cost – porcelain and zirconia cost more
  • Esthetics – most are pretty good, but porcelain can be amazing
  • Longevity – porcelain and zirconia probably last the longest
  • Experience of dentist and lab technician
  • What the opposing jaw is
  • Dental habits
  • Type or prosthesis

My preference for teeth selection for an all on 4

My person preference for restoring an all on 4 or any implant prosthesis changes depending on several factors but a prosthesis with individual teeth is most ideal in my mind. Tooth material selection for me would be zirconia on top and nano-composite denture teeth on the bottom. The nano-composite act as our fail safe system and act as shock absorbers to a minor extent.

Tooth material options – Individual teeth vs single unit for your implant prosthesis

Individual teeth are much more expensive but better long term because if something ever happens to a tooth we can simply change it out and give you a new one without having you give up all your teeth for several weeks. This option is not given very often because it is more difficult. I actually prefer it and try to make the cost not that much more than a prosthesis that is one unit.

 

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