Dental therapy: the next level
Dentistry: The next level
Brook A. Niemiec, DVM, DAVDC, DEVDC, FAVD
Southern California Veterinary Dental Specialties & Oral Surgery
San Diego, CA USA
Teeth are roughly broken up into three layers: enamel, dentin, and pulp.
The innermost layer is the endodontic system (root canal or pulp). It contains the nerves, blood vessels, and connective tissue which supply and nourish the tooth during life. The blood and nervous supply enters the tooth through the very bottom or apex of the root.
The outer layer of the tooth crown is enamel, which is an inorganic substance. It is virtually all (97%) calcium and phosphorus and is the hardest substance in the body. Enamel has no nervous or circulatory system. It is applied in a very thin layer (less than 1 mm thick in veterinary patients) over the tooth surface during development by a cell layer called amelioblasts. Once eruption has occurred, enamel cannot be replaced or repaired.
The central layer, which is the vast majority of the tooth structure in mature patients, is dentin. Dentin has roughly the same mineral content as bone. Dentin is a somewhat living structure which has a nervous supply and can occur can respond to stresses. Running at right angles to the root canal all the way around the tooth from the root canal out to the enamel are dentinal tubules. Each one of these dentinal tubules contains an odontoblastic process, which is basically a nervous supply; however they are only sensory and can only report changes as pain. There are approximately 50,000 dentinal tubules per mm2 coronal dentin. Therefore, a 1 cm area of enamel loss will expose 3-4 million odontoblasts!
Response to Damage:
Exposure of the dentinal tubules will lead to much quicker dentinal fluid flow out through these dentinal tubules via the capillary effect. This increase in fluid flow deforms the A-delta C-delta fibers and thus will be perceived by the patient as pain. Anything that will change the flow rate will cause the nerves to fire and result in pain (sensitivity). This includes heat, cold, and desiccation.
In addition to the sensitivity produced by the exposure of the dentinal tubules, there is a possibility of ingress of bacteria into the root canal system. In some cases this can result in endodontic infection and subsequent abscessation.
Diagnosis: First, perform a thorough visual exam to determine the presence of pulp exposure or other extensive damage. Finally, expose a dental radiograph to rule out endodontic disease. If there is radiographic evidence of endodontic disease root canal therapy or extraction is indicated.
Tooth Preparation: Scale and polish the surface of the tooth to be treated. Make sure to use fluoride free pumice for polishing to avoid interfering with future acid etching.
If treating a small uncomplicated crown fracture, no actual restoration will be placed. Therefore smooth the rough edges with a white stone or fine diamond bur. This can be followed with sanding discs if necessary.
In cases where a restoration will be placed, it is recommended to use a coarse diamond or carbide bur for the preparation. This will leave a rough surface and increase bond strength. Furthermore, all non-occlusal edges should be beveled. This will make a more gradual transition of color as well as increase the amount of enamel for bonding.
For EH cases, remove all weakened diseased enamel with a coarse diamond bur and bevel the edges
For caries cases remove all carious dentin as well as extend the prep into area where there is a high probability of extension. Then make sure that all of the unsupported enamel edges are removed. The bottom of the prep should be flat and the sides of the dentin parallel or very slightly undercut.
Acid etching: This step is performed with a 37% phosphoric acid. The purpose is to remove all impurities from the tooth surface and slightly demineralize the tooth surface of the tooth. This will lead to increased surface area for bonding. Place the supplied acid on the tooth surface and let stand for 10-30 seconds. After the prescribed time, rinse thoroughly (20 seconds) as insufficient rinsing will result in residual acid remaining in the dentinal tubules and result in sensitivity. Finally, dry the area lightly (do not desiccate) as over drying will weaken bond strength.
Place bonding agent
The bonding agent should be applied in a very thin layer. After it is applied, it is light cured with an intense blue light in the visible range for 10 seconds.
For uncomplicated crown fractures, place a layer of unfilled resin over the bonding agent and light cure. This completes the therapy.
For defects to be filled, the composite is placed and then manipulated to fill the defect. This can be done with a plastic filling instrument or a beaver tail coated with unfilled resin. Once the defect is filled (to slightly overfilled) and the restoration roughly contoured, the restoration is light cured. After light curing, the restoration can be smoothed and shaped with white stones, fine diamonds, or sanding discs. Once finished. A layer of unfilled resin should be pace to fill in areas of polymerization shrinkage and smooth the final restoration.
Periodontal Flap Surgery
Introduction: Any pocket with depths greater than normal (for the species) are pathologic and in need of therapy. These are present in the vast majority of patients and represent not only an opportunity to improve patient health, but also to increase practice income. A thorough oral exam will elucidate these pockets and allow for proper therapy.
Periodontal therapy/surgery involves removing the infection from the root surface (i.e. plaque, calculus, and granulation tissue), as well as smoothing the diseased root surface. These steps allow for gingival reattachment leading to a decrease in pocket depth.
In dogs, pockets between 3 and 6 mm which are not associated with tooth mobility or other pathology (furcation, root caries) are best treated with closed root planing and subgingival curettage. This step is performed with a combination of mechanical and hand scaling. This should be meticulously performed in order to achieve as clean a tooth as possible to promote healing. Following this, periocuetic can be administered to improve attachment gain.
Pockets greater than 5 to 6-mm require advanced procedures for effective cleaning, owing to the fact that residual calculus is seen with regularity in pockets greater than 6-mm. In humans this is known as the 5-mm standard. In addition, periodontal surgery is indicated for teeth with even moderate alveolar bone loss, furcation level II and III, and inaccessible areas. Visualization is best accomplished via periodontal flap procedures, which should be offered if the clients are interested in salvaging the teeth. These are advanced procedures, but can be learned by general practitioners.
All surgery should initiate with a complete dental prophylaxis to decrease oral contamination. Ideally, this is performed a few weeks prior to the surgical procedure. Following this, a complete oral exam is performed. This should include the visual as well as tactile senses. Tactile evaluation consists of a combination of periodontal probing and sounding. Finally, dental radiographs should be exposed of the surgical area to document attachment levels.
There are numerous options for flaps, depending on the presentation. The most common flap used in periodontal surgery is a full flap, or one with vertical releasing incisions. This allows for increased exposure, however is somewhat more invasive. The other common flap for periodontal surgery is the envelope flap. This is created along the arcade, without vertical incisions.
Treating the exposed root/bone surface:
The goal of periodontal surgery is to create a smooth and clean tooth surface for reattachment. This is comprised of several steps.
The most important step is thorough root planing. This is best performed with a combination of ultrasonic and hand scaling. This author prefers utilizing the ultrasonic scaler on the root surface to remove the vast majority of the plaque and calculus. Following this, a sharp curette is used to plane the exposed root surface to as smooth as possible a finish.
If bone augmentation is indicated, it is mixed according to manufacturer’s directions and placed in the defect. There are numerous products available; the practitioner must make their own decision based on cost. However, currently, the product with the best track record for regrowth is freeze dried, demineralized cancelleous cadaver bone.
A barrier membrane should be placed over the surgical site, if bone regrowth is desired. In veterinary medicine, absorbable membranes should be utilized. There are several types and manufacturers; this author finds that the lamellar bone membrane works well. Another option for the barrier membrane is to create one out of a perioceutic.