Tip of the Month

Tip of the month for July provided by John M. Coke DDS, Professor and Director, General Dental Residency, UAB School of Dentistry. Email address: jmcoke@uab.edu
Tuesday, January 01, 2008

Your Patients on Plavix

Chances are you are seeing an increasing number of patients that are taking or have taken Plavix (clopidgrel hydrogen sulfate). In 2005 it was the #31 prescribed drug in the United States and it looks like it will move up in ranks in 2006. Plavix is classified as an anti-coagulant medication and basically works by preventing ADP binding to the receptors on the surface of platelets. This prevents the platelets from “clumping together” which is also known as secondary platelet aggregation. Thus Plavix reduces the likelihood of blood clots forming in circulation and forming thrombi. Patients with a history of coronary artery disease, cardiovascular surgery, stoke (CVA), and recent total joint replacement surgery is now being placed more routinely on Plavix. Cindy L. Grimes, MD, et all, reported in the May 2007 JADA that Plavix (and other similar medications) in combination with aspirin is now the norm for patients receiving coronary artery surgery especially with stent placement.1 These patients are often placed on Plavix for months and years. The authors also indicated that taking these patients off Plavix could result in thrombus formation with significant adverse events.

How should you proceed with these patients for both routine and surgical dental care? The most important question for you to ask is, “Why are you taking Plavix?” If your patient responds that they had recent coronary artery surgery, total joint replacement surgery or a stroke, it is best to postpone non-emergent surgical dental care for one year. When the patient is medically stable (2 to 6 months) routine non-surgical dental care can be done without modifications. If you are anticipating doing surgery, contact the patient’s physician about the risk of post-operative bleeding. They will weigh the risks of post-operative bleeding versus systemic complications. As pointed out, it is often more dangerous to take these patients off the Plavix because of the threat of multiple systemic thrombi. Remember there is no specific laboratory test (unlike coumadin) that can give you an accurate picture of their coagulation status.

It has been our experience that routine dental surgery on medically stable patients taking Plavix can be done safely. These patients are kept in the chair 15-30 minutes longer post-operatively with pressure gauze packs to assure the initial clot has formed. Routine post-operative instructions are emphasized several times and the patient is telephoned that evening to assess their clotting status. With routine restorative and periodontal procedures, the patient is also kept in the chair 10-15 minutes longer to assure clotting. The dentist can also use local anesthesia containing epinephrine given in small amounts via infiltration to assist in the initial hemostasis.

1. Grimes, CL; Bonow, RO; Casey Jr., DE; Gardner, TJ; Lockhart, PB; Moliterno, DJ; O’Gara, P and Whitlow, P. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents, JADA 2007; 138 (5): 652-5.

Tip of the month for December courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Monday, December 03, 2007

MRSA unmasked

Recently the lay press has been abuzz with the "news" that a superbug is about to make its unwelcome presence felt and possibly kill us all, or worse. Most reporters focused on the fact that, according to the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, this armored microbe killed more people in the US in 2005 than HIV, the virus that causes AIDS.

So what are the facts?

MRSA stands for methicillin-resistant Staphylococcus aureus and has been with us for about 30 years. S. aureus is a common inhabitant of normal human skin and may produce infection in both superficial and deep wounds. In rare occasions the infection may become systemic or the bugs may enter the lungs and produce bacterial pneumonia. Staphylococci were among the first bacteria to produce beta-lactamase and thus become resistant to beta-lactam antibiotics (the penicillin family). Methicillin is a semi-synthetic penicillin that was introduced specifically to overcome this problem, so the appearance of MRSA was of high concern to the medical community. In the 1970s and 80s, MRSA was almost completely restricted to nosocomial (hospital acquired) infection, but in the 90s it penetrated into communities. Today, about 50% of community-acquired S. aureus infections are MRSA. Current treatments for these infections consist of vancomycin or, when sensitivity tests allow, clindamycin or sulfa drugs. Only on rare occasions a MRSA infection progresses despite antibiotic treatment and elderly and immune incompetent individuals are the typical victims. There is no evidence that the number of Staphylococcal deaths has increased, but with the higher prevalence of MRSA in the community, the number of fatalities attributed to it has also gone up.

Much of the spread of resistant bacteria (MRSA is far from being alone in that group) can be traced to the overuse of antibiotics in medical and dental practices. Every time we write an antibiotic prescription, we basically select the resistant flora for survival. Generally, the normal flora returns within 2-6 weeks, but often a superbug may emerge and thrive. Most hospitals have implemented restrictions on the use of potent new antibiotics and professional agencies have started campaigns to educate medical and dental practitioners on proper usage of antimicrobials. Thus, while sensationalized news should not produce a panic reaction, we should welcome the reminder that judicious use of antibiotic is the best practice and these drugs should be prescribed for infections, not for convenience or legal purposes.

Tip of the month for November courtesy of Charles W. Salmen, DDS,HealthPartners Dental Group,Inver Grove Clinic, Minneapolis, MN. Email address: Charles.W.Salmen@HealthPartners.com
Thursday, November 01, 2007

Is composite the perfect restorative material?

No, but it comes close. I often favor composite vs. porcelain restorations because of excellent bonded strength, esthetic appeal, conservative application and relative low cost. Until recently, I felt that I was merely providing a transitional or compromised esthetic and functional solution for my patients until they can have something “ideal”.

I often begin cosmetic and restorative consultations listening to patients that want porcelain restorations (often veneers), minimal tooth preparation, and natural esthetics. Bolstered by clinical and esthetic successes I find that many patients can have achieve exceptional transitional and long term esthetics and function with composite. Consider these benefits relative to porcelain restorations:

1. Conservation of tooth structure

2. Wear rate of composite similar to that of enamel

3. Ease of placement- single appointments

4. No lab fees, scheduling or communication

4. Allows for phased treatment, transitional and functional provisional changes

5. Lower entry cost to patient with nearly reversible procedure

6. Rewarding for the clinician skilled in freehand bonding

Porcelain and the artists that create it play a vital and increasingly important role in the practice of restorative dentistry. With improvements in composite, however, and our judicious and skilled application- resin bonding is not necessarily inferior to porcelain for many applications. My conservative philosophy and personal preference for natural vs. manufactured smiles often leads me to consider composite for post ortho enhancements, worn dentition, anterior esthetics, and even occlusal and full mouth rehabilitation.

Louisiana dentist and well known presenter, Corky Willhite, DDS, has done much to promote the use of composite in esthetic restorative dentistry. I have recently been inspired by his work with transitional bonding, ultimate esthetic bonding, and occlusal rehabilitation bonding. You can learn more about his approach on the ever- expanding World Wide Web: corky@SmileDesignCenter.com

Tip of the month for October courtesy of Lillian Mitchell, DDS, Assistant Professor, Department of Prosthodontics, University of Alabama at Birmingham School of Dentistry. Email address: lmitchel@uab.edu
Monday, October 01, 2007

Removable Partial Dentures

Removable partial denture service can be a rewarding part of a dental practice. It also can be the most frustrating experience for the practitioner and the patient. Fortunately, there are a few simple steps to help assure a more positive outcome for everyone.

It is important to examine the dental condition presented by the patient. Assuming there is periodontal health, and the chosen abutments are adequate for the job they will be asked to do, then evaluate the occlusion. Are there extruded teeth that will disrupt the occlusal plane? Is the anterior tooth relationship so tight that it would preclude placing a major connector to facilitate replacing the maxillary anterior teeth if needed? Is there a tight occlusal contact where you need to place a rest or pass a minor connector? Are there tipped or tilted teeth that will cause problems with path of insertion?

Check the soft tissues for undercuts that will need to be managed. For example, a prominent canine eminence may prevent the use of a bar clasp, or cause problems when setting anterior teeth. Be sure that there are no maxillary tuberosities in contact with the opposing teeth or residual ridges. Look to see that there will be adequate room between the ridges to set the denture teeth. Ideally these variables are evaluated intraorally, as well as, on mounted diagnostic casts. A dental surveyor is an essential instrument to determine the best path of insertion, areas to prepare guiding planes and to verify the areas of undercut for the retentive clasps.

Good tooth preparation is important to the fit of a partial denture framework. The guiding planes should be prepared on the appropriate surfaces of the abutment teeth first. If the rests are prepared before the guiding planes, the rest seat may be reduced in size and then be ineffective. Another tip is to mark the occlusal contacts with articulating paper prior to preparing the teeth. This allows preparation of the rest seats in areas where there is room for the occlusion, or the option of reducing the opposing tooth to provide room for the rest.

After a rest is prepared, an “instant” impression can be made by pressing a small ball of utility or rope wax into the tooth. When the wax is removed, it will allow you to see if the rest is the best shape and depth that is needed for the RPD design. If the occlusion is a concern, have the patient bite into a ball of wax and check if there is adequate clearance for the rest and minor connector.

Rotary instruments are a personal choice in dentistry, but using 8-bladed carbide burs to prepare teeth for RPD designs have certain advantages. They provide efficient cutting and do not leave the tooth surface so rough that it is not easily polished with conventional tooth polishing systems.

As in all things in dentistry, attention to detail helps insure the best results. The same holds true for removable partial denture therapy. Good evaluation of the patient and good tooth preparations will assure a well-fitting framework and a comfortable prosthesis for the patient. Some planning prior to performing the procedures can prevent remakes and ultimately improve the bottom line in a practice. A positive outcome in removable partial denture therapy is good for the patient, and improves the goodwill of a practice.

Tip of the month for August provided by Ken Tilashalski, DMD,Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: drt@uab.edu
Wednesday, August 01, 2007

Cracked teeth & Cracked tooth syndrome

It is often difficult to determine the extent that a crack has progressed into the surface of a tooth. In fact, sometimes the tooth is extracted before the true nature becomes evident.

Cracks in teeth can be divided into 2 broad categories: craze lines and fractures.

Craze lines are superficial cracks in the enamel and do not extend into the dentin. These are asymptomatic and no treatment is necessary unless there is an esthetic concern.

Fractures on the other hand extend deeper into the dentin. Symptoms can vary from none to severe pain, and treatment varies accordingly, and ranges from a simple restoration, endodontics or even extraction.

When fractures are incomplete, without visible separation of the fractured segments, diagnosis and treatment is more difficult to assess. The term cracked tooth syndrome is often used to describe an incomplete tooth fracture that is characterized by the sudden onset of sharp pain upon biting and thermal sensitivity. Symptoms result from dentinal fluid flow from increased cuspal movement. Biting symptoms are often more pronounced upon release, but this is not absolutely diagnostic. Over time, bacteria can penetrate the fracture line and pulpal symptoms may ensue.

Diagnosis of a cracked tooth can be aided by visual inspection including transillumination, staining with methylene blue or caries indicator, and even microscopic examination, however a crack may not be detectable visually. A devise (ToothSlooth or FracFinder) to isolate each cusp during a biting test can be invaluable in duplicating a patient’s symptoms of biting pain.

The extent of treatment is dictated by the patient’s symptoms. Biting sensitivity without pulpal symptoms necessitates removal or reinforcement of the fracture and usually requires full cuspal restorative coverage (i.e. onlay or crown). If the fracture has propagated to the point that pulpal symptoms are present (irreversible pulpitis) then root canal treatment along with a crown is usually indicated.

Early intervention is the key before a crack extends to the pulpal floor or below the gingival margin and may result in a hopeless prognosis.

Tip of the month for July provided by John M. Coke DDS, Professor and Director, General Dental Residency, UAB School of Dentistry. Email address: jmcoke@uab.edu
Sunday, July 01, 2007

New AHA Guidelines: common sense is finally prevailing

As you all know by now, new AHA guidelines have been published concerning the use of antibiotic prophylaxis for patients with specific cardiac conditions. The past nine AHA guidelines, which were first established in 1955 with the latest in 1997, were closely looked at by a select panel of physicians and dentists. The new guidelines reflect an ever growing concern on the over prescription of antibiotics seen in the United States the past two decades and an increasing emphasis on prevention rather than intervention. We now know that the use of antibiotics can create adverse events for our patients, such as the development of resistant flora and risk of allergic reactions. Simply put, were we doing more harm than good for our patients in prescribing these antibiotics? The new guidelines (below) are simpler for all concerned. There are now only four cardiac conditions that warrant antibiotic prophylaxis and most importantly the laundry list of dental procedures of when to use has been eliminated. The authors of the new guidelines looked at the relative risk of acquiring infective endocarditis from dental procedures on patients with underlying cardiac conditions. Mitral valve prolapse (MVP) deemed to be the lowest risk (1 per 1.1 million) and was thus taken off the list. Most importantly, the authors concluded that “the maintenance of optimum oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis. I applaud their efforts.

Click here to access the AHA Guidelines for Prevention of Infective Endocarditis

Tip of the month for June courtesy of Toni Neumeier, DMD, Associate Professor, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address: neumeier@uab.edu
Friday, June 01, 2007

Cone Beam CT and its impact on the future of dentistry

Computer tomography (CT) has been a useful tool for diagnosis and treatment in medicine. CT can generate 3- dimensional data of a patient. Conventional CT equipment is very expensive, bulky, and located either in the hospital or a diagnostic imaging center. Only medical doctors can order the CT. The patient is placed in the prone position and with a fan-shaped x-ray beam scanning the patient’s body. Cone beam CT is a new form of CT. The equipment is less bulky and slightly larger than the conventional panoramic x-ray machine. It is less expensive, and the price ranges from $150,000 to $ 270,000. The patient sits in the supine seating position, and a cone shaped x-ray beam circles the patient with much less radiation than the conventional CT. Furthermore, dentists can order the cone beam CT for use in their office.

Pros of Cone beam CT:

Cons of Cone Beam CT:

The future impact of Cone Beam CT:

Almost every specialist in the dental field can benefit from the cone beam CT image and it will change patient treatment in the near future.

References:

Tip of the month for May courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Tuesday, May 01, 2007

Heart attacks... not what they used to be

Remember the indication for immediate oxygen for myocardial infarction (MI) victims? Remember the five compressions to two breaths CPR? New basic research and clinical experiments have turned this paradigm up-side-down. Several studies of resuscitation of MI victims have shown that survival rates are superior when the administration of breaths (or high-pressure oxygen) is bypassed in favor of sustained chest compressions. The American Heart Association has modified its guidelines accordingly, currently shifting from 30 compressions to two breaths to no breaths at all. To support these clinical findings, researchers at the University of Pennsylvania in Philadelphia have published studies that showed that myocardial cells do not die from anoxia in the first hours after an MI, as previously assumed. Rather, the researchers say, they commit suicide (mitochondrial-induced apoptosis) when the oxygen flow is abruptly re-established. Indeed, these cells can survive for days in anoxic conditions but promptly collapse when exposed to high levels of oxygen. Clinical data on 36 major MI victims treated with low oxygen and hypothermia after re-opening of the infarcted coronary artery demonstrated an 80% survival as compared to less than 15% for the standard method. The other corollary of these studies is that the heart cells of patients considered clinically dead are actually alive for significantly longer than previously believed. These findings may have significant implications for victim resuscitation as well as organ harvesting for transplants.

Tip of the month for April provided by John M. Coke DDS, Professor and Director, General Dental Residency, UAB School of Dentistry. Email address: jmcoke@uab.edu
Sunday, April 01, 2007

Writing an Effective Medical Consult

All of us, at one time or another, have written a medical consult for one of our patients and either did not receive a timely reply or the reply did not address what we needed to know. Most medical offices are very busy and often look at these consults as low priority items. I have found by writing a very brief and concise medical consult then faxing it to the medical office often speeds up this process. This is how I recommend a medical consult be written:

1. Use your letterhead with all the appropriate information such as address,telephone number and fax number.

2. Your consult should be in four parts: a. Patient description: Include patient’s name and date of birth. b. Patient’s medical problem: Briefly include medical problems that concern you (heart murmur, total joint replacement, hypertension, anticoagulant medication, etc.). c. Your intended dental treatment: Be very general here (use terms like oral surgery, gum surgery, restorations, root canal dentures, etc.). Even if you anticipate surgery in the future, include it here. Most physicians do not understand dental terminology. d. Specific issue you want addressed by physician: Physicians cannot read our minds. Ask specific questions like: “Do I need to premedicate with antibiotics? Does the patient need to come off their anticoagulants? What blood pressure ranges are normal for this patient?”

Here is an example:

Mrs. Joan Doe, DOB 2/1/52, reports a history of mitral valve prolapse with regurgitation. She currently takes 5mg of coumadin daily. Our dental treatment will be the surgical extraction of two teeth with the placement of two implants. Please (1) confirm the need for AHA antibiotic premedication and (2) make recommendations on modifying her coumadin regimen. Also enclose her latest INR. If she does need to be premedicated, we will use the most current AHA recommendations.

Thank you for your timely reply. Your signature

All of this should print out on the top half of your page. Reserve the bottom half for their reply. Remember to keep the consult in your patient chart or scan for your digital chart.

Tip of the month for March courtesy of Charles W. Salmen, DDS,HealthPartners Dental Group,Inver Grove Clinic, Minneapolis, MN. Email address: Charles.W.Salmen@HealthPartners.com
Thursday, March 01, 2007

Pediatric Dental Patient Management

It is 4:15 on a busy Wednesday in your GP dental office. You have just finished filling a tough #31 endo, welcomed a new patient with an initial exam, and numbed an emergency patient gratefully waiting for an extraction before 5:00 PM end of the day. You walk confidently down the hall for towards an ortho extraction just prescribed yesterday by an orthodontist. You swing around the door into the treatment room to sobs and tense faces. 11 year old Will does not want his premolars extracted for braces no matter what his orthodontist or mother thinks. Mother of Will is bound and determined to make this happen- she left work early, he missed his piano lesson and they drove across town in rush hour traffic to get there. All of your experienced, nurturing, kid-savvy assistants are occupied with other vital concerns. Who needs this scene? No one!!

Planning ahead can make the pediatric treatment rewarding and safe for the patient, parent and practitioner. Here are some steps that that have been helpful in my practice:

Prevention: It is crucial to talk with kids and their parents about prevention- most children with parental and provider assistance can reduce their risk for caries and need for invasive dentistry.

• Risk, diet, home care, interventions all need to be part of the conversation from day one
• Appropriate and timely referral to pediatric specialists, including ortho, is crucial
• Welcome parents into the op at preventive visits. Great education, dialogue and bonding can take place
• Use low tech/high tech tangible teaching tools- 18 TSP of sugar in an empty 20 OZ Mountain Dew bottle or digital radiographs enlarged to show early lesions

Plan Treatment: Anticipating a pediatric operative or pediatric oral surgery visit makes a lot of sense. Take 10 minutes- or better yet train a motivated assistant to spend 10 minutes on the phone or face to face with the parent(s) of a pedo patient 2-4 weeks in advance.

• Confirm that diagnostic information, records, referrals are all in order
• Identify any communication barriers- utilize interpreters as needed. 65 million people in the US have limited or no English proficiency
• Assess child/parent readiness. Inform parents of what to expect, and of your expectations for them
• Suggest alternatives, discuss risks, benefits and timing of procedure
• Follow up conversation with written “what to expect” info mailed to parents

Treatment Session: Once you have done the prep- this aspect should move along efficiently and safely for everyone. You may even enjoy it!

• Timing of day can make a big difference for some kids, parents and providers- plan accordingly
• If appropriate bring parent into room for consent (surgical procedures) and questions/updates
• Identify 1 assistant that stays with child at all times- reassuring presence for all
• Doctor answers any questions prior to obtaining consent, giving parent permission to leave op- entrusting care to DDS and assistant
• If parent wants/needs to stay position them behind provider out of eye contact with child
• Tell, show, do technique helpful along w/ ART- atraumatic restorative technique
• Restorative materials helpful in primary dentition- °Compomer- Dyract (light cured)- Dentsply/Caulk °Glass Ionomer- Fuji Fast- GC Corp

My thanks for pediatric inspiration to Dr. Dennis J. McTigue, DDS, MS, Ohio Sate University College of Dentistry and my own dedicated dental team.

Tip of the month for February courtesy of Lillian Mitchell, DDS, Assistant Professor, Department of Prosthodontics, University of Alabama at Birmingham School of Dentistry. Email address: lmitchel@uab.edu
Thursday, February 01, 2007

Today’s patients are more esthetically aware and demanding than ever before. When planning multiple anterior crowns for a patient, or waiting for implants to heal, consider using laboratory processed provisionals to provide a beautiful, strong, long lasting temporary restoration. There are many commercial labs that can provide this service for a reasonable fee, which should be worked into your fee to the patient. For example, BDL Prosthetics, Glidewell, or Trident, are able to use diagnostic impressions, casts, or wax-ups, and interocclusal records, and provide a fully contoured provisional that is relined in the mouth with the compatible cold cure acrylic resin.(Fig 1) They will also provide a clear preparation guide to verify proper tooth reduction if desired.(Fig 2)

Processed provisionals are a wonderful time-saver and a relatively simple technique to learn. Contours and occlusion are easily adjusted when necessary. Margins can be readapted after esthetic crown lengthening or soft tissue grafting, paying attention to surface preparation of the acrylic. It is important to remove the glaze or polish on the outer surface of the temporary, and all of the cement on the inside, so that when it is relined the new acrylic will blend invisibly into the existing crown. (A 25 micron aluminum oxide sandblast does this the best.) These areas should be trimmed, repolished and the clear acrylic glaze placed back over the surface to prevent staining. Be sure to condition the temporary with a few drops of monomer after the sandblast before relining to allow for the best adhesion of the acrylics.

Figure 1.JPG	Figure 2.JPG	Figure 3.JPG	Figure 4.JPG	Figure 5.JPG
Figure 6.JPG

It is often difficult to get well-adapted margins when making provisionals, or relining processed ones. One trick that I have used for years is to load a utility syringe with the same acrylic used to make the provisional and place the acrylic around the margins of the teeth (as if making a final impression) before seating the matrix or processed provisional. (Fig 3) It is important that the teeth be lubricated and have no undercuts so that the temps do not lock on.(Fig 4) These temps fit well! Trim, polish and cement as usual. (Fig 5) Remember to use a non-eugenol containing temporary cement! If the acrylic has been contaminated with eugenol, any reline acrylic added will not set due to the presence of the eugenol. (Fig 6)

Until this technique becomes very familiar, I recommend trying it first with cases where the vertical dimension is not being altered. The occlusion and vertical dimension can get away from you if you are not careful. For the first case, try this on a simple three-unit bridge, or two central incisors, where the patient has a full complement of posterior teeth. Try some processed provisionals on your next anterior esthetic or long term implant case-your patient will love them, and you, for keeping them comfortable and looking well!

Tip of the month for January courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Monday, January 01, 2007

The American Heart Association Issues New Guidelines for CPR

In October 2006 the AHA has issued its newest set of guidelines for administration of cardiopulmonary resuscitation (CPR) in non-responsive patients. This new set has the largest evidence basis, as the AHA members had a wealth of recent information from well-designed studies. With the guidelines, the AHA writers emphasize that the most important factor for survival is the presence of a CPR-trained person at the site of the event who is willing to perform the procedure. The arival of ambulance or proximity of the hospital are secondary. Prompt initiation of CPR and continuation of the procedure until a spontaneous heart rhythm is obtained are the vital factors.

The new guidelines are simplified as all subjects except infants should be given 30 compressions to 2 breaths at a rate of 100 compressions/min. Generally, the compressions must be fast and strong, with as little interruption as possible. If a non-responsive person is not breathing, checking for a pulse is not necessary and chest compressions can start rightaway. Breaths should be given fast while insuring elevation of the thoracic cavity. In the same vein, defibrilation should be attempted only once and, if not successful in obtaining a spontaneous heartbeat, chest compressions must be resumed until the arival of the paramedics. Full information can be obtained by calling AHA or on line at www.americanheart.org.

Tip of the month for December provided by Ken Tilashalski, DMD,Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: drt@uab.edu
Friday, December 01, 2006

New Treatments for Fever Blisters

Fever blisters, cold sores, and herpes labialis are all synonyms for the recurrent lesions associated with the Herpes Simplex Virus (HSV). About one-third of people in the US experience these painful and unsightly lesions on their lips.

There are several treatment choices available. For any treatment to be most effective, the earlier it is used the better. Many people who suffer with recurrent HSV report prodromal symptoms. They often describe a sensation of tingling, soreness, itching, or burning prior to a lesion outbreak. This period of prodrome is the ideal time to start treatment.

There are several new medications that have shown to be effective in decreasing lesion pain and healing time.

 Abreva is available as a cream and it is the first over-the-counter topical medication that has been approved by the FDA to shorten healing time of herpes labialis.

 Denavir (penciclovir) is a new prescription cream that works very well in reducing the pain and duration associated with recurrent HSV.

 Valacyclovir (Valtrex) is dispensed as a caplet and recently gained FDA-approval for the treatment of fever blisters in adults. The recommended dosage is 2 grams taken by mouth twice in one day.

Hopefully, adding these new treatment regimens to your armamentarium will result in happier, healthy patients!

Tip of the month for November courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Wednesday, November 01, 2006

The controversy over the safety of amalgam restorations has been haunting dental practice for decades. This 150-year-old dental restorative material has suffered significant bad press due to the presence in its formulation of toxic mercury. Although the fact that once it is mixed with silver, mercury becomes stable; the amount of this metal in dental fillings is minimal; and that a tuna fish sandwich has ten times more mercury than a dental filling; mercury has received negative press, especially when it comes to children. We finally have definitive proof that it is not harmful.

In an article published in the Journal of the American Medical Association (JAMA) in April 2006, scientists supported by NIDCR report results of the first ever randomized, long-term clinical trial evaluating the safety of amalgam restorations in children. Two independent groups of reserachers, one in the USA, the second in Portugal, reached the same conclusions: children whose cavities were filled with amalgam had no adverse health effects. During 5-7 years of follow-up, researchers extensively tested the brain and kidneys of the over 1,000 school-age children enrolled in the studies, of which half received amalgam and the other half composite resin restorations. The average number of restored surfaces was 15. At the end of the follow-up period, there were no differences between the two groups in any of the analyzed parameters. Similarly, no decrease in IQ, nerve conduction, attention span or renal function was noted in the amalgam group during the study.

Given the rigorous design of the study and the fact that two groups independently confirmed eachother's results, dentists and patients can be reassured that amalgam restorations do not pose a significant threat to health.

Tip of the month for October courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Sunday, October 01, 2006

The evidence for oral cancer detection gadgets

In the past couple of years, several oral cancer "detection" devices have been introduced to the market. Some are a re-packaging of toluidine blue while others use newer techniques like computerized cytology or light reflection. None of these detection methods have been validated by independent studies and the manufacturer-sponsored data are not very strong. The currently published evidence does not support clinical efficacy for any of these methods.

Even in the industry-supported trials, most of these systems have a large percentage of false positive results, which may lead to unnecessary biopsies and patient anguish. Some manufactures point to the fact that most biopsied lesions qualify as "premalignant" and thus require the procedure. This "premalignant" category includes friction keratoses with mild dysplasia and other similar lesions that do not justify invasive procedures. More worrisome are the false negatives, which may remove suspicion from a cancerous lesion. This can have serious consequences that we do not need enumerate here.

A few principles will always serve the practitioner well: 1) there is no replacement for a thorough history and examination; 2) any suspicious lesion must be biopsied or referred, regardless of its luminescence or die-retaining properties; 3) large surface lesions should be biopsied at multiple locations, as their histology may vary from mild dysplasia to invasive carcinoma; 4) to select the best place to biopsy, look for ulceration and/or friable tissue; 5) the best method for biopsy is by scalpel. Once a specimen had been taken, the pathologist will typically inform the clinician if the lesion should be removed, closely observed or left alone.

In diagnosing oral cancer, the general practitioner must use evidence-based methods and should wait for strong scientific support for new devices. Finally, remember that oral cancer is quite a rare find, but do not lose vigilance.

Tip of the month for September provided by Ken Tilashalski, DMD,Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: drt@uab.edu
Friday, September 01, 2006

Whooping cough, shingles, cervical cancer, and genital warts?

What do all of these conditions have in common? There are newly FDA-approved vaccinations for each of these diseases.

Children are routinely immunized for pertussis (whooping cough) as part of the DTaP (Diphtheria, Tetanus, Pertussis) vaccine. While it is recommended that adults receive a Td booster vaccine every 10 years, there has not been a vaccine against pertussis for adults until 2005. It is now recommended that healthcare workers who have direct patient contact get a dose of the newly licensed Tdap (Tetanus, Diphtheria, Acellular Pertussis) as a substitute for one booster of Td.

In May of this year the Food and Drug Administration (FDA) licensed Zostavax, a new vaccine to reduce the risk of shingles (herpes zoster) for use in people 60 years of age and older. Shingles is a reactivation of the chickenpox virus and about 20% of adults will develop the disease in their lifetime. A shingles outbreak is characterized by painful blisters and can cause severe pain, sometimes for months or years after the outbreak. The vaccine reduces the incidence of shingles by about 50%.

The FDA recently approved Gardasil, which is a vaccine that targets the virus that causes cervical cancer and genital warts. The vaccine is 95-100% effective in preventing infection with human papilloma virus (HPV) types 6, 11, 16, and 18. The vaccine is specifically aimed at young women between the ages of 9-26, since it is best to get the inoculated before the start of sexual activity. HPV is the most common sexually-transmitted infection in the United States, with about 6.2 million Americans infected each year. The vaccine is effective against HPV 16 & 18, which are responsible for approximately 70% of cervical cancers and against HPV 6 &11, which cause about 90% of genital warts. The vaccine does not protect against other less common types of HPV and is not effective if there has been infection with HPV prior to vaccination, so it is not a replacement for regular pap screening.

With advances in vaccine research, hopefully we will see a decrease in the burden of many other infectious diseases in the near future.

Tip of the month for August courtesy of Toni Neumeier, DMD, Associate Professor, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address: neumeier@uab.edu
Tuesday, August 01, 2006

What is the Prosthodontic Diagnostic Index (PDI) system? Why is it important to know it?

The Prosthodontic Diagnostic Index (PDI), formerly named the American College of Prosthodontists Classification System, is used to classify completely dentate, partially edentulous, and completely edentulous patients. It was established by the American College of Prosthodontists in 1994. Specially assigned diagnostic codes have been added for partial and complete edentulism classifications (ICD-9-CM International Classification of Disease, Ninth revision, Clinical Modification). A parameters of care document has been updated for every classification and published in the December 2005 Journal of Prosthodontics. With all information combined, the Prosthodontic Diagnostic Index offers the following potential benefits:

• Improved diagnostic consistency for better patient care
• Improved intra-operator consistency
• Improved professional communication within the dental school
• Improved professional communication with colleagues
• An objective method for patient screening
• Simplified, organized criteria for patient referral
• Standardized criteria for outcome assessment and research
• Insurance reimbursement commensurate with complexity
of care

PDI criteria for complete edentulism includes the following (see table 1 for details)

• Mandibular bone height
• Maxillary residual ridge morphology
• Mandibular muscle attachment
• Maxillomandibular relationship
• Conditions requiring preprosthodontic surgery
• Limited interarch space
• Tongue anatomy modifiers

PDI criteria for partial edentulism includes the following (see table 2 for details)

• Location and extent of the edentulous area
• Abutment conditions
• Occlusion
• Residual ridge characteristics

PDI criteria for completely denatate includes the following (see table 3 for details)

• Tooth condition
• Occlusal scheme

All the checklist tables are copied from the American College of Prosthodontists web site, please visit the web site (www.prosthodontics.org) and references 2,3,4, 5 for more detail.

References:

1. Tupac RG, et al. Parameters of care for the specialty of Prosthodontics. J Prosthodontics 2005;14:1-103.
2. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH. Classification system for complete edentulism. J Prosthodontics 1999;8:27-39.
3. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Arbree NS. Classification system for partial edentulism. J Prosthodontics 2002;11:181-193.
4. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. J Prosthodontics 2004;13:73-82.
5. http://www.prosthodontics.org (at the bottom of the home page, click on "Prosthodontic Classification Systems" for the PowerPoint presentations).
6. http://www.prosthodontics.org (enter "Members" section, and click on "Journal" to access the references in # 1-3 above).

Tip of the month for July provided by John M. Coke DDS, Professor and Director, General Dental Residency, UAB School of Dentistry. Email address: jmcoke@uab.edu
Sunday, July 02, 2006

Almost every busy general dental practice has patients that have had total joint replacement surgery (TJR). The latest figures from the American Academy of Orthopaedic Surgeons (AAOS) indicate that there are 450,000 TJR surgeries done annually in the U.S. This same group, in their 73rd annual meeting in March of this year, predicted that this number will leap by 673% - reaching 3.48 million – by the year 2030. Obviously, dental practices will be seeing more and more of these TJR patients in the future.

In 1997, the AAOS and the ADA developed guidelines for the dental management of patients with total joint replacements. It was determined that TJR patients are most susceptible to infection during the first two years after joint placement and in individuals who are immunosuppressed. It is to be noted that no antibiotic premedication is recommended for patients with pins, plates and screws. The following guidelines were established:

Patients at Potential Increased Risk (need to be premedicated): 1. All patients during the first two (2) years after TJR surgery. 2. Immunicompromised/immunosuppressed patients: a. Inflammatory arthropathies (rheumatoid arthritis, SLE) b. Drug induced immunosuppression c. Radiation induced immunosuppression 3. Patients with co-morbidities (e.g.) a. Previous prosthetic joint b. Hemophilia c. HIV infection d. IDDM (insulin dependent diabetes) e. Malignancy Suggested dental procedures: They also recommended to only premedicate on the same dental procedures recommended by the AHA guidelines. However, it is my recommendation to use common sense on this list. If you anticipate any significant bleeding, then go ahead and premedicate with antibiotics.

Suggested antibiotic prophylaxis regimens: 1. Patients not allergic to penicillin: Cephalexin, cephradine or amoxicillin: 2 grams orally 1 hour prior to dental procedure. 2. Patients allergic to penicillin: Clindamycin: 600 mg orally 1 hour prior to dental procedure.

Reference: JADA, Vol.128, July 1997

Tip of the month for June provided by Ken Tilashalski, DMD,Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: drt@uab.edu
Monday, June 05, 2006

When irrigating canals, consider using a small diameter irrigation needle with a side delivery design. The side delivery design helps prevent the accidental delivery of irrigating solution into the periapical tissues. A small diameter needle allows for deeper penetration into the canal for greater contact of solution where it is needed at the apical region of the canals. One such irrigating aid that fits this criteria is the Pro-Rinse® Endo Irrigation Needles by Dentsply Tulsa Dental (shown in the below picture). The diagram highlights some of these benefits.

Tip of the month for May courtesy of Noel Childers, DDS PhD, Professor, Department of Pediatric Dentistry, and Wesley Hollowell DMD, Pediatric Resident, University of Alabama at Birmingham School of Dentistry. Email address: nkc@uab.edu
Monday, May 01, 2006

From television shows like VH1’s “Flavor of Love” to music videos like “Grillz” by hip-hop star Nelly, the minds and eyes of America’s youth are flooded by images of gold, platinum, and often jewel-encrusted dental work, better known as ‘grills.’ According to the online “Urban Dictionary,” the word grill has several meanings. In general, the definition of a grill denotes one’s teeth or smile, or oftentimes, one’s business. This case will focus on the more specific definition for the word ‘grill,’ as presented by the “Urban Dictionary,” which is a “gold/diamond plate that is molded for your teeth. It is decorated with diamonds and/or gold.” In this particular case, a 16 year old African American male with no history of caries over a 10 year period of dental treatment by the same practitioner, presented for a recall appointment with rampant decay across his maxillary anterior teeth. The only change that had occurred since his last recall visit was that he had visited a local jewelry store in his neighborhood mall and had a grill made, which he had begun to wear throughout most of the day. During this period of time, nothing changed about either his diet or oral hygiene, thus, the aforementioned decay can most likely be attributed to the fact that various sugars and other fermentable carbohydrates were allowed to propagate within the confines of the grill. The patient was not educated on the extra hygiene that would be involved in the wearing of the grill on a daily basis, and was neither cleaning it nor using fluoride on a regularly.

The purpose of the presentation of this case is to keep dental professionals abreast of current issues facing our patients, especially those facing the children in our communities. Several questions that can be raised from this case involve issues such as the legality of jewelry store employees fabricating these grills, the personal hygiene instructions that should be given to clients upon purchasing one of these items, and the maturity level of the children and adolescents wearing these prostheses. More specifically, this relates to their ability to grasp the need for the daily sanitizing of their grills. For this patient, he was encouraged to stop wearing the appliance. Three resin restorations were placed. The additional extensive areas of decalcification will be observed. The importance and use of fluoride toothpaste was emphasized. If not discontinued, the was instructed to never wear the appliance when eating or drinking (any liquid other than water). He was also encouraged to clean the appliance when brushing daily and place a little toothpaste in the appliance before inserting in the mouth.

Click here to view photos of a grill and its associated caries.

Click here to view the Urban Dictionary on grills.

Tip of the month for April courtesy of Toni Neumeier, DMD, Associate Professor, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address: neumeier@uab.edu
Monday, April 03, 2006

Restoration of Endodontically Treated Teeth

With the development of new endodontic equipment and techniques, more teeth can be saved by endodontic therapy. Therefore, what is the best choice of treatment for an endodontically treated tooth? It is a challenge for every practitioner and this is a brief summary.

1. More than 3/4 of coronal tooth structure remaining intact, or missing one wall of coronal tooth structure, or an endodontic access filled with temporary filling.

a. For anterior teeth, fill the endondontic access opening with a composite restoration. Crown coverage is not indicated.

b. For premolar or molar teeth, fill the endodontic access opening with either a composite or amalgam restoration, and crown the tooth within 5 years.

2. More than one half of the coronal tooth structure has been lost and tooth will serve as an abutment for a fixed prosthesis or RPD. Complete cusp coverage onlay or crown is indicated.

a. For anterior teeth, esthetics is the main concern. A prefabricated fiber post will be the choice to support a composite core build-up.

b. For premolar or molar, esthetics is not a major concern. Prefabricated metal or fiber post can be used to support the composite or amalgam core build up.

3. Where the coronal tooth structure has been lost at the gingival level, the dentist has to make a decision on the restorability of the tooth. The implant supported crown restoration, bridge or RPD is often a better choice for a long term prognosis. If the tooth has a long to average root length then either crown lengthening or orthodontic extrusion should be considered. Cast post and core will be the choice for anterior teeth or premolars to restore the missing core structure. A prefabricated post with either composite or amalgam core build up will strengthen a molar before crown preparation.

For teeth restored with any kind of post, it is necessary to have 4 to 5 mm of gutta-percha remaining at the apical aspect of the canal and the post length must be equal or greater than the coronal crown length. For a molar 7 mm will be the maximum length for a prefabricated post. The post should not be wider than the 1/3 root diameter and 1 mm thickness of the dentin must be present. Overall a 2mm ferrule is essential for preventing root fracture and to insure the long term favorable prognosis of the endodontically treated tooth.

Reference 1. Charles J. Goodacre DDS, MSD Five factors to be considered when restoring endodontically treated teeth. Pract Proced Aesthet Dent; 2004:16(6):455-460. 2. Rossentiel etc. Contemporary Fixed Prosthodontics. 3rd edition Chapter 12, page 262-312.

Tip of the month for March courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Wednesday, March 01, 2006

Inhaled insulin is currently being reviewed by FDA for use in type 2 diabetic patients. A recent study (1) reported better disease control and secondary outcomes in inhaled insulin users vs. oral hypoglycemic medication. Thus, chances are good that this convenient therapeutic method will be approved and become prevalent among our patient population. The same study also reported that the incidence of hypoglycemia was significantly higher among insulin users. These episodes when plasma glucose goes below homeostatic levels are very dangerous as they develop rapidly and may result in coma and death unless emergency measures are quickly implemented.

How to recognize hypoglycemia:

The patient may suffer from malaise when coming to the office. However, the typical presentation of low sugar is acute onset of dizziness, pallor, sweat, a weak and rapid pulse and shallow, fast breathing. Not all these signs are visible in all hypoglycemic patients. Thus, given the rapid progression of this condition, hypoglycemia should be considered in any diabetic patient on insulin exhibiting one or more of the above signs.

Treatment:

If recognized early, while the patient is still conscious, immediate administration of sugar in any form is mandatory. One-two teaspoons of sweet frosting, candy or a sweet beverage should provide adequate supplies to take the patient out of the danger zone. However, if symptoms persist, re-dosing is necessary. Placing the patient in supine position is also helpful, but it must be after they swallowed the sugar dose in order to avoid choking. If the patient becomes unconscious, parenteral administration of glucose becomes vital. A 10 cc plastic syringe filled with 50% sterile water (D50W) should be maintained in the office for such possibility. If the doctor is familiar with intravenous injection, then that route should be used. If no such familiarity exists or if a vein is hard to locate, injecting sublingually will also produce the desired effect.

Ideally, hypoglycemic attacks should be avoided by recommending (and then following up with questions) that diabetic patients on insulin always have adequate amounts of food before their appointments. However, given the possible dire consequences, we must always be prepared to handle a low sugar emergency.

(1) DeFronzo RA, et al. Efficacy of inhaled insulin in patients with type 2 diabetes not controlled with diet and exercise: A 12-week, randomized, comparative trial. Diabetes Care 2005 Aug; 28:1922-8

Tip of the Month for February provided by Perng-Ru Liu, DMD, Associate Professor and Chair, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address:prliu@uab.edu
Wednesday, February 01, 2006

What are the advantages/disadvantages of the different types of veneers?

DIRECT COMPOSITE RESIN VENEERS (1970's) ADVANTAGES •Chemical or light cure •One appointment procedure •Easy repairing and inexpensive DISADVANTAGES •Polymerization shrinkage •Staining and wear •Loses anatomical form in few years (may need to be replace)

LABORATORY FORMED RESIN VENEERS ADVANTAGES •Heat cure: Isosit •Light cure: VisioGem, Dentacolor, bellGlass •Color can be various and blended •Little finishing DISADVANTAGES •Two appointment procedure •Extra laboratory fee

PORCELAIN VENEERS •Acid etch enamel •Etch and silanated porcelain •High bond strength provide sufficient retention

CERAMIC VENEERS ADVANTAGES •Bond Strength •Resistance to Bulk Fracture •Color •Resistance to Discoloration •Periodontal Health •Inert •Resistance to Abrasion •Fluid Absorption •Low Thermal Expansion DISADVANTAGES •Time Consuming •Technique Sensitive •Fragility •Difficult to Repair •Cost

Tip of the Month for January provided by Perng-Ru Liu, DMD, Associate Professor and Chair, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address:prliu@uab.edu
Sunday, January 01, 2006

Veneers

Indications • Tooth Discoloration • Enamel Defects • Malpositioned Teeth • Changing Tooth Shape and Contour • Diastema Closure • Strengthen Incipient Fracture

For severe tetracycline staining, full coverage crowns are usually indicated due to staining occurring in the dentin,therefore a veneer would not be esthetic

Contraindications • Insufficient usable enamel • Excessive interdental spacing • Actively erupting teeth • Severe crowding teeth • Mandibular Veneer with Deep Overbite • Teeth in severe labioversion • Poor oral hygiene • Mouth breathing • Parafunctional occlusion

Tip of the Month for December provided by Perng-Ru Liu, DMD, Associate Professor and Chair, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address:prliu@uab.edu
Thursday, December 01, 2005

Advantages/Disadvantages of hemostatic agents when using a cord

EPI:

ADVANTAGES

– Kind to gingival tissues

– Very good tissue displacement

– Very good hemostasis

– Clean sulcus

– Minimal tissue loss

DISADVANTAGES

– Possible adverse C/V reactions

– Risk of epinephrine syndrome

– Not to be used on lacerated tissue

– Not to be used with ferric sulfate

Aluminum Chloride (eg hemodent)

ADVANTAGES

– Minimal tissue loss

– Good hemostasis

– Good tissue displacement

– No systemic effect

DISADVANTAGES

– Localized tissue destruction if over retracted

– Very unpleasant taste

Ferric Sulfate

ADVANTAGES

– Excellent hemostasis, including cut tissue

– Minimal tissue loss

– Moderate displacement

– Extended working time

– Compatible with aluminum chloride

DISADVANTAGES

– Transient tissue discolor

– Moderate tissue trauma (> 15%)

– Unpleasant taste

– Not compatible with epinephrine

– Interferes with setting of some impression materials if not rinsed

Tip of the Month for November provided by Perng-Ru Liu, DMD, Associate Professor and Chair, Department of Comprehensive Dentistry, University of Alabama at Birmingham School of Dentistry. Email address:prliu@uab.edu
Tuesday, November 01, 2005

Cording technique

Indications: Ideally you want a supragingival margin, so no cording is needed, but for esthetics, post/core, or restoration, you need a subgingival margin, so cording is necessary.

If you are using a cord impregnated with epi-remember this:

• Maximum dose for healthy adult - 0.2 mg = 10 Carpules of local anaesthetic of a 1/100,000 dilution of epi.

• Maximum dose for cardiac patient - 0.04 mg = 2 Carpules of local anaesthetic of a 1/100,000 dilution of epi.

• 1" of 0.5 mg epi. impregnated cord > Maximum dose

Tip of the month for September provided by James C. Broome, DDS, MS, Associate Dean for Clinical Affairs, The University of Alabama at Birmingham, UAB School of Dentistry. Email address: jbroome@uab.edu
Saturday, October 01, 2005

Adhesively cemented fiber composite posts have become increasingly popular for the restoration of endodontically treated teeth. It is well known that dentin bonding is a “technique sensitive” procedure. ¹ Research conducted at UAB has shown that performing the same bonding procedure within the root canal is even more so. Bond strength to dentin has been shown to dramatically decrease from the coronal area to the apical area. ² While there are slight anatomical differences between coronal and apical dentin, we feel that the real problem is related to the difficulties inherent in bonding in a “deep dark hole”. For example, methods which are used to successfully apply and removing etchant during restoration of a Class 2 prep are ineffective within the root canal. ³ Failure to adequately etch the entire depth of the canal would prevent the formation of a hybrid layer, and thus result in a weak or nonexistent bond. Etchant gel left on the canal walls would physically block adhesive penetration and the resulting low pH might inhibit the set of the dual-cure resin cement. ⁴
The following series of photos illustrates the difficulty of etching within the root canal, and offers a clinical solution.

Fig. 1. A post space has been prepared in a simulated root canal.

Fig. 2. Etchant is applied to the canal using a tip commonly used in cavity preparations (Inspiral Brush Tip, Ultradent Products, Inc., South Jordan, UT).

Fig. 3. Once the gel contacts the canal walls, air is entrapped and prevents it from penetrating further.

Fig. 4. Despite pumping action, gel penetration is inadequate.

Fig. 5. Rinsing with air/water syringe for 10 seconds is a commonly recommended procedure for removing gel.

Fig. 6. Use of air/water syringe results in incomplete removal of gel.

Fig. 7. Gel applied using 20 gauge, 18 mm long Endo-Eze tip (Ultradent Products, Inc)

Fig. 8. Tip is inserted to depth of canal.

Fig. 9. Gel is injected while withdrawing tip.

Fig. 10. Canal is completely filled with gel.

Fig. 11. The same Endo-Eze tip is attacted to a 5cc syringe filled with water and is used to irrigate the full depth of the canal.

Fig. 12. Etchant is completely removed.

Fig_1_JPG.jpg	Fig_2_JPG.jpg	Fig_3_JPG.jpg	Fig_4_JPG.jpg
Fig_5_JPG.jpg	Fig_6_JPG.jpg	Fig_7_JPG.jpg	Fig_8_JPG.jpg
Fig_9_JPG.jpg	Fig_10_JPG.jpg	Fig_11_JPG.jpg	Fig_12_JPG.jpg

1. Frankenberger R, Kramer N, Petschelt A. Technique sensitivity of dentin bonding: effect of application mistakes on bond strength and marginal adaptation. Oper Dent 2000;25(4):324-30.
2. Potesta F. Effect of etching technique on the retention of adhesively cemented prefabricated posts. Master's Thesis, The University of Alabama at Birmingham, 2005.
3. Williamson H, Nunez, M.R., Broome, J.C. Effect of rinsing technique and canal size on etchant removal. J Dent Res 2005;84(Spec Iss A):2992.
4. Sanares AM, Itthagarun A, King NM, Tay FR, Pashley DH. Adverse surface interactions between one-bottle light-cured adhesives and chemical-cured composites. Dent Mater 2001;17(6):542-56.

Tip of the month for September provided by John M. Coke DDS, Professor and Director, General Dental Residency, UAB School of Dentistry. Email address: jmcoke@uab.edu
Thursday, September 01, 2005

On patients who have a history of asthma that requires an inhaler and patients who use nitroglycerine for their angina pectoris, have your front office person remind them to bring their medications when their appointment is confirmed.

This way these medications are handy to both the patient and dentist should an asthma attack or chest pain arise during their dental visit. Sometimes patients, in the rush to get to their dental visits, will forget to bring these important medications and an easily managed medical problem can turn into a medical crisis.

Tip of the month for August provided by Ken Tilashalski, DMD,Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: drt@uab.edu
Monday, August 01, 2005

45 year-old black female presents for routine dental care. Bony lesions noted on full mouth radiographs. There is an absence of signs or symptoms associated with the lesions. The teeth tested within normal limits on pulp vitality tests.

The most probable possibility for these lesions is a periapical cemento-osseous dysplasia.

Periapical cemento-osseous dysplasia is a common lesion that is most often found in the anterior mandibular region in middle-aged black females. The bone in this area is replaced with a fibrous tissue that contains bone and/or cementum. An older term for this lesion is cementoma, but since this is not a neoplastic process, this term has fallen out of favor. The associated teeth are almost invariably vital and seldom have restorations. Early lesions usually appear as circumscribed areas of radiolucency involving the apical area of one or several teeth, and these lesions often develop central areas of dense calcification over time.

Tip of the month for July courtesy of Andrei Barasch, DMD MSD FAAHD, Associate Professor, Department of Diagnostic Sciences, University of Alabama at Birmingham School of Dentistry. Email address: abarasch@uab.edu
Saturday, July 16, 2005

Oral Medicine:

Recent reports have associated the use of bisphosphonates with development of bone necrosis in the jaws. This class of drugs is currently used for prevention and treatment of osteoporosis (e.g. Fosamax) as well as for treatment of bone lysis in cancer patients (e.g. Zometa). Novartis, the maker of two such medications, has released information on this topic and issued a warning to patients under current therapy. The main concern for dentists is infection of necrotic bone secondary to invasive procedures. Patients with a history of bisphosphonate treatment should be warned about the possibility of poor healing of surgical sites as well as formation of osseous defects. Antibiotic premedication/treatment and surgical debridement have not been successful in preventing or treating bisphosphonate-induced bone necrosis. Careful surgical technique, primary wound closing and antimicrobial rinses are recommended for this group of patients.