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The Foundation to Any Clinical Approach

Diagnosis and Detection

The Foundation to Any Clinical Approach

What is Minimally Invasive Dentistry?

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Minimally invasive dentistry is based on advances in science. Emerging technologies will facilitate evolution to primary prevention of dental disease and destruction. The “minimally invasive” approach to treating dental caries incorporates the dental science of detecting, diagnosing, intercepting and treating dental disease on the microscopic level. 

MID Fundamentals  

  • The focus is on maximum conservation of demineralized, noncavitated enamel and dentin.
  • Cavity preparations are designed to conserve maximum enamel and can eliminate the need for macromechanical retention.
  • In the noncavitated lesion, to take advantage of the tooth’s capacity to remineralize, one must first alter the oral environment.

ADA Standard for Patient Risk of Decay 

  • Extreme—Rampant decay 
  • High—two or more cavities within the last year 
  • Moderate—one to two cavities within the last year 
  • Low—no decay within the last year 

Some Minimally Invasive Dentistry techniques: 

  • Remineralization: Remineralization is the process of restoring minerals to repair damage. Fluoride therapy is a common technique. 
  • Air abrasion: If a tooth cannot be remineralized, air abrasion may be used in lieu of a traditional drill. It uses a stream of air combined with a super-fine abrasive powder. 
  • Sealants: Sealants protect teeth from bacteria. Fitting into the grooves and depressions of the tooth, they behave as a barrier. 
  • Inlays and onlays: Inlays and onlays do not require clinicians to remove much of the tooth structure. Inlays fit the cavity in the tooth, and onlays are used for more substantial reconstruction.  
  • Bite splints: Grinding teeth (bruxism) may cause serious damage to the teeth. Grinding can be detected and corrected before much damage has been done. Dentists create bite splints for patients to wear when most teeth-grinding happens (usually at night or during times of stress). 

You have an obligation to keep the patient’s dentate to the end of his or her life. Anything you do to a tooth has a short- or long-term consequence. Everything that happens to a tooth both naturally and in treatment determines its survival. 


 

 

 

The Chemical Aspect of Tooth Wear

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Tooth wear is a predicament often presented by patients in need of full-mouth fixed rehabilitation. Frequent signs of deterioration with such patients may be increased interocclusal distance in conjunction with a shorter mandible, a reduced vertical dimension of occlusion, and tooth sensitivity.1 In order to prevent further deterioration of patients’ oral and dental conditions and to provide patients with predictable long-lasting restorations, the etiology of tooth wear must be predetermined prior to rendering treatment and causal factors must be identified and addressed. Etiology may be of mechanical (eg, attrition, abrasion, and abfraction) or chemical erosion which may be of intrinsic or extrinsic origin. Many times, patients will manifest with signs and symptoms which may be tracked to multifactorial causes.
Chemical erosion is the result of prolonged exposure of teeth to acidic dissolution. Common signs of erosion include:
 

  • Broad concavities within smooth surface enamel;
  • Cupping of occlusal surfaces;
  • Increased incisal translucency;
  • Wear on non-occluding surfaces;
  • Raised amalgam restorations; and 
  • Preservation of enamel cuff at the gingival crevice.2 

Extrinsic factors are related to the intake of acidic beverages, acidic foods, or exposure to environmental acids. Fruit juices, carbonated drinks, herbal teas, and sports drinks have been showed to be highly acidic. The duration and frequency as well as the method consumption are of major significance in terms of the lesions’ development. The higher the frequency of intake and duration of exposure, such as with swishing acidic or carbonated drinks back and forth in the mouth, the higher the likelihood of developing erosive lesions. However, drinking with a straw may reduce such a risk. One less common extrinsic factor is environmental or occupational exposure. Occupational exposure to acetic acid vapors from silicone sealers,3 full-time wine tasting4 and exposure to sulfuric acid mist in battery factories are reported to be associated with increased risk of tooth erosion. This affects predominantly the labial surfaces of the incisors.5,6

Regurgitation is the primary intrinsic cause of erosion, which occurs as a result of gastric acid entering the mouth voluntarily or involuntarily. Involuntary regurgitation may be a common complication from hiatus hernia and chronic alcoholism. Gastroesophageal reflux disease (GERD) may manifest typically with heartburn and regurgitation and may also cause tooth erosion. Commonly employed diagnostic tests for detecting GERD include barium swallow, endoscopy, and 24-hour pH monitoring. GERD can be sometimes difficult to treat. Medications such as proton pump inhibitors are recommended as standard treatment.7 Voluntary regurgitation is considered to be an eating disorder (eg, anorexia nervosa and bulimia nervosa), and the effect of gastric acid can be observed as localized lesions on the palatal aspects of maxillary posterior and maxillary anterior teeth, and on the buccal surfaces of mandibular posterior teeth in patients with eating disorders. With bulimia nervosa patients, additional cervical lingual lesions can be detected on the mandibular anterior teeth in conjunction with incisal erosion.8
Once the early signs of tooth wear are recognized, individual prevention can be initiated once the etiology of erosion has been identified. If the erosive factor is intrinsic, the diagnosis and treatment of the underlying condition is a pre-requisite. The patient should be referred to a physician for diagnosis and treatment. If the erosive factor is extrinsic, patient education and lifestyle changes are required to control additional tooth surface loss. A healthy diet and eating habits will help to reduce tooth wear. The quality and quantity of saliva are considered as important modifiers. Sugar-free diet or consumption of xylitol containing products instead of sugar, have also been shown to be effective in the prevention of tooth surface loss.9

Conclusion
Early detection of signs and symptoms of erosion and recognition of the etiology are critical for proper diagnosis and treatment. Such diagnosis by clinicians working in conjunction with other professionals is essential for managing and preventing further damage to patients’ dentition. An individualized prevention protocol must be established based on the input of all involved professionals such as physicians, dietary consultants, and dental professionals.

*Associate Professor and Director, Graduate Prosthodontics. Department of Restorative Dentistry, University of Washington, Seattle, Washington.
Assistant Professor, Department of Restorative Dentistry, University of Washington, Seattle, Washington.

References
 

  1. Verrett RG. Analyzing the etiology of an extremely worn dentition. J Prosthodont 2001;10(4):224-233. 
  2. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Pract 1999;1(1):16-23. 
  3. Johansson AK, Johansson A, Stan V, Ohlson CG. Silicone sealers, acetic acid vapours and dental erosion: a work-related risk? Swed Dent J 2005;29(2):61-69.
  4. Wiktorsson AM, Zimmerman M, Angmar-Månsson B. Erosive tooth wear: Prevalence and severity in Swedish winetasters. Eur J Oral Sci 1997; 105(6): 544-550.
  5. Petersen PE, Gormsen C. Oral conditions among German battery factory workers. Community Dent Oral Epidemiol 1991; 19(2): 104-106.
  6. Kelleher M, Bishop K. Tooth surface loss: An overview. Br Dent J 1999;186(2):61-66. 
  7. Vaezi MF. Atypical manifestations of gastroesophageal reflux disease. MedGenMed. 2005;7(4): 25.
  8. Valena V, Young WG. Dental erosion patterns from intrinsic acid regurgitation and vomiting. Aust Dent J 2002;47(2):106-115.
  9. Milgrom P, Rothen M, Milgrom L. Developing public health interventions with Xylitol for the US and US-associated territories and states. Suom Hammaslaakarilehti. 2006;13(10-11):2-11.

The Importance of Early Cancer Detection

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In the United States alone, a person dies from oral cancer every hour of every day. It is estimated that approximately 34,000 people will be diagnosed with oral cancer in 2007. When detected at an early stage, oral cancers can be cured at an 80% to 90% success rate. Unfortunately, the majority of these are discovered at a late stage, accounting for a high mortality rate. Only half of those who are recently diagnosed will survive five years--a statistic that has not significantly improved in decades. Such mortality statistics are higher for oral cancer patients than for those with cervical cancer, Hodgkin’s disease, cancer of the brain, liver, testes, kidney, or skin cancer (ie, malignant melanoma).

 

Since detecting cancer in its earliest stages provides patients with a greater chance for survival, dental professionals should emphasize--with both the office staff and the patient--the importance of a thorough oral and head and neck screening as part of the routine dental examination. Screening should thus include an examination of the patient’s head and neck areas, checking for abnormal nodes or lumps, white or red patches, ulcerations, loose teeth, tissue and skin changes that may indicate cancer or an infection. Use of sufficient magnification and illumination are paramount throughout this process.

 

Fortunately, technologies that detect and diagnose oral cancer continue to evolve as a result of efforts put forth by dental industry manufacturers and researchers throughout the medical and dental communities. To gather samples for biopsy, a small brush is scrubbed against the suspect tissue; the samples are then forwarded to a screening laboratory for analysis. Computed tomography scans too afford healthcare professionals a dynamic view of the affected soft tissue areas of the body in greater detail than feasible with a simple x-ray. Chemiluminescent lights also enable the dental professional to distinguish healthy versus abnormal tissue. If confirmation of disease is determined, the patient should be referred to a proper medical institution or medical professional.

 

The Role of Education 

Following professional screening, patient education should begin with a discussion on the risk factors for oral cancer (Table); cigarette, cigar, or pipe smoking, the use of smokeless tobacco, and excessive consumption of alcohol remain the prevalent factors for the development of oral cancer. Approximately 25% of oral cancers, however, occur in those who do not smoke and who do not have any increased risk factors.

While an annual screening for oral cancer is important, any intraoral changes that become evident require examination between screenings. It should also be emphasized to patients that they contact their dentist or physician immediately if they observe the following symptoms:

  • A sore or lesion in the mouth that does not heal within two weeks;
  • A lump or thickening in the cheek;
  • A white or red patch on the gingiva, tongue, tonsil, or lining of the mouth;
  • A sore throat or a feeling that something is caught in the throat;
  • Difficulty chewing or swallowing;
  • Difficulty moving the jaw or tongue;
  • Numbness of the tongue or other area of the mouth; and
  • Swelling of the jaw that causes dentures to fit poorly or become uncomfortable.

It is important to use consumer-friendly terminology to ensure patient understanding throughout the dialogue, and certainly to understand the psychological and emotional impact that cancer has on the patient. This aspect of cancer can encompass multiple facets of the individual’s life and, as a caregiver, the practitioner should ensure the patient maintains a healthy lifestyle (ie, proper diet, regular exercise, sufficient sleep) to ensure the best possible outcome of cancer treatment.

 

Conclusion 

The most important step in reducing the mortality rate from oral cancer is early discovery. No group has a better opportunity to have a positive impact than members of the dental community. Start a dialog with your patients today. Remember, early detection means more lives saved.

 

Additional Resources 

Numerous resources are available to assist patients who request additional information on oral cancer:

  1. Oral Cancer Foundation. Available at: www.oralcancerfoundation.org.
  2. American Cancer Society. Available at: www.cancer.org.
  3. Holland JC, Lewis S. The Human Side of Cancer: Living With Hope, Coping With Uncertainty. HarperCollins Publishers, New York, NY: 2000.
  4. Centers for Disease Control. Available at: www.cdc.gov/oralhealth/topics/cancer.htm.

 

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