Mark Cannon, DDS, MS

When the American Dental Association asked dental offices to temporarily close, except for emergencies, on March 16, 2020, little was known about the relationship between oral hygiene and the severity of COVID-19 infections. Since that time, new research is showing that poor oral hygiene can directly affect how patients are able to fight off the disease. The short-term lack of access to preventative dental care, especially in minority populations, now underscores the risk factors that can accompany poor oral hygiene, including diabetes, hypertension, obesity and cardiovascular disease.

 in June 2020 reflects that relationship in a very relevant and urgent way. It concludes that poor oral hygiene may be connected to serious COVID-19 complications due to high levels of harmful oral bacteria.

The authors explored the connection between high bacterial load in the mouth and post-viral complications, and how improving oral health may reduce the risk of complications from COVID-19. They concluded that the development, severity, and risk of complications following a COVID-19 infection depend on a number of host and viral infections.

The four main co-morbidities related to COVID-19 are also associated with altered oral biofilms and periodontal disease. In addition, an 

 published in Dental Research and Management detailed the close relationship between a number of systemic conditions that are all most likely initiated by one single oral pathogen strain.

 The prevention of these prevalent systemic illnesses needs to be started at the earliest possible point, with intervention starting with good Oral Maternal-Fetal health.

COVID-19 affects people in different ways, with patients exhibiting a range of symptoms and severity. So why do some people suffer more severely? It’s become clear that bacterial superinfections are common in patients suffering from a severe case of COVID-19. Over 80% of COVID-19 patients in ICUs exhibited an exceptionally high bacterial load, with more than 50% of deaths exhibiting bacterial superinfections.

While COVID-19 has a viral origin, it’s suspected that in severe cases, complications such as pneumonia and acute respiratory distress (ARDS) may be caused by bacterial superinfections. And those bacteria may originate in the mouth. In addition, SAR-CoV-2 has a significant salivary level, providing for testing with salivary sampling. The oral cavity, via saliva and plaque, is strongly felt to be significant in the modes of transmission with COVID-19.

How bacteria travel from the mouth to the lungs

The oral microbiome is considered a “gateway” microbiome. Our human-specific oral microbial species have all evolved with the host to help protect the host and to also process the nutritional intake of the host. The oral bacteria, yeasts, viruses, archaea number in the thousands of strains, and rapidly adapt to dietary influences, allowing for homo sapiens to change and survive. Significant dietary changes in our developmental history, with the massive increase in carbohydrates, encouraged the expansion of pathogenic strains that injure the human host, even suppressing the host’s immune responses. Maintenance of a healthy oral microbiome is therefore essential.

Micro-organisms that colonize the mouth propagate via the saliva. The pathogenic bacteria or viruses within the saliva can then be aspirated into the lower respiratory tract and cause or aggravate an infection. Periodontitis and decay are the two most common oral diseases associated with an imbalance of pathological bacteria in the mouth. This imbalance is a “Dysbiosis”, whereas the increase in pathogens follows the decrease in competing probiotic bacteria and the strain shifting of commensals into co-pathogens. This illustration from the 

Oral care probiotics seem to be relatively new to the dental industry and are often confused with traditional probiotics, which are designed to improve gut health. However, oral-care probiotic research is more than 35 years old and the best products have been around for more than 10 years. There are scientific distinctions that can help dentists prescribe and consumers choose the best product for their patients. Those that support throat health only provide minimal support to the health of teeth and gums, while those oral-care probiotics that use gum and tooth specific strains provide the best overall support and benefits to both periodontal and tooth health and have the longest research behind them.

Generally speaking, oral care probiotics are live bacteria that are identical to the beneficial microorganisms found naturally in the oral biome. The addition of oral care probiotics to an oral care regimen can restore the natural balance of the oral biome by repopulating beneficial bacteria, which can be depleted by diet, stress, medication, illness, or other factors.

Specifically, only oral care probiotics that include bacteria Streptococcus oralis KJ3, Streptococcus uberis KJ2, and Streptococcus rattus H145, support teeth and gums, the inherent source of these strains. These products can be seen as a first line defense against pathogens coming into the mouth. While all patients will see benefits, for those with periodontal disease, caries, and other oral care concerns, oral care probiotics are an effective adjunct to extend treatment benefits.

One key takeaway from this article is that, with COVID-19 and other viral diseases, inadequate oral hygiene can increase the risk of inter-bacterial exchanges between the lungs and the mouth, increasing the risk of respiratory infections and potentially post-viral bacterial complications.

Good oral hygiene has been recognized as a means to prevent airway infections in patients, especially in those over the age of 70. In fact, studies show that improved oral care can significantly reduce the incidence of ventilator-associated pneumonia in ICU patients.

The other key takeaway from the article’s authors is that improved oral hygiene may play a part in reducing the risk of complications. The authors write, “We recommend that oral hygiene be maintained, if not improved, during a SARS-CoV-2 infection in order to reduce the bacterial load in the mouth and the potential risk of a bacterial superinfection.”

In addition to diligent home care, adding oral care probiotics to the daily regime can also help reduce harmful bacteria in the mouth. According to my recent peer-reviewed study in the 

, (oral care) probiotics significantly reduced the caries rate of high caries prone pediatric subjects without any reported side effects.

 The article continues, “Indeed, probiotics simply reduce the pathogens that modern, high sugar diets, feed.” While the study was conducted on children over a three-year time period, the findings can be extrapolated to adults, who may also benefit from taking oral care probiotics to reduce the bacterial load in the mouth.

Preventive care continues to be a problem during the pandemic, as patients may be fearful of returning to their dentists. Home care has never been so important. “Our patient protocol includes 

 treating, and repopulating the beneficial bacteria in the mouth,” says Lora Hooper, BS, RDH, FDA Dental Hygiene, part of the oral care team at the Heart Attack and Stroke Prevention Center of Central Ohio. “I have seen a dramatic improvement in oral health in patients using oral care probiotics.” The practice is run jointly by a dentist and cardiologist, who unify oral and systemic care for all patients.

As the search for COVID-19 treatments and vaccines continues, dentists and hygienists can help patients stay healthy with good communication and education. Oral health is a key factor in helping fight the pandemic. We’re all in this together.

Br Dent J. Could there be a link between oral hygiene and the severity of SARS-CoV-2 infections? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319209/

; 228(12): 971–975. Published online 2020 Jun 26

Cannon ML and Peldyak JN. The prevention and treatment of neural arterial gingival simplex (2019) Dental Res Manag 3: 32-37 

http://edelweisspublications.com/articles/30/424/The-Prevention-and-Treatment-of-Neural-Arterial-Gingival-Simplex#%C2%A0Citation

Mark Cannon* and John Peldyak. Pediatric Oral Systemic Health: From Fetus to Adolescence. Inter Ped Dent Open Acc J 3(2)- 2019. IPDOAJ.MS.ID.000158. DOI: 10.32474/IPDOAJ.2019.03.000158

Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. [Erratum appears in Prev Chronic Dis 2020; 17. 

http://www.cdc.gov/pcd/issues/2020/20_0266e.htm

.] Prev Chronic Dis 2020; 17:200266. DOI: 

http://dx.doi.org/10.5888/pcd17.200266external icon

Mark L Cannon, Ashlee Vorachek, Catherine Le, Kevin White; Retrospective Review of Oral Probiotic Therapy. 

 1 October 2019; 43 (6): 367–371. doi: 

https://doi.org/10.17796/1053-4625-43.6.1

Articles

With research suggesting oral health might be related to the severity of coronavirus disease 2019 (COVID-19) complications, dental professionals might be able to help with prevention and disease management.

COVID-19: Can Dentistry Be Part of the Solution?

	Many dental practitioners have reported on the prevalence of tooth sensitivity in their patients following placement of composite resin restorations. This has prompted a number of research studies, clinical trials and reviews of the literature searching for an answer to this common dental issue.


	Unfortunately for the dental profession, one out of eight patients already claim they have sensitive teeth before the added insult of dental caries and subsequent restoration.

 This is particularly true for the young dental patient, providing an additional dilemma in pediatric dentistry.


	The proposed solutions to the numerous cited causes for post-operative sensitivity include the following; slow start polymerization, use of self-etch rather than total-etch of the dentin, bulk-fill or incremental-fill, placement of liners or bases, and use of improved dentin adhesives.


	For the young patient, permanent dentition also poses additional challenges as the pulp chamber is larger and the dentinal tubules more patent.

 A more shallow preparation will be relatively closer to the pulp chamber, most likely increasing the post-operative sensitivity prevalence. The young patient is more likely to report and complain about the sensitivity, as it will be a newer condition for them and older patients may actually expect some tooth sensitivity after dental visits.


	It is a major concern for the empathetic practitioner because the first restorative visits may set the stage for the opinion and fears of that young patient for a very long time. Anecdotally, we all have experienced the frightened dental patient, still recoiling from a “bad experience.” Whether it is historically accurate or not, the patient’s opinion of the visit shapes the future patient’s attitude.
	Managing teenagers is never easy-ask any parent-and the dental issues may be significant, with potential lifelong consequences.

 Very little has been published on the specific needs of the young adolescent dental patient, especially in regards to social context.


	As for common dental issues, the erupting permanent molars are typically protected with pit and fissure sealants, unless the grooves and pits present with early carious involvement.

 An additional issue may be poorly developed or hypomineralized enamel, as in the case of molar incisor hypomineralization (M.I.H.), with an occurrence rate of almost 10 percent.16 A complicating factor is that restorations of teeth with M.I.H. have been reported to have a reduced survival outcome and a higher rate of post-operative sensitivity.


	Naturally, treatment of young adolescent patients requires the use of esthetic materials, cosmetics being a real concern, and the restoration of the carious and/or of the hypomineralized dentition is most often accomplished with resin-based composite materials.

 Therefore, reduction of postoperative sensitivity following resin-based composite restorations is even more paramount in the young adolescent dental patient.

	A 14-year-old female with history of previous restorative visits at the referring general dental office and a chief complaint of “painful teeth” postoperative presented at my practice.
	Unfortunately, pit and fissure sealants had not been previously placed on the patient’s posterior dentition. 

Consequently, the patient still had carious maxillary second molars to be restored (Fig. 1). She was concerned the restorations would be “painful” postoperatively and worried about the consequences of the planned posterior composite restorations.
	To reduce the possibility of another difficult postoperative course, the treatment plan includes a technique using Shield Force Plus from Tokuyama Dental America to reduce postoperative sensitivity after posterior composite restoration.
	Following anesthesia from Milestone Scientific’s Single Tooth Anesthesia system using 3 percent Carbocaine with 20,000 Neo-Corbefrin, a rubber dam was carefully placed for tooth isolation. The injection technique was performed with minimum pressure after the placement of topical anesthesia gel, 20 percent benzocaine, into the sulcus. The injection sites were carefully spaced to allow for complete dental anesthesia but not in a manner to increase the possibility of postoperative discomfort.
	

	After placement of the rubber dam, the preparation was performed with a high-speed handpiece using sufficient water spray and the carious dentin exposed (Fig. 2). The carious infected dentin was removed with a #4 round bur (keeping the dentin moist) in a slow-speed handpiece and with judicious use of a sharp spoon excavator (Fig. 3).


	Due to the patient’s history of postoperative sensitivity, a layer of Shield Force Plus desensitizer was carefully applied only to the prepared dentin. Shield Force Plus was allowed to infiltrate the dentin for 10 plus seconds, followed by a stream of light air for 5 seconds, then strong air for five additional seconds, and finally, it was light polymerized for 10 seconds (Figs. 4,5).

	
	Due to the history of sensitivity, the judicious placement of etchant only on the enamel, selective etch, was considered. Another viable option would utilize the self-etch technique, also reportedly less likely to cause postoperative sensitivity.


	The decision was made to use the self-etch technique utilizing Tokuyama Universal Bond from Tokuyama Dental America, self-cured and self-etched truly universal adhesive. The Tokuyama Universal Bond adhesive Part A and B components were mixed together and then applied to the de-sensitized dentin and cut enamel (Fig. 6). Tokuyama Universal Bond, considered an eight-plus generation adhesive, was dried with gentle air for 5 seconds followed by 5 seconds medium air to evaporate the solvents, while no light curing was required.

Fig. 6 Mixing and application of Tokuyama Universal Bond, which is a self-cure universal adhesive.
	The preparation was then filled in increments of less than 4 mm with Estelite Bulk Fill Flow shade A1 from 

	Tokuyama Dental America (Figs. 7,8). Following light curing of the final increment of Estelite Bulk Fill Flow, the gross anatomy was achieved with a Raptor bur from BISCO (Fig. 9).

Fig. 9 The gross anatomy was created with the Raptor bur from BISCO.
	The rubber dam was then removed, and the occlusion adjusted with a spiral multi-fluted carbide bur followed by fine polishing with Rally points from Garrison Dental Solutions (Fig. 10). 


	The patient’s parents were contacted the next day to check on the postoperative sensitivity and they were pleased to report the patient had none. In this situation, the desensitization of the prepared dentin delivered an exceptional restoration outcome, without post-op sensitivity and improved the dental attitude of this young dental patient.
	Creating a happier young dental patient should produce a more ideal end result as they will not be hesitant to seek proper dental care in the future.

		Monu Survashe et al. (2016), Immediate Post-operative Sensitivity after Composite Resin Restoration – A Review of Treatment Protocol. Int J Dent and Oral Heal.2:2, 14-23. DOI: 10.25141/2471-657X-2016-2.0046

		Berkowitz, G., Spielman, H., Matthews, A., Vena, D., Craig, R., Curro, F., & Thompson, V. (2013). Postoperative hypersensitivity and its relationship to preparation variables in Class I resin-based composite restorations: findings from the practitioners engaged in applied research and learning (PEARL) Network. Part 1. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995), 34(3), e44–e52.

		A. L. F. Briso, S. R. Mestrener, G. Delício, R. H. Sundfeld, A. K. Bedran-Russo, R. S. de Alexandre, and G. M. B. Ambrosano (2007) Clinical Assessment of Postoperative Sensitivity in Posterior Composite Restorations. Operative Dentistry: September 2007, Vol. 32, No. 5, pp. 421-426.

		Costa T.R.F., Rezende M., Sakamoto A., Bittencourt B., Dalzochio P., Loguercio A.D.  Reis A. (2017) Influence of Adhesive Type and Placement Technique on Postoperative Sensitivity in Posterior Composite Restorations. Operative Dentistry 42:2, 143-154. Online publication date: 3-Mar-2017.

		Cunha-Cruz, J., Wataha, J. C., Heaton, L. J., Rothen, M., Sobieraj, M., Scott, J., … Northwest Practice-based Research Collaborative in Evidence-based DENTistry (2013). The prevalence of dentin hypersensitivity in general dental practices in the northwest United States. Journal of the American Dental Association (1939), 144(3), 288–296. doi:10.14219/jada.archive.2013.0116

		The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry 2019.

		Reis A., Dourado Loguercio A., Schroeder M., Luque-Martinez I., Masterson D., Cople Maia L. Does the adhesive strategy influence the postoperative sensitivity in adult patients with posterior resin composite restorations? A systematic review and meta-analysis. Dent Mater. 2015;31(9):1052-1067.

		Sue M., Oda T., Sasaki Y., Ogura I.. Age-related changes in the pulp chamber of maxillary and mandibular molars on cone-beam computed tomography images. Oral Radiol. 2018 Sep;34(3):219-223. doi: 10.1007/s11282-017-0300-1. Epub 2017 Aug 7.

		Ghanei, M., Arnrup, K., & Robertson, A. (2018). Procedural pain in routine dental care for children: a part of the Swedish BITA study. European archives of pediatric dentistry: official journal of the European Academy of Paediatric Dentistry, 19(5), 365–372. doi:10.1007/s40368-018-0368-2

		Cabrera, F., Herrera, A., Rubalcava, S., & Martínez, K. (2017). Behavior Patterns of Antisocial Teenagers Interacting with Parents and Peers: A Longitudinal Study. Frontiers in psychology, 8, 757. doi:10.3389/fpsyg.2017.00757

		Masoe, A. V., Blinkhorn, A. S., Taylor, J., & Blinkhorn, F. A. (2014). Preventive and clinical care provided to adolescents attending public oral health services New South Wales, Australia: a retrospective study. BMC oral health, 14, 142. doi:10.1186/1472-6831-14-142

		Paiva, P. C., de Paiva, H. N., de Oliveira Filho, P. M., Lamounier, J. A., Ferreira e Ferreira, E., Ferreira, R. C., … Zarzar, P. M. (2014). Development and validation of a social capital questionnaire for adolescent students (SCQ-AS). PloS one, 9(8), e103785. doi:10.1371/journal.pone.0103785

		Broadbent, J. M., Thomson, W. M., & Poulton, R. (2006). Oral health beliefs in adolescence and oral health in young adulthood. Journal of dental research, 85(4), 339–343. doi:10.1177/154405910608500411

		Ahovuo-Saloranta, A., Forss, H., Walsh, T., Nordblad, A., Mäkelä, M., & Worthington, H. V. (2017). Pit and fissure sealants for preventing dental decay in permanent teeth. The Cochrane database of systematic reviews, 7(7), CD001830. doi:10.1002/14651858.CD001830.pub5

		Naaman, R., El-Housseiny, A. A., & Alamoudi, N. (2017). The Use of Pit and Fissure Sealants-A Literature Review. Dentistry journal, 5(4), 34. doi:10.3390/dj5040034

		Davenport, M., Welles, A. D., Angelopoulou, M. V., Gonzalez, C., Okunseri, C., Barbeau, L., … Hodgson, B. D. (2019). Prevalence of molar-incisor hypomineralization in Milwaukee, Wisconsin, USA: a pilot study. Clinical, cosmetic and investigational dentistry, 11, 109–117. doi:10.2147/CCIDE.S172736

		Fragelli CM, Souza JF, Jeremias F, Cordeiro Rde C, Santos-Pinto L. Molar incisor hypomineralization (MIH): conservative treatment management to restore affected teeth. Braz Oral Res. 2015;29

		William V, Messer LB, Burrow MF. Molar incisor hypomineralization: review and recommendations for clinical management. Pediatr Dent. 2006;28:224–32.

		Kotsanos N, Kaklamanos EG, Arapostathis K. Treatment management of first permanent molars in children with Molar-Incisor Hypomineralisation. Eur J Paediatr Dent. 2005;6:179–84.

		Opdam, N. J., van de Sande, F. H., Bronkhorst, E., Cenci, M. S., Bottenberg, P., Pallesen, U., … van Dijken, J. W. (2014). Longevity of posterior composite restorations: a systematic review and meta-analysis. Journal of dental research, 93(10), 943–949. doi:10.1177/0022034514544217

Relieving sensitivity in younger patients improves outlook for future dental visits.  

How to: Treat the Young Adolescent Dental Patient and Prevent Post-operative Sensitivity

	Besides being a very proud father of five successful young adults, and a grandfather of one adorable grandson, I also feel accomplished in my profession as a pediatric dentist. With more than 40 years in my chosen field, an extremely busy time with family, research, teaching and clinical practice, it’s still surprisingly exciting to see new and better dental materials constantly being developed.

	For instance, young dental practitioners enters a practice with substantially more available technology than us “old-timers”. They simply wouldn’t accept an older way of charting, nor should they. However, acceptance of new technology is still a slow process with older practitioners and smaller practices less readily adapting to change.

	Fortunately, the adaptation to improved restorative materials is a much simpler transition due to advancements in resin-based composites.

 Advancements include increased ease of polishability, the ability to bulk fill the preparation and fully photo-polymerize due to resin/filler optic synergy, and more recently, universal shade matching resin composites.

	Universal shade matching resin-based composites are extremely useful in a pediatric practice providing operative care to younger children and those with special needs on a daily basis. Matching the shade without needing to interrupt a procedure is important in time management, especially when time may be limited by patient cooperation and comfort.

	The advent of universal adhesives, not requiring the numerous steps and components that once were necessary, has made dental adhesion less complicated and quicker for the dental practitioner.

 This is, however, a situation that has had a few caveats, with early simplified hydrophilic systems not being as reliable and predictable.

	The newer universal adhesives now are less hydrophilic and less acidic, thus claiming to be more resistant to water resorption and hybrid layer dissolution.

 Bonding to the smear layer may still be problematic, even with the new universal self-etching adhesives.

 Some clinicians suggest removal of the smear layer with the total-etch technique may still be advisable, especially with a very short dentin etch time of two to three seconds.

	A patient presented as a 6-year-old female with a medical history of sensory issues and Mast Cell disease as well as a dental history of moderate to severe apprehension. Of note is in this pediatric population, the author’s patients diagnosed with Mast Cell Activation Syndrome appear to also have neurologic sequela, although this has not yet been well defined in the literature.

	Clinically, the patient presented with large carious occlusal lesions of the second primary molars requiring restoration. After consultation with the responsible legal guardian/parent, behavior was to be managed with video distraction, nitrous oxide analgesia and the Single Tooth Anesthesia System® (STA) from Milestone Scientific.

	After application of a 20% benzocaine topical gel into the sulcus of the second primary molar, anesthesia was obtained using STA mode with three percent carbocaine.

	Fig. 1                                                                             Fig. 2

	A #4 rubber dam clamp was atraumatically placed and a nonlatex rubber dam applied (

). The preparation was performed with a #330 carbide bur from Tri Hawk with copious water spray to reduce smear layer formation

). Deep dentin caries was removed with a #4 round bur and a sharp spoon excavator, removing infected but leaving affected dentin (

	Fig. 3                                                                              Fig. 4

	The preparation was etched with the enamel treated for 30 seconds, and then the etchant was rubbed onto the dentin for two to three seconds to remove the smear layer (

). The etchant was then rinsed off for 10-15 seconds, leaving the enamel etched and the smear layer removed but with the dentinal plugs remaining (to reduce sensitivity). A resin-based tricalcium silicate base was then placed and light cured for 20 seconds (

	Fig. 5                                                                                   Fig. 6

	Following the light curing, a universal dentin bonding adhesive was gently applied to the preparation and then moderately air dried, taking approximately 25 seconds. Tokuyama Universal Bond from Tokuyama Dental America, an eighth-generation adhesive, is a self-etching adhesive that doesn’t require light polymerization (

	OMNICHROMA from Tokuyama Dental America, a universal resin-based composite matches every tooth shade with a single shade of composite, was then incrementally placed in 2 mm layers and light polymerized (

	Fig. 8                                                                              Fig. 9

	The final increment had the gross anatomy placed with a lateral condenser, which is also known as an acorn condenser (

	Fig. 10                                                                             Fig. 11

	Polishing was accomplished with the RAPTOR

 bur system from BISCO and Rally rubber points from Garrison Dental. After rubber dam removal, the occlusion was adjusted with a “football”-shaped gold carbide bur, and the restoration was “power cured” to harden the final surface (

	Fig. 12                                                                             Fig. 13

	The patient appeared to have a very positive experience, and the parent was quite pleased, both with the child’s behavior and the finished restoration. The patient and parent reported no reaction to the visit nor the materials used.

	Providing appropriate restorative care to children and those with special needs is more than just “filling decay.” It’s having the appropriate environment, team members, attitude, training and dental materials that best suit the patient and his or her needs. OMNICHROMA allows the practitioner to confidently place resin-based composites without the added step and time of shade matching. It’s a true benefit for both the young pediatric or special needs patient and the dental practitioner. 

	1. van der Zande, M. M., Gorter, R. C., Aartman, I. H., & Wismeijer, D. (2015). Adoption and use of digital technologies among general dental practitioners in the Netherlands. PloS one, 10(3), e0120725. doi:10.1371/journal.pone.0120725.
	2. Milgrom P. M., Horst J.A. The Effect of New Oral Care Technologies on the Need for Dentists in 2040. J Dent Educ. 2017 Aug;81(8):eS126-eS132. doi: 10.21815/JDE.017.019.3. Alexander, G. , Hopcraft, M. , Tyas, M. and Wong, R. (2014), Dentists’ restorative decision making and implications for an ‘amalgamless’ profession. Part 1: a review. Aust Dent J, 59: 408-419. doi:10.1111/adj.12209.
	4. Kameyama, A., Nakazawa, T., Haruyama, A., Haruyama, C., Hosaka, M., & Hirai, Y. (2008). Influence of finishing/polishing procedures on the surface texture of two resin composites. The open dentistry journal, 2, 56-60.
	5. Van Ende A., De Munck J., Lise D.P., Van Meerbeek B. Bulk-Fill Composites: A Review of the Current Literature. J Adhes Dent. 2017;19(2):95-109. doi: 10.3290/j.jad.a38141.
	6. Cannon M. L., Clinical Excellence, Universally Providing the Proper Shade for Posterior Composite Restorations. Dentaltown, March 2019.
	7. Trevor Burke F.J., Lawson A., Green D.J.B., Mackenzie L. What’s New in Dentine Bonding?: Universal Adhesives. Dent Update. 2017 Apr;44(4):328-30, 332, 335-8, 340.
	8. De Munck J1, Van Meerbeek B, Yoshida Y, Inoue S, Vargas M, Suzuki K, Lambrechts P, Vanherle G. Four-year water degradation of total-etch adhesives bonded to dentin. J Dent Res. 2003 Feb;82(2):136-40.
	9. Zhang Z.Y., Tian F.C., Niu L.N., Ochala K, Chen C., Fu B.P., Wang X.Y., Pashley D.H.4, Tay F.R. Defying ageing: An expectation for dentine bonding with universal adhesives? J Dent. 2016 Feb;45:43-52. doi: 10.1016/j.jdent.2015.11.008. Epub 2015 Nov 30.
	10. Chen C., Niu L.N., Xie H., Zhang Z.Y., Zhou L.Q., Jiao K., Chen J.H., Pashley D.H., Tay F.R. Bonding of universal adhesives to dentine--Old wine in new bottles? J Dent. 2015 May;43(5):525-36. doi: 10.1016/j.jdent.2015.03.004. Epub 2015 Mar 20.
	11. Takamizawa T., Barkmeier W.W., Sai K., Tsujimoto A., Imai A., Erickson R.L., Latta M.A., Miyazaki M. Influence of different smear layers on bond durability of self-etch adhesives. Dent Mater. 2018 Feb;34(2):246-259. doi: 10.1016/j.dental.2017.11.002. Epub 2017 Nov 13.
	12. Cannon M. L., How to use cavity liners to provide better care. Dental Products Review. April 2018.
	13. Frieri, M. Mast Cell Activation Syndrome. Clinic Rev Allerg Immunol (2018) 54: 353. https://doi.org/10.1007/s12016-015-8487-6.

How one pediatric dentist uses OMNICHROMA to quickly and confidently place composite. 

How to manage shade selection and a patient's needs

	As dental students, most of us were indoctrinated with the calcium hydroxide philosophy. That is, we placed calcium hydroxide under all restorations. Brands such as 

™ (Kerr) were to dentists as ubiquitous as Kleenex is to our patients. The philosophy served the profession well, until the concept was challenged.

	The renegades who challenged the calcium hydroxide cult met stiff resistance and, in my humble opinion, were treated as heretics.

 A slew of scientific articles debated the issue of pulpal protection, some with dramatic titles (“

The disastrous effects of the ‘total etch technique’ in vital pulp capping in primates

”) while other studies had totally differing results.

 Now after almost two decades of clinical practice, literally tens of millions of human teeth in this country have had dentin etched (76 million composite restorations in one year alone, 2004), and the pulps have survived.

There is good reason for the survival of the vast majority of dental pulps. Dentin has significant buffering capacity, as would logically be expected due to evolutionary development.

 In addition, the dentino-pulpal complex utilizes a dentino-pulpal fluid flow that helps protect the pulp and remineralizes the dentin.

 In the diseased state, the dentin caries progresses due to the extreme acidity of lactic, acetic and, interestingly, propionic acids produced by cariogenic bacteria.

	The acidic environment demineralizes the dentin but - equally importantly - stimulates the matrix metalloproteinases (MMPs 1, 2, 8 and 9) to break down the collagen matrix.

 Humans and our microbiome have co-evolved so that we have developed symbiotic relationships, including within the oral cavity. Indeed, the host and the symbiont microbiome form a holobiont virtually sharing the hologenome.

 It has been recently stated that the microbiome is even the driving force of evolution.

 As such, the dental caries process has developed a complex microbiome, not only of cariogenic bacteria but also of commensal competitive bacteria that help to control the carious progression.

 A process that is just now being appreciated.

	One curious concept is that somehow a few seconds exposure of dentin to acid etch would severely injure pulpal tissue while the carious process has often exposed the very same dentin to a harsh acidic environment over a period of months (and during that same time the pulp was also challenged by bacterial toxins)

 - especially as the overriding constant factor effecting pulpal vitality is now considered to be the presence of bacteria.

 As in all surgical procedures, control of pathogenic bacteria is of primary importance.

	This is where both of the opposing camps were actually correct. The alkalinity of the calcium hydroxide products provided protection against pathogenic bacteria.

 In addition, the presence of the calcium ions may strongly induce dentin bridge formation.

 A restoration that does not leak is always essential to survival of the pulp.

 The only issue with etching the dentin was the removal of the smear layer that would subsequently increase dentin permeability with hydrophilic adhesives.

 The increase in permeability would allow for not only bacterial invasion but also the penetration of cytotoxic resin components.

	Fortunately, we now have better adhesive agents that not only penetrate the etched dentin replacing the smear layer (which ironically contains bacteria, yet it has been advocated to leave this contaminated debris) - the adhesives provide a better layer of protection from pathogenic bacteria as the smear layer produces voids in the hybrid layer.

 Smear layers, left intact, reduce the bond strength of the dentin adhesives.

 Unfortunately, some dental products still contain cytotoxic components capable of pulpal insult.

 Also, hydrophilic dental adhesives degrade over time and stimulate MMP activity, leaving voids in the hybrid layer and allowing for decreased bond strength and increasing microleakage.

	Resin-modified glass ionomers play an extremely important role in clinical dentistry. The fluoride release is quite beneficial in re-mineralizing enamel and inhibiting cariogenic biofilms.

 However, they are quite acidic with a setting pH below 3 and the polyacrylic acid component actually inhibits apatite formation, a key precursor of dentin bridge formation.

 However, the release of fluoride from RMGIs helps enamel by creating fluorapatite, thereby reducing solubility

 - which is not, however, as much benefit for dentin that contains over 33 percent organic matter with only 45 percent calcium hydroxyapatite, making fluorapatite formation less significant.

The above notwithstanding, the overall clinical benefits of glass ionomer products cannot be discounted - especially in the caries-prone individual, and as polymerization contraction stress relief under restorations is quite significant.

 Unfortunately, cytotoxic constituents of glass ionomer products may again be detrimental to pulp vitality.

 Of interest is that clinical manifestations of pulpal irritation are not always indicative of histological findings, further confusing the situation.

	The ideal pulp capping or deep cavity material would be light-cured for easy placement and time control. The material would be alkaline and calcium-releasing to encourage dentin bridge formation. In addition, the material would have sufficient mechanical properties. The dental material closest to having all these properties is 

(BISCO), a light-cured, resin-based dicalcium and tricalcium silicate.

	A 7-year-old male patient presented with a history (maternal report) of severe dental apprehension and extensive recurrent caries. Upon examination the patient was noted to have a strong but manageable gag reflex, some airway concerns and slight “long face syndrome.” The dentition was mixed with permanent first molars and incisors. Patient reported sensitivity with eating on the upper-right quadrant and the primary molars restorations in that quadrant presented with severe micro-leakage (Fig. 1). The patient was appointed for restorative care as soon as possible.

	Upon the operative visit he remained very cooperative. 

 (Milestone Scientific) was utilized for local anesthesia and a rubber dam placed (Fig. 2). Removal of the previous restorations was quick, as they demonstrated no evidence of bond with tooth structure. Gross caries was present under the restorations along with obvious micro-leakage staining (Fig. 3).

	Following gross carious dentin removal, the pulps were not exposed but a pinking blush was noticeable. Following debris removal by copious rinsing, the enamel margins were etched with 

 w/ BAC (BISCO). The dentin was etched to remove the smear layer but not widen the dentinal tubules (Figs. 4-5). 

	Leaving dentin moist (dentin should never be dried anyway) TheraCal LC is applied and light-cured. Because TheraCal LC incorporates hydrophilic monomers, it spreads better on moist dentin and adheres after light curing (Fig. 6). The alkaline pH and calcium release, very similar to ProRoot MTA (Dentsply), stimulates dentin formation and inhibits bacterial growth.

 adhesive (BISCO), a seventh-generation adhesive, and was restored with a resin-based dual cure (

) composite (Fig. 6). After removal of the rubber dam, the patient thanked me for making him “numb.” He claimed it was the first time he had been anesthetized for dental care. His mother was unaware that he had never received anesthesia for treatment, and had thought that he was just being “too sensitive.” The patient has returned for recare appointments and the teeth have remained asymptomatic (Fig. 7).

	Proper restorative care should include local anesthesia when appropriate, proper isolation and the correct choice of dental materials. TheraCal LC is the modern replacement for older cavity liners such as Dycal and Life, which are not indicated for placement under newer restorative materials (resin-based composites) used in the contemporary dental practice.

	1    Fusuyama T. New Concepts in Operative Dentistry. Chicago, Ill: Quintessence Publishing Co, Inc; 1980.

	2    Nakabayashi N, Kojima K, Masuhara E. The promotion of adhesion by the infiltration of monomers into tooth substances. J Biomed Mater Res. 1982;16:265-273.

	3    Kanca J. A method for bonding to tooth structure using phosphoric acid as a dentine-enamel conditioner. Quintessence Int. 1991;22:285-290.

	4    Kanca J. Improved bond strength through acid etching of dentin and bonding to wet dentin surfaces. J Am Dent Assoc. 1996a;123:35-43.

	5    Pameijer CH, Stanley HR. The disastrous effects of the "total etch" technique in vital pulp capping in primates. Am J Dent. 1998 Jan;11 Spec No:S45-54.

	6    Hafez, A et al. “An in vivo evaluation of hemorrhage control using sodium hypochlorite and direct capping with a one- or two-component adhesive system in exposed nonhuman primate pulps.” Quintessence international 33 4 (2002): 261-72.

	7    American Dental Association (2007) 2005-06 Survey of Dental Services Rendered. American Dental Association, Survey Center. Chicago, IL

	8    Teaford, M, Smith, M Ferguson, M. Development, function and evolution of teeth. (Cambrige University Press, 2000).

	9    Rangcharoen M., Sirimaharaj V., Wanachantararak S., Vongsavan N., Matthews B. Observations on fluid flow from exposed dentine in primary teeth: An in vitro study. Arch Oral Biol. 2017 Nov;83:312-316. doi: 10.1016/j.archoralbio.2017.08.013. Epub 2017 Aug 25.

	10   Hojo S, Komatsu M, Okuda R, Takahashi N, Yamada T. Acid profiles and pH of carious dentin in                 active and arrested lesions. J Dent Res. 1994 Dec;73(12):1853-7.

	11  Chaussain-Miller C1, Fioretti F, Goldberg M, Menashi S. The role of matrix metalloproteinases (MMPs) in human caries. J Dent Res. 2006 Jan;85(1):22-32.

	12  Rosenberg E, Zilber-Rosenberg I. Microbes Drive Evolution of Animals and Plants: the Hologenome Concept. MBio. 2016 Mar 31;7(2):e01395. doi: 10.1128/mBio.01395-15.

	13  Zilber-Rosenberg I, Rosenberg E. Role of microorganisms in the evolution of animals and plants: the hologenome theory of evolution. FEMS Microbiol Rev. 2008 Aug;32(5):723-35. doi: 10.1111/j.1574-6976.2008.00123.x. Epub 2008 Jun 28.

	14  Belda-Ferre P1, Alcaraz LD, Cabrera-Rubio R, Romero H, Simón-Soro A, Pignatelli M, Mira A The oral metagenome in health and disease. ISME J. 2012 Jan;6(1):46-56. doi: 10.1038/ismej.2011.85. Epub 2011 Jun 30.

	15  Hiraishi N, Kitasako Y, Nikaido T, Foxton RM, Tagami J, Nomura S. Evaluation of active and arrested carious dentin using a pH-imaging microscope and an X-ray analytical microscope. Oper Dent. 2003 Sep-Oct;28(5):598-604.

	16  Murakami K, Kitasako Y, Burrow MF, Tagami J. In vitro pH analysis of active and arrested dentinal caries in extracted human teeth using a micro pH sensor. Dent Mater J. 2006 Sep;25(3):423-9.

	17  Aas JA, Griffen AL, Dardis SR, Lee AM, Olsen I, Dewhirst FE, Leys EJ, Paster BJ. Bacteria of dental caries in primary and permanent teeth in children and young adults. J Clin Microbiol. 2008 Apr;46(4):1407-17. doi: 10.1128/JCM.01410-07. Epub 2008 Jan 23.

	18  Cooper PR, Chicca IJ, Holder MJ, Milward MR. Inflammation and Regeneration in the Dentin-pulp Complex: Net Gain or Net Loss?J Endod. 2017 Sep;43(9S):S87-S94. doi: 10.1016/j.joen.2017.06.011.

	19  Tziafas D, Koliniotou-Koumpia E, Tziafa C, Papadimitriou S. Effects of a new antibacterial adhesive on the repair capacity of the pulp-dentine complex in infected teeth. Int Endod J. 2007 Jan;40(1):58-66.

	20  Zancan RF, Vivan RR, Milanda Lopes MR, Weckwerth PH, de Andrade FB, Ponce JB, Duarte MA. Antimicrobial Activity and Physicochemical Properties of Calcium Hydroxide Pastes Used as Intracanal Medication. J Endod. 2016 Dec;42(12):1822-1828. doi: 10.1016/j.joen.2016.08.017. Epub 2016 Oct 21.

	21  Mohammadi Z, Dummer PM. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endod J. 2011 Aug;44(8):697-730. doi: 10.1111/j.1365-2591.2011.01886.x. Epub 2011 May 2.

	22  Farhad A, Mohammadi Z. Calcium hydroxide: a review. Int Dent J. 2005 Oct;55(5):293-301.

	23  TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Oper Dent. 2009 Sep–Oct; 34(5): 615–625.

	24  Manar M, Abu-Nawareg, Zidan A, Zhou J, Agee K, Chiba A, Tagami J, Pashley, D. Adhesive sealing of dentin surfaces in vitro: A review Am J Dent. 2015 Dec; 28(6): 321–332.

	25  Dursun, E, Fron-Chabouis, H, Attal, J.-P,  Raskin, A. (2016). Bisphenol A Release: Survey of the Composition of Dental Composite Resins. The Open Dentistry Journal, 10, 446–453. 

http://doi.org/10.2174/1874210601610010446

	26  Van Landuyt KL, De Munck J, Mine A, Cardoso MV, Peumans M, Van Meerbeek B. Filler debonding & subhybrid-layer failures in self-etch adhesives. J Dent Res. 2010 Oct;89(10):1045-50. doi: 10.1177/0022034510375285. Epub 2010 Jul 14.

	27   Yoshida E, Uno S. Voids formation along the bonding interface between a smeared dentin surface and all-in-one adhesives. Dent Mater J. 2004 Dec;23(4):643-9.

	28  Gupta K, Saxena P, Pant V, Pant A. (2012). Release and toxicity of dental resin composite. Toxicology International, 19(3), 225–234. 

	29  Oliva A, Della Ragione F, Salerno A, Riccio V,Tartaro G, Cozzolino A, D'Amatoc S, Pontonia G, Zappia V. Biocompatibility studies on glass ionomer cements by primary cultures of human osteoblasts Biomaterials Volume 17, Issue 13, July 1996, Pages 1351-1356.

	30  Nicholson JW,   Czarneck B. The biocompatibility of resin-modified glass-ionomer cements for dentistry Dental Materials Volume 24, Issue 12, December 2008, Pages 1702-1708

	31  De Munck J, Van Meerbeek B, Yoshida Y, Inoue S, Vargas M, Suzuki K, Lambrechts P, Vanherle G Four-year water degradation of total-etch adhesives bonded to dentin J Dent Res. 2003 Feb;82(2):136-40.

	32  Chau NP, Pandit S, Cai JN, Lee MH, Jeon JG. Relationship between fluoride release rate and anti-cariogenic biofilm activity of glass ionomer cements. Dent Mater. 2015 Apr;31(4):e100-8. doi: 10.1016/j.dental.2014.12.016. Epub 2015 Jan 17.

	33  Ben-Amar A, Liberman R, Apatowsky U, Pilo R. (1999), pH changes of glass–ionomer lining materials at various time intervals. Journal of Oral Rehabilitation, 26: 847–852.

	34  Smith DC, Ruse ND. Acidity of glass ionomer cements during setting and its relation to pulp sensitivity. J Am Dent Assoc. 1986 May;112(5):654-7.

Why one practitioner says that TheraCal LC® from Bisco is the closest thing to an ideal material.   