For years now, dentistry has been diagnosing, for the most part, interproximal decay in pretty much the exact same way. Since the introduction of the concept of the bitewing radiograph, the process of locating and diagnosing decay between the teeth has only gone through minor changes.

The good news is that, with better collimation and 

, we have managed to increase our diagnostic ability while greatly decreasing the amount of radiation that is needed to create the images.

This, of course, means that we are seeing more and diagnosing more accurately while exposing patients to less and less radiation.

However, most of us will admit that we still routinely come across areas on a radiograph that are questionable.

Now dentistry prides itself on conservative diagnosis and treatment, so we are faced with a clinical Catch-22.

Do we open a possibly non-carious area to make absolutely sure, or do we follow these areas hoping that the patient keeps his or her re-care appointments so that we can check these areas again in a year and see if the area appears to have changed?

Neither one of these choices is an easy one to make and, in the eyes of most practitioners, both have a significant downside.

However, how amazing would it be to be able to transilluminate with a device that allows us to save what we see as a digital image so that we can review it at a later date? Then let’s take this concept one step further.

How cool would it be to be able to not only save that image but to compare it directly to the bitewing you just took earlier in that exam?

Well, this is no longer pie-in-the-sky or a dream. The above concept is now a reality thanks to the hard work of the people at DEXIS.

Since early January, I have been using and testing 

The device is a transilluminator with a built-in infrared camera. It shines near-infrared light through the teeth from both the buccal and lingual aspects simultaneously and puts the live image on the operatory computer screen where it can be viewed live by doctor and patient.

 along with intraoral photos and digital radiographs taken with 

One of the best things about using the CariVu is the way its image capture capabilities were built into the software.

Images are assigned to a tooth and, when captured, the most recent radiograph of that tooth comes up in the software next to the CariVu image. This allows for immediate comparison between the two types of images. Because the CariVu provides such crisp and clear clinical images, it is very easy to see interproximal decay as darkened areas in the transilluminated pictures.

The CariVu captures black and white images so they appear very much like a radiograph. Decay shows up as a darkened area in the lighter surrounding tooth structure.

The device can be used to view the interproximal surfaces anywhere in the mouth as well as the occlusal surfaces. This allows the dental professional to finally be able to see under the enamel and find things such as decay around existing restorations, cracks, smooth surface caries, and interproximal caries with one device that does not use ionizing radiation.

Scanning the mouth with the CariVu device is quick and easy. It connects to the operatory computer via USB and is easily recognized by the DEXIS software.

While scanning and saving every tooth is an option, many offices will choose to scan but only save those images with potential problems.

Since CariVu uses infrared light, it will not replace radiographs for routine diagnosis. However, since using the device, I have certainly seen things that I have not seen on radiographs.

DEXIS has done a remarkable job of designing this device for ease-of-use clinically. They have also done a great job integrating this into their imaging software.

If you are one of those doctors, like me, who frequently struggles with doing the right thing when it comes to questionable areas on a radiograph, the CariVu may be just what you’ve been looking for.

Articles

DPR tech editor gives thumbs up to the DEXIS CariVu transilluminator

Planmeca PlanScan, driven by E4D Technologies

, is described as an innovative, technologically advanced, ultra-fast intraoral CAD/CAM system for restorative dentistry.

With video-rate scanning and Thunderbolt™ connectivity to your Planmeca PlanCAD® laptop, Planmeca PlanScan captures and processes data almost as quickly as you move your hand – even with full-arch cases.

 makes restorative dentistry quicker and easier– from intuitive computer-guided image capture to plug-and-play technology that gives you the freedom to scan at multiple Planmeca PlanScan workstations. Additionally, it’s powder-free.

It’s the only intraoral scanner in the world with blue laser technology. Its smaller wavelength (450 nm) is more reflective, resulting in sharper images. Its ability to capture fine details allows for more clinically precise prosthetics.

The new scanner and new open CAD software suite for easy 3D design, Planmeca PlanCAD™, is integrated within the 

 and is a perfect tool for designing prosthetic works from individual inlays to full-arch bridges and abutments.

For practitioners who place implants, the Planmeca Romexis software enables them to import data needed for treatment planning from another system, whether or not it is Planmeca’s. Users of Planmeca Romexis software can now share images (2D and 3D) and documents with minimal effort via a Planmeca Romexis Cloud.

Information is securely transferred into the cloud and the recipient is automatically notified of new cases requiring his or her attention.

The Planmeca PlanScan, driven by E4D Technologies, is described as an innovative, technologically advanced, ultra-fast intraoral CAD/CAM system for restorative dentistry.

3 reasons to apply Planmeca PlanScan in your practice

"Then my friend turned to me and said, ‘You’ve got some straight white teeth!’ Things like that let you know the process did work. I definitely would recommend  

After several years of contemplating braces and concerns about overcrowding of the teeth in his lower jaw, Gerald Blackman asked his dentist about his options. Gerald wanted straighter teeth and a better smile, but made it clear to Dr. Thomas Watkins that he was not interested in traditional metal wire braces.

	“I’ve always been kind of conscious of my bottom teeth. I could feel them over the years kind of shifting and crowding up,” he said. “My daughters also both go to Dr. Watkins and one day I just asked him what I should do about the crowding of my bottom teeth.”	 	The San Antonio dentist listed a number of options, but after Gerald, who speaks to business associates on a regular basis, said he did not want traditional braces, Dr. Watkins told him about ClearCorrect clear aligners. After an assessment, it was determined that Gerald was indeed a candidate for the clear aligner therapy. 	 	“When I told him I talk at business meetings in front of a lot of people, he recommended ClearCorrect,” Gerald said. “The process was smooth. I came in and they made the moldings and they sent them off. Then I came back and they did the fitting.”	 	Gerald was surprised at how well the process went. He wore each set of clear aligners for three weeks, but usually visited the practice every six weeks to get the next sets to further carry on the care.	 	“Honestly speaking, it was such a smooth process. I had to ask myself at one point, is this really working?,” Gerald wondered. “Every time I put on a new set of braces, I’d feel the tingling and the pulling but in my mind I was still wondering how they were going to fix the crowding.	 	“I was worried it would be a problem talking and holding these in my mouth, but they fit so snug and comfortably that I didn’t have to worry about that. It was easy from the start.”	 	During the process, Dr. Watkins and his team would check to make sure the aligners were always properly down on the teeth, and would report on the treatment’s progress.	 	“He would show me how things were coming together but also after awhile I could tell,” Gerald said. “You could really feel which tooth it was actually working on. In some cases the tingling was so profound and I was like, it’s really working...actually aligning your teeth as they’re supposed to be.”	 	Dr. Watkins placed spacers at some points during the process to allow other teeth to spread out more and even up and fall into line. Gerald wore the aligners for about 18 months total.	 	“To be quite honest, I was like, is it over already?,” he said. “Yes, I am very happy with the results. Now people have commented to me: What did you do? Did you have some type of face lift or something? Why are your teeth so straight?”	 	So Gerald tells them he wore ClearCorrect clear braces, and that he would do it all over again with no doubts.	 	“A funny thing happened 2-3 weeks ago when I met up with a friend of mine that I haven’t seen in 20 years. We were out to eat and the waitress took a picture of me and a couple of friends. Then my friend turned to me and said, ‘You’ve got some straight white teeth!’ Things like that let you know the process did work.”	 	So now Gerald is quick to flash his smile and quick to recommend the care to others.	 	“I definitely would recommend ClearCorrect to friends or colleagues because it’s an easy process. It’s not the big silver lining in your mouth that everybody notices.”

  "Then my friend turned to me and said, ‘You’ve got some straight white teeth!’ Things like that let you know the process did work. I definitely would recommend  ClearCorrect to friends or colleagues...”    

Correcting smiles with ClearCorrect clear aligners from a patient's perspective

Every restorative dentist will be, at some point, faced with a patient that presents with root caries apical to an existing crown margin. The choice is whether to remove the existing crown and additional decay and replace the crown, or to attempt to directly restore the affected area without crown replacement.

Let’s further assume this root caries exists on a strategic abutment of a long span bridge-this compounds the decision, especially if economics does not allow the patient to replace the bridge. What are the options now?

One critical aspect that will impact on the ability to restore an area of the tooth or root below an existing restoration will be clinical access to the area.

Often these lesions will be subgingival, so access to restore may require a gingivoplasty, or “mini flap procedure,” to access all the restorative margins. If a flap procedure is not needed for access, use of a soft-tissue dental laser is ideal for this procedure. The wavelength of a diode laser can help with localized hemostasis and is considerably less invasive as far as a zone of necrosis when compared to electrosurgery.

Also, it is difficult to use electrosurgery instrumentation safely around metallic restorations.

The second clinical problem is that the surface of the root is not a very good substrate on which to use resin-bonded dental materials. It is well documented that glass ionomer cements “seal” this type of dentin better than adhesive resins.

The difficulty in using traditional glass ionomers may be in the clinical placement into these difficult to reach areas and then maintaining the field to allow for the self-cure set of the material, which may be minutes. Light-cured resin-modified glass ionomers offer a more realistic approach utilizing command set, but often do not allow long-term diffusion of ions through the resin limiting the “healing effects” of the material.

A new RMGI restorative material (ACTIVA BioACTIVE-RESTORATIVE from Pulpdent Corp.) 

has been shown to allow continual passive diffusion of calcium, phosphate and fluoride ions through the restorative material and to have excellent compressive strength, which is unusual for light-cured RMGI materials.

Activa was chosen to restore this carious lesion on the root of this posterior tooth with a full coverage restoration.

Clinical Case: Root Surface Repair With A Bioactive Restorative Material

The patient in Figure 1 of the above slideshow presented with root surface decay apical to existing porcelain to metal crown.

She is in her late 60s and has battled periodontal disease most of her life. Having lost several maxillary posterior teeth and had them replaced with implants, the treatment goal at this time is to maintain her existing restorations as long as possible. In order to gain access to the carious area, a full thickness flap was reflected.

A SmartBur II (SS White Burs) round polymer bur is used to carefully excavate the carious area. Thirty-seven percent phosphoric acid is used to “clean the preparation” for five seconds, then rinsed away with copious amounts of water. Air dry, but do not over-desiccate the surface of the dentin.

The metal mix tip with metal cannula supplied with 

 is ideal for access in this area as it can be bent to the appropriate angle to allow for easy and precise delivery of the restorative material to the center of the preparation.

It is important not to overfill the preparation to limit the amount of finishing, since access to the restoration with finishing instrumentation will be difficult. Ideally, just enough ACTIVA Restorative should be placed so that removal of excess or finishing after curing is not needed.

Figure 2 in the slideshow shows the ACTIVA Restorative material after placement and light curing. After verifying the accuracy of placement with a bitewing radiograph, the flap will be closed with a silk suture through each side of the interproximal papilla. After one week, the suture is removed.

Figure 3 in the slideshow shows a similar type of lesion radiographically on the mesial abutment (tooth No. 31) of a long span bridge. It is financially not feasible for this patient to have the bridge replaced at this time. Rather than section away the pontics (tooth Nos. 29 and 30) from the anterior abutment and extract the distal abutment, it was decided to see if the lesion could be excavated and successfully restored using ACTIVA BioACTIVE-RESTORATIVE.

Figure 4 is a post-operative radiograph after placement of ACTIVA Restorative on the root surface of tooth No. 31. There was no pulp exposure during preparation and the patient was told, “we will see how the tooth responds to therapy.” Our hope is that by removing the caries and placing a bioactive restorative material such as ACTIVA Restorative, the ion exchange will help to remineralize any affected dentin remaining and the clinical life of this fixed prosthesis will be extended for an indefinite period of time.

These are cases where teeth with recurrent root caries in difficult to access areas have been restored with a bioactive restorative material in hopes of preventing further tooth loss and extending the life of the existing restorations.

This is one of many clinical examples where a bioactive restorative material, such as 

 will prove to be extremely useful in our quest to help patients maintain their dental health.

How to restore root caries with ACTIVA BioACTIVE-RESTORATIVE material [VIDEO]

In this installment of “I Use That,” we asked Dr. Eric Hurtte and his lead dental assistant, Tija Hunter, CDA, EFDA, FADAA, about their use of 

With a thriving practice in suburban St. Louis (O’Fallon, Mo.), Dr. Hurtte and Tija believe these two products have changed the way they approach dentistry.

What the dentist (Dr. Hurtte) says about CEREC and IPS e.max:

 about two years ago. In that time, I have probably done close to 450 restorations and the majority of them using

. I prefer e.max over other restorative blocks for several reasons including beautiful shade matching, esthetics, and strength.

Adjustments to contacts and occlusion are easily made before the crown is glazed, eliminating intraoral adjustments that may leave the restoration feeling rough to the patient. Once the crown is glazed and fired, the esthetics are good and the material is incredibly strong. The material is easily bonded to the tooth providing superior retention over other materials. I can never go wrong when choosing IPS e.max.

What the dental assistant (Tija) says about CEREC and IPS e.max:

Just over two years ago, we entered into the world of CAD/CAM dentistry and purchased a CEREC. We love how it has transformed our practice. Forget about what they say about saving money on lab fees, the convenience of having everything in our office, and being able to do a crown in one visit is something that our patients and our team love.

We can deliver a level of customer service like never before. Our patients love being involved in every step of the process.

Like everything, there is a learning curve, not only with the technology but the materials as well. There are several different blocks you can purchase from a number of companies, each claiming to have the best. In the beginning, we bought them all. Time and time again, Ivoclar Vivadent’s IPS e.max blocks consistently performed the best for our needs.

This material is so easy to manipulate in the blue stage, making any adjustments super easy. It’s a very versatile block that we use it for inlays/onlays, veneers, and crowns. Once glazed and fired, it is a beautiful restoration, bonded into place with a strength that is rivaled by none.

For the patients, they see a gorgeous restoration, done in a little over an hour that matches the shade of their existing teeth, and will stand up to years of wear. They love the one visit as much as we do!

For us, it’s about having the confidence in delivering a quality in-office restoration that is both functionally sound and esthetically beautiful for anterior and posterior restorations.

CEREC is the unique CAD/CAM system for patient individual all-ceramic restorations in one single appointment. Together with CEREC, dental professionals come quickly and safely to the desired results for both them and their patients: aesthetic restorations.

A further important objective is also achieved, the creation of value remains where it belongs in your practice. To meet the individual needs of every single dentist, Sirona has 

expanded its product range to include two camera solutions and three different milling units.

 is an innovative lithium disilicate glass ceramic that delivers durability, esthetics, and long-term clinical success to CAD/CAM dental professionals.

Unlike any other CAD/CAM material, IPS e.max CAD covers a comprehensive spectrum of indications, offers a wide range of translucency levels, shades and block sizes and coordinated cements to ensure clinical performance and esthetic success.

In this installment of “I Use That,” we asked Dr. Eric Hurtte and his lead dental assistant, Tija Hunter, CDA, EFDA, FADAA, about their use of CEREC from Sirona and IPS e.max from Ivoclar Vivadent.

How Sirona’s CEREC and the IPS e.max® System have transformed this practice

The snowy morning before Thanksgiving, Mary Cook was mentally preparing for the next day. Cooking was the main concern, along with getting the complete grocery list and thinking about who all was attending the holiday gathering. 

These were the things rushing through her head as she began to brush her teeth that morning.

“A thorough brushing is what my Mom had taught me. She did have gorgeous teeth and a great smile, so it seemed well worth it to me to emulate her good habits,” Mary said.

While methodically brushing her teeth, Mary heard something clang into the sink. She quickly pulled up the stopper so that nothing would go down the drain.

“I carefully looked around and picked up whatever this something was. I cleaned it off and began to examine it carefully,” she said. “It looked like part of a tooth! Oh no, I thought. Not today!”

After checking her mouth closely a couple of times, Mary realized there was a large hole in one tooth. Could there be a worse time for this, she thought? She worried that dentists might not be working on the Wednesday before Thanksgiving.

“I got my phone and nervously dialed my dentist, Dr. Tim Bizga,” said Mary. “To my amazement, he answered by saying, ‘Come on in and I’ll fix it.’ ”

At an earlier time, Dr. Bizga had fixed her bite in order to correct a TMJ issue (a painful jaw condition). He had also ingeniously repaired a tooth that another dentist had wanted to pull out.

 Spectra™ Universal Composite Restorative in your practice 

“On top of that, he is truly a painless dentist – I barely feel it when he gives me the shot that temporarily numbs part of my mouth,” said Mary, who has referred family and friends to her dentist. “Above all, I thought as I was driving, he is incredibly personable and genuinely cares about each and every patient.”

Mary arrived a few minutes late due to the snowy road conditions, yet the visit turned out quite well.

“He told me that earlier in the week he had asked his assistant to work a half a day on the day before Thanksgiving because he knew there would be patients who would have emergency dental issues,” she recalled. “It turns out that I was the third patient he had helped that morning because of our unforeseen dental problems.”

Upon examination, he noted Mary had lost a lot of her tooth as the old filling was a large one. Mary wondered if she’d lose the tooth or maybe need a crown.

Dr. Bizga paused, and then said, “No, you won’t. I think I can fix it with a new product I have been using.”

In the past, Mary was suspicious of new products in dentistry, but she trusts Dr. Bizga, noting that his use of new technology always benefits his patients, and that he is thorough in his research.

“When it came time for the tooth to be filled, it felt unlike other filling material that had been used in the past to fill my teeth,” she said. “Dr. Tim inserted the product. I sat in the chair while the filling set. Soon, he was back to check the progress of the filling. There was no scraping of the filling surface as there usually is when bits of the filling material fall into your mouth. And it didn’t take Dr. Tim long to adjust my bite.

“As I was answering his questions about how the tooth felt, I was amazed at the filling and told him that. Then I apprehensively asked him when I was going to have to come back ‘for the real filling.’

“You’re done,” he said as he smiled. “I rebuilt your tooth and that filling will last you a long, long time.”

Mary’s dentist explained the product used was

 and that he was using it successfully on his patients.

“I left his office and marveled at his mastery of dentistry and his constant quest for knowledge that had led him to this new filling material,” she said. “I have a great appreciation for him and his work in dentistry. I am very grateful that he is the dentist for me and for my family.”

It’s been months since that dental visit and the TPH Spectra restoration has stayed perfectly and comfortably in the tooth. Now Mary is looking at other treatments.

“I am choosing to replace old silver fillings with this new product,” she said. “There couldn’t be a happier ending to a dental story-perfect doctor and perfect product.”

The snowy morning before Thanksgiving, Mary Cook was mentally preparing for the next day. Cooking was the main concern, along with getting the complete grocery list and thinking about who all was attending the holiday gathering.  These were the things rushing through her head as she began to brush her teeth that morning.

Patient Perspective: How DENTSPLY Caulk's TPH Spectra™ saved one woman's tooth

I recently had the opportunity to ask Dr. Jack Ringer, president of the 

 (AACD), what trends he sees in cosmetic dentistry and what role universal adhesives might play in advancing the specialty. 

On top of his position at the AACD, Dr. Ringer is in private practice at Advanced Smile Design in Anaheim Hills, Calif. and has lectured on and taught contemporary esthetic dentistry for 16 years.

What trends do you see in cosmetic dentistry for 2014?

There are two major trends I see in cosmetic dentistry for 2014. The first is the continual advancement and development of technology that assists diagnosis, e.g. 3D imaging, and restoration manufacturing, e.g. CAD/CAM. Dentists and labs will find it easier to acquire and utilize these devices because as their cost drops, they are becoming more precise and accurate, as well as “talk to each other” due to the open architecture that manufacturers have developed for these devices.

The second trend I see is a definite increase in the demand for cosmetic therapy. This was also confirmed by a recent survey done by the AACD. I believe that the increased confidence in our economy has helped motivate many to engage in elective cosmetic work that they may have put off previously.

With all of the advances in materials and adhesives, what advice do you and the AACD have for keeping up with the latest trends?

Since there are many dental manufacturers who are eager to have a “slice of the economic pie” when it comes to the sale of materials and equipment, it is imperative that dentists review independent studies about these products to make sure they fit the practice’s style and expectations before purchasing and incorporating them into their arsenal.

Dentists have to make sure that what manufacturers are promoting for their products is substantiated and will make clinical and financial sense for their practice.

How do you see universal adhesives fitting into the dentist’s arsenal?

Universal adhesives have been proven to be extremely valuable for dentists in regards to efficiency and success when placing direct and indirect restorations. Due to their chemical nature and versatility, less time is spent cementing restorations, bond strengths in most cases are comparable to other adhesive systems, and patients are experiencing less post-operative sensitivity.

This, however, is dependent on the dentist accurately following the manufacturer’s recommendation on how, where, and when to place the adhesives. Universal adhesives are the latest development for bonding restorations, so they have the shortest track record as far as their long-term success is concerned. Therefore, though the results initially look extremely promising, dentists must keep an open mind as to how the adhesion will hold up over time.

What is the focus of this year’s AACD scientific sessions?

The AACD’s focus at all our scientific sessions is comprised of education, accreditation, philanthropy, and fun. 2014 is our 30th anniversary, so to celebrate we are bringing in some of the world’s top educators in the field of comprehensive cosmetic dentistry, we will be providing diverse programs; such as marketing strategies and business management; for the dentist, lab technicians and the team, and we will be putting on more hands-on clinical programs than ever before for our attendees.

Times are changing and evolving, and so is the AACD as we are continually focusing on bringing new offerings for our members to ensure a true value proposition for being a member. 

I recently had the opportunity to ask Dr. Jack Ringer, president of the American Academy of Cosmetic Dentistry (AACD), what trends he sees in cosmetic dentistry and what role universal adhesives might play in advancing the specialty. 