Gordon Christensen on veneers

Gordon Christensen on veneers

March 25, 2008 -- The 16-year-old came to Gordon Christensen in tears. Her enamel hypoplasia was so bad she couldn't attend her junior prom. Her parents were also distraught, but for a different reason: The cost of 28 veneers for their daughter was $30,000. Since the father’s annual income was $48,000, that level of treatment was out of the question. But in just 40 minutes, Dr. Christensen treated the teenager and sent her on her way, ready for the big night. His solution: Six resin-based ceramic veneers artfully placed just on her front teeth.

Veneers comprised fully one-third of the $8 billion worth of laboratory units produced in 2007, Gordon Christensen D.D.S., M.S.,Ph.D. told a packed audience at the recent 143rd Midwinter Meeting of the Chicago Dental Society. Yet, he added, "At least a third to a half [of all veneers] should never been done." Veneers are in greater demand than ever before, but it pays to know when they are really needed. In a detailed three-hour session, the well-known dentist, lecturer, and publisher (Clinicians Report, AKA, CRA Newsletter) surveyed the available types of veneers as well as options for cements, tools, and prep techniques. Dr. Christensen's product recommendations were seconded by many of the dentists and technicians in attendance.

Veneer Material

Before you get started, says Dr. Christensen, pick your materials. There are four options when it comes to veneers: Ceramic (fixed or pressed) and polymer (direct and indirect). Direct polymer goes to the head of Dr. Christensen’s class because it can be made to match the color of adjacent teeth and it bonds well to new resin. Indirect polymer wears the dunce cap in Dr. Christensen's classroom, along with a sign around its neck reading: "I’m no more than chemically dead resin." Adds the good doctor: "Trying to bond indirect polymer to new resin is asking quite a bit."

Dr. Christensen then got down to the nitty-gritty of preparing teeth for veneers, focusing on three general approaches: no or slight prep; conventional prep in enamel; and deep prep, mostly in dentin. Dr. Christensen's big on the no prep option, pointing out that it's been a proven technique over the many years. He summarily ruled out the deep prep in dentin option. When deep bonds are called for in dentin, says Dr. Christensen, crowns are preferable to veneers. "The bond to dentin is inferior to the bond to enamel, despite what you read in some studies. The bond is good until you've had a thousand cups of coffee and a bunch of ice cream, and then the veneers fall off." His preference: Conventional prep in enamel, which works especially well with malformed teeth: "If you do them correctly, you can't get them off."

Resin-based composites

Dr. Christensen devoted at least an hour to a detailed examination of resin-based composites, with an emphasis on keeping dentists from being misled by vendor claims. The various fills can be used on both direct veneers, which bond better and make economic sense in situations where only a small number of teeth need work, and indirect veneers, which he doesn't favor due to bonding problems. But he's not swayed by promises of superior strength or smoothness made about microhybrid composites such as 3M/ESPE's Filtek Z250. He finds that they frequently turn rough after six months of brushing. The culprit: The relatively large particles (400 to 600 nanometers) of glass that are found in microhybrids and that inevitably produce roughness in a matter of months in either an indirect or direct veneer application.

His take on the "old" microfilled posterior composite Heliomar A2? "It's weak and I don't like it."

Don't be misled by "nanohybrids" either, says Dr. Christensen. It’s simply another name for microhybrids, but with none of the constituents of the preferred nanofills. Flowable microhybrids, microfills, and nanofills might be suitable for addressing "nicks and cracks in an older person's teeth" but they don’t last long enough for a middle-aged patient.

Dr. Christensen sang the praises of two options for the external layer of a veneer: microfilled anterior composites (Durafill, Renamel, or Venus); and Filtek Supreme Plus, the single nanofill option currently available. He gave the anterior microfills credit for looking good for years: "They stay smooth and get smoother as you brush them." But what these silicon dioxide-based anterior microfills gain in smoothness, they lose in strength. For Dr. Christensen, nanofill is the option of choice. Why the high praise? Filtek Supreme Plus is comprised of tiny, 20-75 nanometer zirconium oxide balls that produce both exceptional smoothness and a strong bond. Nanofills also provide four levels of opacity -- dentin, body, enamel, and silox -- with body being the most popular.

But not everyone should take this route, especially if you’re treating a woman in her forties who doesn't care much about smoothness. A patient will often choose a bright white veneer over one with more naturalistic stains. Remember, too, says Dr. Christensen, that ease of application makes resin-based composites ideal. For example, an 82-year-old woman came to Dr. Christensen on a Wednesday, hoping to attend her daughter's wedding reception the following Saturday. First, he removed two teeth crowding her mouth, then applied Filtek Supreme Plus and some bleach to the remaining teeth. That was all it took to send her off to the big event with a beautiful smile on her face. This minimal approach made sense in terms of time and work required. With older patients, says Christiansen, a few judiciously placed veneers make more sense than working on every tooth.

The no-prep way

Thin, no prep veneers aren't for everyone, says Dr. Christensen, but they are excellent options for patients with small teeth, anterior teeth with diastemas, or teeth in lingual version.

No-prep thin veneers are also a good pick when patients want fuller or longer teeth. But no-preps should come with a warning label, says Christiansen. Not only can you end up with some nasty cuts on your fingers when you apply them (because they're so thin), but they can break unless you handle them with extreme care. Another downside is the potential for lower contour. Still, the results can be dazzling. As an example, Dr. Christensen showed photos of a young Asian woman who wanted to lengthen her teeth. Thin veneers were perfect because her teeth were already in good condition. Dr. Christensen did periodontal recontouring and used a chlorhexadine rinse, as well as the thin veneers, to achieve the desired effect.

Dr. Christensen estimates he has applied 4000 veneers and replaced very few. "Thin veneers are an excellent choice because they last so long -- that is, as long as you use resin cement."

Tools and accessories

It’s essential to choose the right tool for the task, and much of Dr. Christensen’s session focused on tools that help dentists apply veneers properly and efficiently. His recommendations:

Resin-curing lights: He favors plasma arc curing lights with a wider tip, which speeds the curing of large veneers.
Articulating media: Most products are too thick, says Christiansen. But two products that pass the test are Madame Butterfly Silk from Almore International and AccuFilm II by Parkell.
Polishing material: Diashine from VH Technologies.
Bonding agent for big composites: Add&Bond by Parkell.
Gingival protection when applying veneer preparations: Zekrya Gingival Protector, from Clinician's Choice.
Trimming and finishing: GC New Metal Strips, from GC America.

Still another Gordon fave: Filtek Supreme Plus, the only single nanofill option available.
Veneer Repair

Even if you use all the proper materials and apply them properly, you can still run into situations where veneers need repairing. Christensen gave the example of a girl who fell and broke her nose -- as well as a veneer. "Boy, we were heavily into dentin," he says. He sent the girl home after applying a provisional restoration with Durafill. He knew a crown wouldn’t work because he would never be able to match the color of adjacent teeth.

When she returned for a veneer, he used a one-quarter-round bur to make lateral holes in the dentin. Such "potholes," he emphasizes, are essential to improving the bond if the surface is all dentin. He then acid etched only the enamel portion as the dentin would be sensitive. Next, he applied a self-etching primer and washed it off quickly so it wouldn’t land on other teeth. After the primer stood for just 15 seconds, he put the bond on the veneer and the tooth, put the cement on the veneer, and seated the veneer. Veneers that come off in one piece can be reattached using the same sequence: Drilling lateral potholes, etching with hydrofluoric acid, and then applying the cement.

Christensen’s bottom lines: Ceramic veneers now comprise about one-third of U.S. dental laboratory production. Properly placed ceramic veneers can last many years, even longer than ceramic crowns. Fees charged for veneers should be as highor higher than crowns. Preparation work on dentin is to be avoided; however, non-prep veneers are a viable alternative for many patients.

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Seven secrets to calming kids

Seven secrets to calming kids

March 24, 2008 -- Before the needle touched him, the four-year-old started crying. So, David E. Thome, D.D.S., knew he had to act quickly. "We use sleepy juice here," he said. "It will put your tooth to sleep so it won't feel anything at all." He then applied a topical anesthetic and challenged the boy to find his belly button with his hands. Being careful not to let him see the syringe again, Dr. Thome quickly administered the shot.

That kind of kid-savvy know-how has helped the Cameron, Missouri-based Dr. Thome grow the number of children under age 15 to more than two-thirds of his patient base. It’s an exceptional number for a general dentist. Children this age make up 20 percent of the general population, according to U.S. Census figures. But a 2003 study in the Journal of the American Dental Association found that they comprise a much smaller proportion of most dentists’ practices. And only 2 percent of all dentists specialize in pediatrics, so the majority of general dentists are overlooking lots of potential clients."They aren’t maximizing their potential revenue," says Marvin Berman, D.D.S., co-author of Essentials of Modern Dental Practice and producer of several videotapes on child management for dentists.

There's no magic bullet when it comes to soothing fearful kids, Dr. Thome and Dr. Berman agree. But simple strategies, applied carefully, can make appointments successful for everyone. What follows are seven tips culled from interviews with some of the country’s leading experts on calming kids in the dental chair.

One: Prepare the child -- and the parent

Even if you have an advanced degree in child psychology -- or raised six kids -- it’s almost impossible to know how kids will react in any given stressful situation. And for a child, what could possibly be more anxiety-producing than a visit to the dentist, even for a routine cleaning? The quiet formality of the waiting room; the sleek, severe dental chair; the harsh overhead light; the whirring buzz of the drill -- it’s the stuff of kids’ nightmares.

Such terror, more than anything, leads to the kicking and screaming so many general dentists dread. A 2007 study published in the International Journal of Paediatric Dentistry, showed that kids’ dental fear is the most important reason general dentists refer patients to pediatric specialists.

Another study from the same journal suggests that the mother’s state of anxiety, and the child’s level of maturity, also contribute to potentially difficult behaviors.

That study is consistent with others going back to the 1970s, says Paul Casamissimo D.D.S., M.S., chair of pediatric dentistry at Ohio State University College of Dentistry and past president of the American Academy of Pediatric Dentistry. The research "consistently shows that if the parent -- usually Mom -- is anxious, then the child will be, too."

Smart dentists who cater to kids provide parents with as much information as possible and patiently answer every question before the first appointment.

When parents calls to make an appointment, says Dr. Casamissimo, chat with them reassuringly. Send them a welcoming letter with a list of frequently asked questions and answers, brochures showing families having fun at your office and pictures of your waiting room with kid-friendly amenities. Instruct them not to share their anxiety with their children.

"I ask parents to be prepared to be silent observers when they come in with their child," says Dr. Thome, "and encourage them not to comment during the appointment."

Before their first visit, Brian Quo, D.D.S., M.A., a Palo Alto, Calif., pediatric dentist, strongly recommends that parents read their kids a children’s book about visiting the dentist. He especially likes Show Me Your Smile!: A Visit to the Dentist by Christine Ricci and Robert Roper.

Dr. Quo invites parents to come by prior to the visit and borrow the book or suggests they go to a library for similar titles. Such books help kids become familiar with names of dental instruments, the office chair, the overhead light, and more.

Two: Design for them

When the child finally arrives, a comfortable, kid-friendly environment helps set the right tone. If your office has a funky old sofa and copies of Field and Stream magazine on the waiting room table, neither parent nor child will have a good first impression.

Dr. Quo’s waiting room is designed with kid-friendliness in mind. Bright colors, walls covered with murals, and a ceiling hung with airplanes provide the backdrop where kids can read books; watch TV; use a Playstation; build with Legos; or play with toys, maps and puzzles. "I want the waiting room to feel like a child’s own bedroom," he says. He provides materials for kids ages six months to 15 years of age.

At the same time, you don't want the space to be a turn-off to adult patients. Dr. Thome’s office features a children’s waiting room separate but visible from the main waiting room.

Three: Meet them and greet them

Of course, human interactions matter even more. Sometimes, being patient and taking the time to establish an informal relationship may be all that's necessary. Matt Comfort, D.D.S., a general dentist in Rocklin, California, was scheduled to see an extremely fearful little three-year-old. Dr. Comfort had him visit the office once a week for about two months. He'd just come in and play a game, and Dr. Comfort would have him sit in the dental chair but not work on him. After the eighth or ninth week, Dr. Comfort said "How about you help us clean your teeth?" He let the boy hold the instrument, and before long he had a happy patient.

Kid-savvy dentists also know how to make their smallest patients feel important. Kellie Paxton, D.M.D., a general dentist at the University of Iowa dental clinic, always pretends she's been happily waiting to see them for a long time. "I am so happy to see you!" she says with a smile. "I've been looking forward to your appointment all day. Look at those cute shoes and your bright-colored sweater. You got all dressed up today." Kids appreciate the validation, she says, and it takes their mind off dentistry. She also recommends making this connection in the waiting room rather than the operatory.

To avoid coming off as an intimidating presence, when Dr. Quo first meets a new patient, he makes it a point to get down to the child’s level -- often on one knee. "I give high-fives all around," he says.

Equally valuable is making sure the child respects your authority. "I let the child know he’s not in charge. I become more serious," says Dr. Quo. "I make sure to look the child in the eye when talking to him. It’s almost a form of tough love, but once the child knows you mean business, he’s usually OK with that."

Coach your staff in these approaches too, advises Dennis J. McTigue D.D.S. M.S., professor of pediatric dentistry at Ohio State University College of Dentistry. "It should feel like you have a bunch of moms in the office." When hiring, ask potential employees if they're willing to chat with kids and even get on the floor to play with them.

Four: Position their parents

Conventional wisdom has long dictated that parents should spend the appointment in the waiting room. Citing the research on how parents' attitudes and anxieties affect their childrens' behavior in the chair, many dentists still adhere to this practice. "The dentist needs to gently separate the parent from the child," says Dr. Quo. Parents may feel that they know their child best and want to help their child through the experience, but they don’t always know when to step back. Their presence may encourage the child to cling or resist treatment.

But some dentists welcome parents in the operatory. Dr. McTigue's treatment team involves the parent, dentist, and child. He prefers that the parent accompany the child all the way to the chair. That way, the importance of dental care is clearly reinforced with the child.

But Dr. McTigue cautions parents about what to say and what not to say in such circumstances. "I don’t want a parent sitting next to child asking me ‘Is this going to hurt her?’" he says. He makes it clear to the parent that if the child cries, it’s perfectly normal. And he acknowledges that bringing parents into the operatory means that the dentist may need to calm the parents as well as the children.

Five: Show them what you’ve got

During the first visit, introduce the child to the familiar before the unfamiliar, according to Dr. Berman. Instead of giving the child a "ride" in the chair (which frightens some kids) or showing her your tools, give her something familiar and talk about familiar things. Hand her a toothbrush and ask her to show you how she brushes her teeth. Offer her a glass of water.

If you allow the parents to be with their children, ask Mom or an older sibling to take the chair first. This technique is called "modeling," with the child watching a family member happily undergo dental care.

Dr. Berman's method echoes the "Tell, show, do" approach described in the American Academy of Pediatric Dentistry’s Guideline on Behavior Guidance for the Pediatric Dental Patient. "The technique involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do)."

"Simply put, ‘Tell, show, do’ desensitizes the child so she doesn't feel freaked out," says Dr. Mike Ignelzi, a pediatric dentist and orthodonist in Greensboro, N.C. For example, when talking about the rotating brush used for cleaning, he’ll tell the patient: "This is my friend Mr. Bumpy. He's nice and soft." He flexes it on his thumbnail, then on her thumbnail. "He also spins around and makes noise." He shows her how by cleaning her thumbnail. This way she experiences it, hears it, and becomes familiar with it before the brush goes in her mouth. Then you do it, perhaps saying, "Now we're going to clean just one tooth."

When practicing "tell, show, do," says Dr. Ignelzi, include the five senses. What is the child going to see? (Show her which tool you'll be using.) Hear? (Let her hear the brush spin before you put it in her mouth.) What is she going to taste and smell? (Let her choose the flavor and taste it ahead of time.) Feel? (Let her touch the rubber tip and feel it spin on her thumbnail.)

Six: Distract them

Young children can't concentrate for long periods, so they’re easily distracted -- a real advantage for the dentist. "Start up a conversation about his best friend, teacher, pet, new tennis shoes -- ‘Wow, those are neat. Did your mom buy them for you?’" says Dr. Ignelzi.

Dr. Ignelzi describes a teaching video that shows how useful distraction can be. In the video, the dentist is about to give a child a shot, and he tells her to open up wide. When she does, he says, "Wow, you open up really big! I can see your toes!" You can see wheels turning in the child’s head: Can he really see down to my toes? Am I really opening up that wide? What does he see? Meanwhile, the dentist gives her a shot and it's over before she's done thinking it through.

Other kid-friendly distractions, situated right by the dental chair, can include videos and headsets (depending on the child’s age), which take the child’s focus away from what you're doing.

Even with distraction, some kids will cry through the entire procedure, but many pediatric dentists -- after getting permission from parent to continue beforehand -- keep on working, even if the child is screaming.

"If you can't stand to see a child cry, then you're in the wrong business," says Dr. Berman. He doesn’t take the crying personally and doesn’t ask the child to stop. Rather, he continues trying to distract the child’s attention.

Seven: Sweeten their memories

Inevitably some children will leave an appointment determined never to set foot in an operatory again. However, even for those kids, hope has emerged from another 2007 study reported in the International Journal of Paediatric Dentistry. Lead author Jacqueline E. Pickrell, Ph.D., a cognitive psychologist in the Department of Dental Public Health Sciences at the University of Washington, explains that "memory restructuring," can improve children's attitudes and behavior on subsequent visits.

Her findings show dentists can sweeten a child’s memory of a dental visit several weeks later by reinforcing the positive aspects of their behavior. In the study, children who got praise from a researcher like "you really didn’t cry that much," or "you were very brave when the dentist examined you," felt less anxiety and behaved better in subsequent dental procedures than children in a control group who just chatted with the researcher.

It’s one more piece of evidence showing that small things matter.


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UIC researchers develop 3D dental training simulator

UIC researchers develop 3D dental training simulator

March 24, 2008 -- Hot on the heels of the Macy Study that explores new models of dental education, the University of Illinois at Chicago (UIC) has introduced cutting-edge dental training technology.

Researchers at the schools of dentistry and engineering are collaborating to develop a 3D computer training system -- PerioSim -- using haptic virtual reality technology.

"Haptics is the science of applying touch sensation and control to computer applications. It allows the user to 'feel' what is pictured on a computer screen," states a UIC press release.

What does that mean for dental education?

Dental students will be able to feel sensations as they perform various periodontal procedures using a stylus connected to the system that resembles a dental instrument.

"We can enhance the learning and training of a wide variety of tasks or procedures using this system," said Dr. Arnold Steinberg, a professor of periodontics at UIC and project leader, in a press release. "The need to practice on mannequins, animals, and patients can be significantly reduced, and in some cases, eliminated entirely."

A recent study in the Journal of Dental Education found the PerioSim to be a potentially useful devise for dental education."Faculty/practitionersfound the images very realistic for teeth and instruments, but less so for gingival," notes the study abstract. "Tactile sensation was realistic for teeth but not so for gingival."

The system allows students to choose different procedures to practice, and instruments to use. Instructors can also create short scenarios of periodontal procedures, which can be saved and replayed.

"Today's dental schools are faced with rising costs, faculty shortages and an overloaded curriculum," said Dr. Steinberg in the press release. "Haptic-based simulators such as the PerioSim require less initial investment, maintenance, and replacement of parts than earlier generation mannequin-based simulators and are more versatile."


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Japanese launch home-use intraoral camera

Japanese launch home-use intraoral camera

March 24, 2008 -- Dentists have a huge range of options when it comes to intraoral cameras. So, the Japanese have created one for the patients' use.

RF System Lab-- a Japanese company -- has introduced the Miharu Home Care Camera that plugs into a TV, and lets patients examine their own teeth. The video endoscope tip illuminates any area of the mouth so patients can clearly see plaque or tartar build-up (illuminated in pink). Just slip on a disposable cover, plug it into a TV, and view away.

The Miharu intraoral camera (images from the Miharu Web site)
Apart from personal use, it can be utilized in satellite clinics, mobile dental practices, and in secondary and tertiary treatment rooms, says Dr. George Freedman, D.D.S. in a testimonial on the Miharu Web site.

"It helps you (dentists) to educate patients on using proper brushing technique and the importance of periodic dental cleaning," he further states.

The camera comes with 25 disposable covers for sanitary use, operates on AAA batteries, and sells for $298.



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Everything you always wanted to know about orthodontics

Everything you always wanted to know about orthodontics

March 20, 2008 -- Attention orthodontists! Need help dealing with that patient who has a million questions? Refer them to bracesreview.com, a new independent site where patients can educate themselves about treatment.

The site features articles on a wide variety of topics from the cost difference between Invisalign and conventional braces, to what the patient should expect during treatment.

Also, patients can surf a state-by-state orthodontists directory, vent and share stories in a half dozen forums (including "Invisible Braces" and "Ask Our Orthodontist" forums), and view the photo of the month (the current picture is of a clear ceramic braces user after one year). Upcoming attractions include best dental insurance companies, and braces before and after pictures.


A discussion forum on bracesreview.com
"At bracesreview.com you may do you research prior to getting braces and educate yourself before your consultation," says a company press release. "There are several different methods and technologies now available, so putting in your due diligence will only benefit you."


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