January 11, 2021
by Carla Cohn, DMD
Saving irreplaceable tooth structure is invaluable. It is even more important for the kids in your practice as they and their teeth have a lifetime ahead. Several methods to preserve tooth structure exist. Among such methods is incomplete caries removal. It has been used effectively for many years and there is substantial evidence that the removal of all infected dentin in deep carious lesions is not required for successful caries treatment. Incomplete or partial caries removal has high success rate and reduces the incidence of pulpal exposure thereby preserving tooth vitality. The lesion however must be sealed from the oral environment effectively.1,2 This is no easy task, and even with full coverage, restorations are prone to leakage. Minimally invasive dentistry has been recognized as a valuable strategy to manage dental caries and preserve tooth for nearly two decades.3
With the continual development and introduction of new materials and technologies, it is both practical and reasonable to be less intrusive and to be able to preserve more tooth structure at the same time as definitively treating carious lesions. In recent years there has been an overwhelming influx and development of bioactive and biomimetic materials.4 This has allowed for restoration in a way that will have a biologic effect and one which mimics biochemical processes of the dentition. The added benefit of minimally invasive dentistry and bioactive biomimetic materials is that they allow for faster and less invasive procedures. Although these techniques and materials have been available for some time, they have not been used to their full potential. The time to do so is now.
Knight, Geoffrey Macdonald; McIntyre, John Malcolm; Mulyani. Bond strengths between composite resin and auto cure glass ionomer cement using the co-cure technique Australian Dental Journal, 2006; 51(2):175-179.
Caries arresting treatments, such as Riva Star (SDI) are powerful tools in our efforts to practice minimally invasive dentistry. Riva Star (SDI) is a two-step treatment that consists of application of a silver diamine fluoride (SDF), followed by potassium iodide. This is available in capsule forms or bottles. The silver ion in the SDF, acts as an antimicrobial which denatures proteins and breaks down cell walls, inhibiting DNA replication and as a coagulant which occludes dentinal tubules. The fluoride ion in the SDF, promotes mineralization, creates fluorohydroxyapatite, inhibits demineralization and inhibits bacteria. From all available evidence, there is no doubt that SDF is effective.5-9 However, the hallmark of SDF is that it leaves the arrested lesion with a black stain or scar. This is unsightly and in many instances the aesthetics are unacceptable to the patient. The application of potassium iodide, the second step of Riva Star (SDI) acts to minimize the black staining. By applying the potassium iodide solution over the SDF, a silver iodine precipitate is formed which minimizes the staining in comparison to using other SDF treatments alone.
Treatment with Riva Star (SDI) alone will arrest caries but will not restore the cavitation. In order to restore the tooth back to form and function, an ideal technique is the Silver Modified Atraumatic Technique, given the acronym SMart. The SMart method marries Riva Star (SDI) with glass ionomer cement, the restorative material of choice in this technique. A glass ionomer cement is a dental restorative material which is based upon the reaction of silicate glass powder (fluoro-alumina-silicate glass) and polyalkenoic acid, an ionomer. Riva Self Cure (SDI) is a high-quality glass ionomer cement restorative material available in different viscosities and set times. Use of Riva Star (SDI) prior to restoration will the enhance the bond of the restoration to dentin.10 Another added benefit of conditioning with 38% SDF is to increase resistance of both glass ionomer cement and composite resin restorations to secondary caries.11 To further enhance the strength of the restoration it is desirable to “sandwich” the glass ionomer cement with a resin modified glass ionomer cement or bonding agent, such as Riva Bond LC (SDI) and then a strong overlay of composite resin. The strength is further improved by curing all layers simultaneously in a co-cure technique. All layers are shown in diagram 1, which depicts a cross sections of a restoration in this SMart co-cure method. The advantages of the co-cure technique are the elimination of several placement steps and the resultant significantly stronger chemical bond between glass ionomer cement and composite resin than other techniques.12
The following is a case study of a young child and a severely decayed first permanent molar. Treatment with silver modified atraumatic co-cure method is completed in order to preserve both tooth structure and tooth vitality. The method can be completed quickly and definitively with very little use of a handpiece. The entire SMart co-cure method is depicted clinically in figs. 1-7. In fig. 1: permanent molar of a young child, gross decay selective caries removal (not shown total etch / wash/ dry). Fig. 2: Riva Star (SDI) silver application to arrest decay. Applied for 60 seconds. Fig. 3: Riva Star (SDI) potassium iodide application to minimize stain. Rub potassium iodide until creamy appearance turns clear. Wash and dry, but not desiccate. Fig. 4: Placement of Riva SC, self cure (SDI). Fig. 5: Application of Riva Bond LC (SDI). Fig. 6: Finish with flowable composite–light cure all together now in co-cure technique. Fig. 7: Final SMart silver co-cure definitive restoration.
Pre-operative caries excavated.
Silver application Riva Star SDI.
Potassium iodide application Riva Star SDI.
Glass ionomer Riva SC SDI placement.
Riva Bond LC SDI placement.
Flowable composite placement.
Final SMart cocure.
Our paradigm for managing carious lesions must change. The techniques and materials are well established. It is time for us to step out of our comfort zone of traditional dentistry for the benefit of our patients and our profession and make a change for the better with minimally invasive dentistry, the use of caries arresting agents and bioactive restorative materials.
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About the Author
Dr. Carla Cohn is a general dentist, devoted solely to the practice of dentistry for children. She maintains a private practice at Kids Dental and Western Surgery Centre in Winnipeg, Canada. She is proud to be a member of the American Academy of Pediatric Dentistry Speakers Bureau, Catapult Education Speakers Bureau, Pierre Fauchard Academy, and a cofounder of Women’s Dental Network. Dr. Cohn has been named as Dentistry Today’s Leader in Continuing Education multiple years in a row. She has published several articles, and webinars and enjoys lecturing on all aspects of children’s dentistry for the general practitioner both nationally and internationally.
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