There is no question that we live in an amazing world as it relates to dental technology, dental materials, and our ability to treat our patients.
Adhesive resin materials and techniques have been a significant accomplishment, allowing us to practice minimal-intervention dentistry and conserve tooth structure. The minimally invasive approach to dentistry is certainly here, and we practice it every day in our offices. How do we take this approach to the next step and go beyond bonding? It has always been my dream to be able to treat diseased tooth structure without having to use invasive techniques.
Let me introduce you to the wonderful world of remineralization. Let’s start with a common scenario that occurs with so many of our patients: You or your hygienist are doing a clinical exam and notice that the patient has some decalcified white spots on a number of teeth. The spots may be a result of wearing orthodontic appliances, a high sugar diet, heavy plaque buildup, or for a reason not readily apparent. This patient may also have a high caries risk and/or a problem with dental hypersensitivity. We all face this clinical question every single day that we practice.
What is our answer? I would venture to say that many dental practitioners would turn to watchful waiting to see what will happen with these white spots. These white spots on teeth feel rough to an explorer and are possibly even a bit spongy. They have not yet cavitated, so we hope and pray that they won’t do so. I completely understand this dilemma as to what to do with these lesions. After all, if it ain’t broke, why fix it?
If you perform an invasive procedure into these white spot lesions, and the tooth is a virgin tooth, you will have to restore it, knowing that the future of this tooth will include repeating this restoration a number of times over the patient’s lifetime. The restoration will get bigger and bigger, someday possibly involving the pulp. If you do nothing, chances are the lesion will cavitate anyway, but you just don’t feel right about cutting into this tooth at this time. This is where the wonderful world of remineralization comes into play for your patients.
These white spots really are the precursors to actual dental caries. Yes, they are produced by acids released by the bacteria that attack the enamel, leeching out apatite-forming calcium and phosphate ions from the tooth and causing demineralization. Over time, this leads to the destruction of the enamel subsurface, which is seen clinically as these white spots. There is a mineral imbalance going on here and, if left alone, only bad things can and will happen. The natural balance has shifted with the demineralization reaction occurring over remineralization.
Now let’s really introduce you to the wonderful world of remineralization. Amorphous calcium phosphate, or ACP, has been known for years to be able to restore this mineral imbalance by providing the necessary calcium and phosphate ions to rebuild the tooth surface. These ions can be put back into the tooth surface by adding amorphous calcium phosphate to the patient’s saliva, increasing the amount of calcium and phosphate ions available that are then taken up by the tooth. Let’s not forget the important role that fluoride plays here, as well. The more calcium and phosphate ions around, the more fluoride gets absorbed, and the stronger the remineralized enamel will be.
The trick here is to get the calcium and phosphate ions delivered directly to the place they are needed most, which is on the enamel surface. There needs to be a molecular delivery system to get this ACP to the tooth surface. Thankfully for our patients, this technology exists today. Recaldent is derived from the milk protein, casein. For many years it has been known that milk has a tooth-protective effect. Research from Dr. E. C. Reynold’s group at the University of Melbourne, Australia has shown that casein phosphopeptide (CPP) can carry the amorphous calcium phosphate and bind it to enamel, dental plaque, and soft tissue. The calcium phosphate ions will be delivered exactly when and where they are needed; right up against the tooth structure. Numerous studies have proven the effectiveness of Recaldent (CPP-ACP) in preventing and reversing early carious lesions that are often seen as white spot lesions. Recaldent is also excellent and very effective in occluding open dental tubules to eliminate dental hypersensitivity.
Prospect MI Paste by GC America is the first product for professional use to include the amazing technology of Recaldent. It is a water-based, sugar-free cream that is applied topically to the tooth surface. This allows you to treat these precarious lesions medically instead of surgically. This is a major advancement in the minimally invasive treatment of these pre-carious lesions. We now have a huge paradigm shift in the way we should now be thinking about treating patients with these white spot lesions. We can literally remineralize and repair enamel in the patient’s mouth without resorting to any kind of tooth preparation.
MI Paste has become an integral part of my daily treatment for patients. Let’s take some examples of where I use and dispense MI Paste. We all know that both tray and in-office whitening causes significant sensitivity to patients, even with the best desensitizing formulas of whitening gels. MI Paste is now included with every whitening treatment that I provide to eliminate the sensitivity and also to remineralize the enamel.
Any patient that has evidence of teeth with white spot decalcification, whether it be from orthodontic appliances, fluorosis, or dental erosion is fitted with a custom tray to be used with MI Paste. If a patient has general hypersensitivity for any reason, including from periodontal disease or post-periodontal treatment, they also receive a custom tray to be used with MI Paste. After scaling and root planning, I polish the patient’s teeth with MI Paste, and give the patient the rest of the tube to take home.
Many patients are undergoing full-mouth reconstructions and extreme makeovers. We need to do everything we can to protect the margins of these restorations, whether they are heavily invasive crowns, veneers or minimally invasive Lumineers. If decay is going to happen, it will be at the margins. If a patient has invested thousands of dollars to restore their oral cavity, the least we should do is provide them with long-term protection for their investment, much like an insurance policy or maintenance plan. These patients are prime candidates for a custom tray application with MI Paste. As dentists, we are so proud of our beautiful esthetic result that we forget about what will happen to this smile in the future. Our responsibility continues for that dental patient, even after they walk out the door.
The cost of using the MI Paste custom tray system is easily integrated into the fees of whitening, esthetic procedures, and periodontal procedures. If we make custom-fitted trays for dentinal hypersensitivity, or to remineralize white spots, our typical fee for this is $75 to $100 for the tray and 2 tubes of MI Paste. We then provide MI Paste to patients at cost because we believe this is a great service for our patients. It also demonstrates our commitment to their overall and long-term dental health. In addition to creating beautiful smiles for our patients, we want these smiles to last for a very long time.
As you can see, from both a clinical and practice-management perspective, using this new minimally invasive paradigm can be a terrific addition to current techniques. The success of our clinical cases is not just measured on the day you seat the case, but also on what the smile looks like five to ten years later. Remineralizing white spots, eliminating dentin hypersensitivity, and ensuring long-term wellness are within the realm of today’s dental practice. It is really an exciting time to be practicing dentistry.