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Behind a Beautiful Smile

Dimensions of Dental Hygiene speaks with Ronald E. Goldstein, DDS, an expert in esthetic dentistry, about what hygienists need to know when working with esthetic restorations.

What types of esthetic materials are used today?

Esthetic dentistry has moved beyond ceramics. Composite resins or modified resins are more prevalent today. The other material used is glass ionomer, which is utilized for both restorations and cements. Each of these materials has its own advantages and disadvantages.

It is imperative that dental hygienists know what type of restorations a patient has before beginning the appointment. Dental hygiene procedures should be different for a patient with natural teeth and no restorations as opposed to a patient with class five restorations, especially teeth restored with esthetic materials.

How does the hygienist identify a resin restoration over a glass ionomer or an adhesive dentistry product?

If a patient has had all of her dental treatment done in one office, it is as simple as checking the chart. More difficult is seeing a new patient who has beautiful restorations that may not be easy to visually identify. It is very important to get the patient’s complete dental records from her previous oral health care provider so they can be reviewed first. Hygienists should also ask the patient what type of restorative treatment she has received. Unfortunately, not all patients remember. At that point, the hygienist must become a detective to determine what restorative treatment may have been done.

With the three restorative materials, what is the maintenance protocol for each type?

Ceramic restorations are bonded in place using an adhesive, usually a resin cement or a glass ionomer cement. The glass ionomer cement definitely has better adhesion to dentin and roots, which can be a problem because excess glass ionomer can be extremely difficult to remove if there is excess. Sometimes the scaler can go right over glass ionomer and it seems as if it is the root. Hygienists should look at the radiograph to see if there is a small protrusion or anything that looks like the root is not perfectly straight. The protrusion could be calculus also, but glass ionomer shows up differently. It is more radiolucent.

Being careful with ceramic restorations means exercising caution with the prophy jet or air abrasion unit. Over time, prophy jets can affect the porcelain surface of any ceramic restoration. A class four restoration that restores the area from incisal angle to the gingival area is not a problem, but if it is a class five restoration that goes under the gingiva, the scaling direction is absolutely essential. In this situation, scaling must be done laterally—not vertically. If there is a small ledge or something is irregular, alert the dentist. The dentist can then finish it down better. Not only can the ledge hold plaque, it can also irritate the tissue. The smartest approach is to use the explorer to go around the cervical edges to make sure that overhangs are not present. If overhangs are there, avoid them and alert the dentist so they can be corrected.

Ultrasonic vibrations are potentially damaging to any resin or ceramic restoration because it can break the adhesive bond. If it is bonded to enamel, it is very strong. But most restorations, especially at the gingival area, involve dentin and the bond is not as strong—not nearly as strong as to enamel. Ultrasonic vibrations can result in loosening that bond. The restoration may not come out, but microleakage at the margin can occur.

As far as instrumenting teeth with these particular restorations, what are the limitations?

I do not advise using the prophy jet or a medium or coarse paste on esthetic restorations. Our dental hygiene protocol consists of using fine polishing paste and hand instrument scaling in a lateral direction, being careful not to pull against any margin. We also avoid using ultrasonic instruments on these restorations.

Is glass ionomer only a cement product or is it also a restorative material?

Glass ionomer is an excellent restorative material because it is so esthetic. I use it often with elderly patients who have a lot of caries and even in young patients who have a lot of caries. It is appropriate to use when a problem exists in controlling decay, like in a cancer patient or someone who has had radiation. The glass ionomer material is fluoride releasing.

Is the use of magnification or loupes helpful?

One of the most exciting advancements I have seen in oral health care is microscopic dentistry. Magnification allows you to see what you cannot see any other way. The intraoral camera is also very useful. I think dentistry is missing maybe 70% to 80% of patients’ restorative needs because most clinicians are not using the intraoral camera. The camera can show the patient where there are microcracks and any potential fracture. This can motivate the patient to have it restored right away. I believe that microscopic dentistry will become the standard of care, especially in diagnosis. A photo can be taken so easily and then recorded into an image retention system.

Once you use the microscope, you never want to go back. Pits and fissures are not really visible without magnification. If a tooth is enlarged 20 times and then viewed dry, you can see into the pit and fissure to help determine if there is caries involvement that needs to be addressed.

“It is imperative that dental hygienists know what type of restorations a patient has before beginning the appointment.”

Let’s talk about coarse prophy pastes on some of the esthetic restorations. What cautions should hygienists exercise?

I think a coarse prophy paste is appropriate on a natural tooth that has a great deal of stain. However, I am cautious when it comes to bonded restorations, which is why I don’t use a prophy jet as it can take the finish off. Good light reflection on these bonded restorations is pleasing. Many are hybrid restorations without much luster anyway. The prophy jet or coarse pumice can dull them down. Some stain is removed, which is sometimes necessary. If they are heavily stained, then coarse prophy paste is a useful tool. If this is not successful, the dentist needs to remove the stain with either the air abrasion unit or finishing burs followed by a polishing system.

How about the use of acidulated topical fluorides?

I think neutral-based fluorides should be used. Acidulated topical fluoride should not be utilized on porcelain. I also do not believe that fluorides are used enough in dentistry. In my opinion, patients should be using neutral-based fluoride toothpaste nightly, especially with restorations that involve any gingival recession or margin exposure. Over time, some margin exposure may occur and to avoid caries, fluoride protection should be implemented at least once a day.

How about radiographs? Are there indications for more frequent radiographs with some restorative materials?

The frequency of radiographs depends on the ability of the patient to resist caries. Some patients can have a full set of radiographs every 2 to 5 years, others need radiographs every year, which is why digital radiography is so useful. Patients are very wary about radiation and digital radiography eases those worries. It is one of the fastest growing areas of dentistry. Plus, there is no wait with digital radiography.

Many mistakes are being made in the interpretation of defective margins. Today, you cannot look at an x-ray and diagnose caries because bonded cements are radiolucent so they show through like decay. Both dentists and dental hygienists need to be careful with digital radiographs because sometimes burn-out occurs and it is very easy to interpret this as caries (see Figure 1).

How should the hygienist treat a patient who has developed a pocket in an esthetic area with an esthetic restoration? How can we treat the pocket yet preserve the esthetic result that the dentist has created?

It may mean that the patient needs to come in every 4 to 6 weeks. It is our policy to scale pockets to keep them under control, and patients need to understand that they must maintain their tissue level. For example, if it is an anterior tooth and we do surgery to eliminate the pocket on the labial surface, it will cause gingival recession and can ruin the smile. Maintenance is a must along with a lingual access approach for surgery and maintaining it with periodontal therapy.

Are chemotherapeutic agents advised?

I believe that chemotherapeutics are one of the biggest advances in periodontics today. I am also a great believer in vitamin C and vitamin E megadoses, especially when trying to heal tissue after periodontal surgery. In addition to root planings and scalings, we have found Arestin, Periostat, and the Periochip to be very effective.

For the patient who has gingival recession and it causes an esthetic concern and a functional concern (ie, they have sensitivity or it’s a food trap), how can the hygienist assess whether a soft tissue graft or a tooth-colored restoration is the most appropriate treatment?

I believe that if there is not enough attached gingiva, a graft should be used. I also refer the patient for a graft if the recession involves the papilla. A periodontist should be consulted when deciding on whether a graft should be done before the bond or if only bonding is needed or if a graft is better than bonding.

Are there any specific oral hygiene procedures that should be reinforced with patients who have porcelain veneer restorations?

Dental hygienists are the main source of reinforcement because they see the patient every 4 to 6 months. They need to reinforce to patients that if they bite on a carrot with their laminated teeth, there is a potential for fracture. If you apply torque on a laminate, it can break. Many laminates are broken by nail biting. Hygienists should review flossing technique. Is the patient wearing a bite appliance? We make a bite appliance—either a small anterior bite appliance or a full mouthguard—for almost every patient with esthetic restorations. We want to prevent any clenching or grinding because they are the main causes of fracture or breakage of esthetic restorations, especially with porcelain veneers. Porcelain veneers are strong restorations if you can bond to enamel. If you have to bond to the dentin as most dentists do to achieve a positive result, it is not nearly as strong as enamel bonding.

What is the role of the hygienist in identifying patients who may benefit from tooth whitening procedures?

The media has influenced our patients tremendously over the years and currently, white teeth are the standard of care. Most people are embarrassed to have dark teeth so they either want laminates or bleaching. I normally ask patients if color is a concern and if they say they would like their teeth to look whiter, the door is opened. Even if patients say no, you can ask them if they could wave a magic wand over their teeth, would their current color be their color of choice? Most people say no. Then you can discuss the options. I believe the hygienist can and should play a prominent motivating role in every dental office. The quality time the hygienist spends with patients helps build a sense of trust that can encourage patients to obtain the esthetic restorations they desire. So certainly bleaching is just one way the hygienist can help patients achieve a better looking smile.

Are there conditions where bleaching is contraindicated?

Bleaching is not indicated for patients with gray teeth, heavy tetracycline stain, and teeth with a great deal of incisal staining. Bleaching is very successful for patients with yellow teeth. Yellow/brown is the next indication, followed by brown. Moderate results are possible with the brown teeth. Gray generally becomes translucent, which can appear to the patient as if the tooth is getting darker not lighter, so you need to be careful. Bleaching is not as effective for patients with tetracycline stain because the final result doesn’t provide the esthetic appearance most patients desire.

Are any esthetic restorative materials adversely affected by bleaching?

Not that I know of, but it is best to wait a period of time after bleaching before bonding. Before performing the bleaching treatment, a hygiene appointment should be scheduled so the tissue is healthy and in good shape.

What can be done about excessive wear facets on anterior teeth?

Hygienists are in the perfect position to look at the incisal edges of the anterior teeth. If patients are wearing down the cusp tip, they can lose a great deal of their attractiveness. It is important to diagnose wearing early and not wait until the patient is older. Patients can be counseled about their habits that may cause wear. A biteguard can be recommended and cosmetic contouring can be done to make these teeth look better.

Ultimately, we want the patient to be satisfied. That is my goal and the hygienist’s goal. It’s a true team effort.

From Dimensions of Dental Hygiene. November / December 2003;1(7):14-16, 18.

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