Secondary Caries: We All See Them, How Do We Shortcut Their Occurrence?

You're listening to The Dr. Phil Klein Dental Podcast Thanks for joining us on the show. I'm Dr. Phil Klein. Today we'll be addressing the controversial question, when we restore teeth due to caries, is it appropriate as the final step in the restorative procedure to apply a fluoride varnish? We will explore the thinking behind this question and how it relates to the prevention of secondary caries. Our guest is Dr. Jean Creasey, a former dental hygienist who found success in dental practice by focusing on prevention first. She currently teaches ethics and professionalism at California's newest dental school, California North State College of Dental Medicine. Dr. Creasey, it's a pleasure to have you on Dental Talk. It's a pleasure to be back, Phil. Thank you. Yeah, so in a podcast that you did earlier this year with Viva Learning, and that was titled... prevention-centered success, a win for the dental team, the patient, and the practice, you made the interesting suggestion that for restorative procedures caused by caries, it might be appropriate as a final step in the restorative procedure to apply a fluoride varnish. Why do you think that? Well, it might sound like an out-of -the-box suggestion to place fluoride varnish as the final step, but I think it's really more consistent with a prevention focus. And that's something more and more dentists embrace and patients desire. As dentists, we can be restoring caries almost as if removing the evidence of the disease, removing the carious lesion by restoring it is going to eliminate the disease. And I've heard that thinking is a little analogous to treating diabetes by amputating a toe. So whenever I treat caries by replacing a restoration, which right in itself indicates that the patient has a risk for caries, I think there's more of an opportunity to think proactively, to think in terms of what can I do for this patient right now to help make the tooth structure stronger and more caries resistant. The bottom line is we have no control over how compliant our patients are once they leave our office, but we can control every opportunity we have. to increase the caries resistance of the tooth structure. And fluoride varnish application is an easy, inexpensive way to do that. In your practice, do you put fluoride varnish? Do you apply fluoride varnish on every tooth that you restore? Yes. And we've started doing that just because it's easy. And fortunately, my patients are... The majority of them are very much prevention oriented because we've had our practice for over 35 years. And even though I started out as a hygienist in that practice, and I've only been practicing as a dentist for 20 years, our patients are used to us doing things that are, I would say, unusual to help, you know, to really be prevention focused. Do you see the application of fluoride varnish following a restorative procedure standard of care at some point in time for dentistry? Yeah, standard of care changes. It's a very slow moving ship. I will tell you that because... at least at this point in the profession. And so do we actually have it in our standard of care that you should wear loops, for example? And which I think, yes, that should be standard of care. But to be honest, I think it takes a very long time. You know, and standard of care is a loosey goosey term in and of itself. To me, it is. And so. that you can't really find if you Google standard of care and dentistry, it's a very time and place sensitive issue. But it's an interesting thing to think about. So for me, it is because doing what's best for the patient always seems like the standard of care. Right. And it's a responsibility of the clinician in their own practice, like you said, to do what they think is best. And I know you have a prevention focused practice, which has been very successful for you over the years. So let's switch gears a little bit and talk about glass ionomer material. Tell us why you like using glass ionomer-based restorative materials. Well, I think glass ionomer, I was a little resistant when I first started using them because you have to retrain yourself a little bit. It's not exactly like using composite by any means. Glass ionomers have three qualities that I think just scream, use me. The first one is it's remineralizing capabilities. It's a water-based product. And so ions, the fluoride, the calcium, the strontium, the phosphate ions, these are all tooth strengthening. It can actually move out of the material and into the tooth. Glass ionomers are self-adhering, which eliminates the... the sensitivity of the bonding step, which is very technique sensitive to get good bonding that doesn't have post-operative sensitivity. Glass ionomers almost never have sensitivity issues afterwards because of that bonding. They self-cure, which, you know, there's the resin reinforced glass ionomers that are both light cured and self-cured, but they actually get harder over time. So I think one of the coolest things about them, though, is that they can recharge with fluoride so that repeated applications of fluoride varnish, they'll act as somewhat of a reservoir of fluoride leaching out into the tooth. Do you use Glossonomer primarily for patients that are at high risk for caries or that have experienced secondary caries? Absolutely. And because of this quality of being caries resistant. you know, of actually helping to protect the tooth, it is to me the superior material to use in a high-risk or at-risk patient. I almost find it irresponsible to place composite in a high-risk patient because it's not going to last. Some of the newer resin-reinforced glass ionomers. are getting much better in their strength and their aesthetic capabilities. And you can place composite over the top of some of those. And so you can get some of the benefits of the glass ionomer plus the aesthetics of a little composite finish on top if it's a highly aesthetic zone. Yeah. And I was going to ask you that, not only for aesthetics, but also for wear resistance. Isn't that one of the challenges of GI materials? Yes, and again, they are getting stronger, and they do get stronger over time. What made me kind of a true believer is the residency program where I used to teach at University of Pacific. My mentor, Dr. Alan Wong, is a big proponent of glass ionomer materials, and he works extensively in the ER with sedation patients with special needs. And what he saw... where time is of the essence. You have to be able to place things in a wet field on an anesthetized patient. And he was seeing that even restorations that he had placed where he didn't have a lot of hope for their durability, they were actually doing quite well over a period of time. And so I think especially, I mean, that special needs population is extremely high risk for caries. And the fact that They turned out to be such good restore that the glass ionomer turned out to be such a good restorative material and very high risk populations helped convince me that they were worth pursuing for my high risk patients as well. Yeah, that makes a lot of sense. And then do you place varnish over the glass ionomer based restorative material? Absolutely, because you don't. want to have it desiccate in its early stages. And to me, you need to put some people use like a little, there's a little sealer that comes from the company that's likely a lot more expensive than the varnish. But why not put something over the top that is actually going to help reinforce the recharging and the fluoride content of the GI and the surrounding tooth structure at the same time? Right. And do you place varnish over a composite restorative material? Well, composites, of course, have different qualities than glass ionomer materials. They don't uptake, they don't recharge, or they don't give out fluoride to the tooth. But to me, it still makes sense because the patient has come in, they have a carious lesion. By definition, they're at risk for caries. probably high risk if you have an active lesion. And so why not place that as a final reminder to the patient? And it's an opportunity to strengthen the adjacent tooth structure where you've just placed that, which that margin between the restoration and the tooth structure. is usually where if you're going to have any micro leakage around the edge of the composite, that's exactly where it's going to happen. So why not give it that little extra boost of resistance to decay? Right. So pretty much all your restorative procedures are followed by the application of a fluoride varnish, whether it's GI, composite. Yeah. Unless it's in the anterior, I'm not going to put fluoride varnish. Usually people, the first thing they're going to do when they get out in the car is look in the rearview mirror and see if their new filling shows. And I don't want to confuse them by placing the fluoride varnish, which is going to change the aesthetic of the look of it in the anterior. So my typical behavior, to be honest, is I just use it in the posterior. Typically in your practice, what kind of fluoride varnish do you use? I like to use the Floridose. I think it's made by Centrix. They have a lot of nice flavors. It looks good. Patients don't complain about the flavors, which to me is a big selling feature. And it handles well when I use it. So let me ask you this. Do you have much experience in using silver diamine fluoride in adults for caries control? And if so, what are the benefits and the challenges? Well, I'm glad you asked about that because that's something I get really excited about. And that's the success I've seen using SDF or silver diamine fluoride in my adult patients. Case selection is really critical with regard to the aesthetics, but there are so many situations where you can place it, where it doesn't show and it literally stops the caries process. It reminds me, I tell patients it's a little bit like using a fire extinguisher on a fire. I've spoken to a lot of dentists, a lot of my friends who are hesitant to use it because they've read it turns the tooth black. But I don't think this really paints a true picture of the power of SDF. It does turn the lesion itself a dark gray. And again, your listeners can look up online photos to see for themselves what it does to the lesion. It turns the lesion gray, but there are a lot of ways to minimize that because you can place material via the look of the darkness. In my practice, when our hygienist finds a sticky spot on the root surface, that they suspect might need to be restored, they'll call me over. If it's on a posterior tooth, I can have them place the SDF right there in the chair at the cleaning appointment. I've found when I get the patient back in to see me to evaluate what type of restoration we're actually going to place, many times that surface is very hard after even one application. So I simply apply more SDF, clean up the margins, and I can place a little glass ionomer over that. And in some cases, this can obviate the need to replace a crown. And in older adults, the elderly adults, I'm very careful of who I say are older adults these days because I can be pointing the finger at myself. But if they're quite geriatric, let's put it that way, you don't want to keep those people in your chair for a long crown appointment. They might not have the means to afford having a crown replaced. And if you can restore that, if you can repair around the margin, it gives you another option to ask them if they would prefer that method. So in those cases where I've restored and very minimally, oftentimes I don't even need to anesthetize the patient if it's root caries because the SDF has done such a good job of penetrating into the... tubules and blocking it so effectively that I can just buzz in there, clean up the edges, place some glass ionomer. Much less traumatic for the patient. And to be honest, it's less traumatic for me as well. I was going to say there's a term, an acronym. for using the SDF with the glass ionomer over the top. And it's called the SMART technique. It's S-M-A-R-T. And if your listeners look that up, they can see some really nice photos of it. In kids, in primary teeth, they use this technique. And you can get some really aesthetic results that doesn't look like a gray tooth, even in the anterior. So it's pretty exciting. Yeah, it's very important as clinicians to open your mind to options that allow your patients to have different treatment based on their age, their outlook on what they want to do with their teeth, their finances, whatever it is. It's so important to have options and being familiar with SDF and having an open mind like you do and having a prevention-centered practice is just so important. There's no one solution for every patient. That's for sure. If you have any closing remarks, Dr. Creasey, before we wrap up this podcast, that'd be much appreciated. Well, I do want to close by saying the time we take to establish those relationships with our patients where they really know we have their best interest at heart, it's well worth it because all the fluoride varnish in the world, all the SDF, cannot help them change the behaviors that lead to more caries. But having a relationship where they don't feel judged, where they're open to your suggestions, it's the whole package. It's helping them change what they do every day with regards to their diet, how they care for their teeth, their attention to their oral health. And then we have these added tools that augment their efforts. And we are their coaches on the side, so to speak, that come along and help make that journey as successful as possible. Very, very well said, Dr. Creasey. We appreciate you sharing your incredible philosophy of practice with our audience. And I hope that the young dentists who are listening to this, the people that have been practicing and they're in the middle of their career, and even people that are getting close to retirement could listen to your comments about what you just said and take that to heart. And I think it'll help every patient who's out there. Thank you very much for joining us on Dental Talk. We hope to have you on again soon, Dr. Creasey. Thank you, Phil. It's always a pleasure to talk with you and share our experiences.