Cosmetic/Esthetic - A Quarterly Newsletter on Dental SpecialtiesJADA
4th Quarter—2014

An integrative approach to an attractive smile

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Moderate fluorosis and hyperpigmented gums can be treated quickly and easily with an integrative approach that is painless for patients and provides them with satisfying esthetics, according to a case report published in the Winter 2014 issue of The International Journal of Esthetic Dentistry.

“The results of this case report include a recovery of the esthetics of teeth, disappearance of gingival pigmentation and diminution of the enamel stains and remineralization of the enamel,” authors said. “This kind of treatment is the only appropriate one since it aims at the maximum preservation of the dental structures and avoids the damages that are inflicted during the operative recovery of the dental surfaces affected with fluorosis.”

Scientists illustrated the positive outcomes by describing the experience of a 20-year-old man who sought noninvasive, painless treatment to correct his complaints: black colored gingiva and brownish yellow stained teeth.

Researchers said the patient’s gums were dark to black and diagnosed mild to moderate fluorosis. The patient was opposed to treatment options involving significant removal of tooth structure, such as porcelain or composite resin veneers or any surgical procedures for the rehabilitation of his hyperpigmented gingiva. Doctors devised a treatment plan of laser-assisted depigmentation, followed by microabrasion of the superficial enamel staining, remineralization and at-home bleaching.

Laser-assisted depigmentation was performed on all affected areas. There was slight bleeding after wiping of the operative fields, but the patient reported that the procedure was completely painless. Authors described less bleeding during laser therapy compared with conventional surgical techniques and gingival healing as visually similar to the normal untreated gingiva, “pink and healthy looking.”

The restorative phase of treatment started with microabrasion. Etched enamel surfaces were polished with a cup-shaped porcelain polishing rubber abrasive to smooth and polish the enamel surface. Fluoride trays were placed for four minutes to remineralize tooth enamel.

For the following three weeks, the patient slept with custom bleaching trays containing amorphous calcium phosphatecaesin phosphopeptide paste.
Because the teeth appeared slightly yellower than they did with the fluorosis-induced whitish speckled discoloration (a common occurrence), the patient elected to pursue a second restorative phase to whiten his teeth further by using vital tray bleaching. He reported mild sensitivity for which he used desensitizing toothpaste in the bleaching tray one hour prior to the bleaching for one week. He followed up with the routine overnight regimen of bleaching for four weeks.

There were no recurrences of gingival pigmentation at the 12-month follow-up and the patient was very pleased with the results.

In conclusion, authors advised that clinicians should be aware of the specific indications for conservative treatment options and be able to integrate them efficiently into a private practice.


Diet and dental materials

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Are stain-producing foods and beverages a large portion of your patient’s diet?

The answer may be an important consideration when selecting restorative materials most likely to maintain their original appearance, new research showed.

Scientists publishing in the Dec. 1 online edition of the Journal of Esthetic and Restorative Dentistry compared stain resistance, color stability, gloss and gloss retention of a nano-filled resin modified glass ionomer (RMGI) to traditional RMGIs and resin-based composites (RBCs).

RMGIs are often placed in anterior teeth where esthetics matter most. Some studies have shown they don’t maintain their surface texture — which often is measured as gloss — and color stability as well as RBCs.

Although there is conflicting evidence about whether nano-filled RBCs have better gloss and gloss retention than materials filled with larger filler particles, nano-fillers were introduced into RMGIs potentially to improve gloss. That’s why scientists aimed to determine if a nano-RMGI had higher gloss and gloss retention than a conventional RMGI.

In addition, laboratory studies have shown that RMGIs are less stain resistant than RBCs. Because polished materials have better stain resistance and some believe nano-RMGIs have better polishability (gloss), the second aim of this study was to determine whether a nano-RMGI has better stain resistance than a traditional RMGI.

To compare materials, scientists fabricated specimens of four materials commonly used for anterior restorations: a nano-filled RBC, a nanohybrid RBC, a nano-filled RMGI and a traditional RMGI. The scientists measured color and gloss values for each material, and then measured them again after the specimens were stored in distilled water for a week and in staining solution for a week.

Results showed that the nano-RMGI and traditional RMGI had similar color stability compared to each other, but worse color stability compared to either of the RBCs after a week of water storage. The nano-RMGI had lower stain resistance than all three of the other tested materials after immersion in a staining solution for a week. Scientists also found among the results that the initial and final gloss of the nano-RMGI was higher than the traditional RMGI, but less than either of the RBCs after staining immersion.    

“The clinician should be aware that the use of a nano-RMGI may improve the gloss of an RMGI restoration; however, color change will likely occur, particularly if the patient consumes a staining diet,” authors cautioned.

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Gingiva-shade ceramics and grading esthetic risk

Potential influences should be evaluated when predicting the esthetic results for gingiva-shade ceramics, researchers publishing in the Winter issue of The International Journal of Esthetic Dentistry reported, bolstering the case for using systematic guidelines for risk assessment.

Authors identified different factors that influence satisfactory esthetic results using gum-shade ceramics and presented them in a risk-assessment table showing their impact: low, medium or high.

The classification system authors proposed is based on clinical cases that have an average follow-up of six years. The eight risk factors are:

For example, if the oral rehabilitation is not shown when the patient is smiling (smile line), the esthetic risk is listed in the table as low. However, when the transition between white and pink is exposed, the case is considered to have a higher esthetic risk. With regard to color, pink tones are easier to reproduce and yield a medium esthetic risk, while red tones are shown to be higher risk, due to toxicity in red stains.


Light activation and in-office bleaching

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A critical summary published in the November 2014 issue of The Journal of the American Dental Association assesses the tooth-whitening value of light activation systems when used with different concentrations of hydrogen peroxide (HP).

The author evaluated research that considered randomized controlled trials in which investigators compared light-activated and nonactivated bleaching systems. There was no restriction on the type of light source, but the same bleaching protocols were used in each study. The research separated trials into two subgroups: those involving the use of high concentrations of hydrogen peroxide (25-30 percent) and those involving the use of low concentrations (15-20 percent).

“The results of many studies of light-activated systems seem to be contradictory, and none of the investigators in the reviews assessed the results quantitatively,” according to comments in the critical summary.

No significant differences between the light-activated and nonactivated bleaching systems were found when high concentrations of HP were used. However, the use of a light-activated bleaching system resulted in better bleaching efficacy when a low concentration of HP was used.

In the trials where tooth sensitivity was analyzed, researchers found a higher likelihood of sensitivity was associated with light-activated systems. Researchers reported inconclusive evidence to support the use of light-activation systems to enhance the efficacy of high concentrations of HP.

They also concluded that light activation increases the risk of tooth sensitivity, and noted that there is some limited evidence that it may increase the immediate effect of lower HP concentrations.

 “The evidence to support the use of light activation with in-office vital bleaching is weak,” commentary on the implications for dental practice included.

The critical summary author also called for more studies with larger sample sizes and different light sources. She cautioned that the use of light activation, regardless of concentration of HP, increases tooth sensitivity and “should be used with caution, if at all, until the results of further studies confirm its efficacy.”

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Discount offered on ‘Smile Makeover’ brochure

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Now through Jan. 15 the ADA is offering members free shipping on all patient education brochures with a minimum $75 order.

Members can order “Smile Makeover” (W213) through the ADA Catalog, using promo code 14372E.  The 8-panel brochure is available in packets of 50 for $27; retail price $40.50, Discounts are also available in higher quantities.

       Written for the dental patient, the brochure discusses the effects of age on teeth and gums and examines the various procedures used to correct teeth that are discolored, unevenly spaced or misaligned, missing or worn down. It explains to patients various smile-enhancing dental procedures, including orthodontia, veneers, reshaping, whitening, tooth colored fillings and bonding.

Members can preview this and other ADA brochures online at Orders can be placed online or by calling the ADA Member Service Center at 800.947.4746. Remember to use promo code 14372E to get free shipping with a minimum $75 order.

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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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