Biocompatible Quadrant Dentistry for Overall Health

INTRODUCTION
Dentistry’s tectonic plates are shifting. New discoveries in science and innovation are redirecting the evolution of dentistry to include whole-body health and to create new value. The creation of new value comes in 3 forms:

1. This evolution is an opportunity for better health for our patients, both in how we treat periodontal disease (the most prevalent chronic inflammatory disease on the planet) and with the use of biocompatible materials to restore the mouth (the most powerful place on the body).

2. This evolution creates an opportunity and value for the office by way of increased periodontal therapies and acceptance of quadrant biocompatible care, resulting in a healthier and more prosperous practice.

3. This evolution creates the opportunity for the dentist with regard to personal and professional satisfaction.

When patients accept quadrant dental care, your procedures are more efficient and profitable, your patients receive better care, and your confidence is more evident. It is a win-win-win situation!

The current shift in the perception of dentistry and whole-body health began in the late 1980s with the insight that periodontal disease is an infection that impacts whole-body health.1 We are becoming more aware of what we do in the mouth and how it impacts the whole-body health of our patients, positively or negatively.2 This awareness forces us to abandon our preconceived thoughts that dentistry is only about teeth and gums. We are moving beyond the merely mechanistic view of creating oral health and experiencing the transformation of dentistry from a mechanical model into a medical model. Dentists who see their future in the evolution of dentistry for whole-body health can expect more growth for their businesses and better health for their patients.

The New Biocompatible Patient
In 2014, the number of patient visits to alternative healthcare providers exceeded the number of visits to traditional healthcare providers. Eighty percent of adult females say they are interested in living a more balanced and healthy lifestyle, and 30% to 40% of adult Americans are pursuing alternative healthcare possibilities.3 This means that at least 30% of your new patients and at least 30% of your existing patient base will be interested in dentistry that concerns itself with whole-body health. These numbers are just too big to ignore for practitioners who want to grow their business and, at the same time, provide a service that fits the lifestyle of this growing population.4 Patients at all income levels5 are buying into their health like never before6 and therefore are more likely to accept full-mouth periodontal therapy and quadrant biocompatible restorative care.

All-natural products and biocompatible procedures are indicated for patients who are interested in Lifestyles of Health and Sustainability (LOHAS),7 which the New York Times says is “the biggest market you’ve never heard of.”8

Starting With the Opportunity for Health
The starting place for dentistry for whole-body health is with the foundation—the periodontium and bone support of the teeth. Periodontal disease impacts whole-body health by increasing the risk of cardiovascular events, stroke, diabetes, and pneumonia.9-11

Our protocol for treating gingivitis (all the way to treating advanced periodontal disease) includes education, oral hygiene instructions, scaling and root planing with advanced ultrasonic techniques, dispensing an adjunct natural rinse, and follow-up home care with flossing and regular use of the Waterpik (Water Pik).

We find that the follow-up periodontal care and compliance with instructions is much better with all-natural products than with 0.12% chlorhexidine gluconate because 0.12% chlorhexidine gluconate (1) needs a prescription, (2) requires travel time to the pharmacy, (3) stains teeth and tooth-colored provisional restorations, (4) tastes bad, and (5) contains alcohol. We have found that, when given the choice, patients do not want alcohol or harsh chemicals in their healthcare products. Tooth & Gums Tonic (Dental Herb Company) contains only pure essential oils and organically grown herbal extracts. The efficacy is proven12-14 and compliance is not ever a problem, in the author’s experience.

Biocompatible nonmetal dentistry cannot be completed where there is saliva, bleeding, or suppuration. The contamination of the bond with these fluids is unacceptable. The case studies below were taken through hygiene therapy with a zero tolerance attitude to bleeding before starting their restorative phase of care.

A Protocol for Biocompatible Quadrant Dental Care
After administration of the local anesthetic, any fractured tooth structure and caries were removed. Then, biocompatible cores and fillings were placed and contoured to final prep design for lab fabricated restorations. Using biocompatible materials ensures the health of the teeth, the gums, and the overall health of the patient. It is important to note that the mercury-safe protocol of the International Academy of Oral Medicine and Toxicology was followed and that these patients were tested for the biocompatibility of materials to be placed. The point of testing is to not place something in the body that is toxic to the patient; nor a material the patient is allergic to; nor one that the patient may not tolerate well (or at all).

The author prefers to temporize quadrant care with provisional restorations that are fabricated as one unit. This makes it much less likely that a failure will occur. However, this also makes it extremely difficult for the patient to keep the gingival tissues under the provisional healthy because the patient cannot floss between the units. The provisional restorations are made with attention to opening the interproximal embrasure areas to make sure the provisional is not impinging upon the tissues and to facilitate the ability of the patient to keep the affected area clean.

Provisionals are fabricated using a vinyl polysiloxane (VPS) (Blu-Mousse [Parkell]) impression of the teeth before preparations (Figure 1). After preparing the teeth for onlays or crowns, a biocompatible provisional material is placed in the VPS impression and placed in the mouth over the preps and timed until it gels. The provisional restorations are then removed and shaped with a high-speed, flame-shaped fine diamond bur (Brasseler USA No. 8860.31.012) and a low-speed, flexible serrated diamond disk (Brasseler USA No. 365) (Figure 2) to shape and expose the interproximal col area to provide a cleansable area.

Oral hygiene instructions include soft diet, flushing interproximal areas with a Waterpik and rinsing twice a day with Tooth & Gums Tonic. (Note: Flossing with a floss threader is not recommended during the time the provisional restorations are in place because of the risk of having the provisional come off, causing an emergency for the patient.) This home-care protocol offers the best chance for the tissues to be clean and healthy at the restorative delivery appointment. A home repair kit of Zone (Pentron) temporary cement and instructions are also given along with a 2-oz bottle of Tooth & Gums Tonic (Figure 3).

CASE REPORTS
Case 1

A 65-year-old female diagnosed by her physician with heavy metal toxicity and a compromised immune system presented with chronic Lyme disease, osteopenia, and was being treated for intestinal parasites. She requested to be not only mercury-free but metal-free. She was tested by BioComp Laboratories (Colorado Springs, Colo) for the biocompatibility of dental materials and found to be compatible with DiamondCrown (DRM Research), Variolink II cement (Ivoclar Vivadent), and Aelitefil and Aeliteflo composite resins (BISCO Dental Products).

In this case, quadrant care would consist of fabricating 4 units of lab-fabricated biocompatible restorations, onlays would be placed on teeth Nos. 2 and 3, and a full-coverage crown on tooth No. 5.

CASE 1
Figure 1. Preliminary impression (Blu-Mousse [Parkell]) of the quadrant to be restored. Figure 2. Diamond burs (Brasseler USA) were used to optimally shape the provisional restorations assist the patient in keeping the area clean.
Figure 3. A home care kit with the products used and instructions is provided while patients are in provisional restorations.
Figure 4. Pre-op photo of the upper left quadrant. Figure 5. Quadrant preparations and gingival reduction for margin exposure.
Figure 6. Sculpted temporary resin for one-piece quadrant provisional. Figure 7. Provisionals (Luxatemp A-2 [DMG America]) were temporarily cemented (Zone [Pentron]). Note the open embrasures to allow for easier cleaning of the area.
Figure 8. Healthy tissues were observed upon removal of the provisional restorations due to the home-care protocol and excellent patient compliance. Figure 9. Final cementation was done using a dual-cured resin cement (Variolink II [Ivoclar Vivadent]). Note the healthy gingival tissues.


The existing dental work had margins below the gumline (Figure 4). To expose the shoulder margins of the new preparations, the soft-tissue interferences were excised (Figure 5) using a Electrosurge 500SE (Parkell) to expose the margins and to control fluids and moisture. Next, provisional restorations (Figure 6) were fabricated using Luxatemp A-2 (DMG America). The interproximal contours were opened up to improve cleansability then cemented using a temporary cement (Zone) (Figure 7). The patient was given oral hygiene instructions, a home repair kit as well as a 2-oz bottle of Tooth & Gums Tonic with directions to rinse twice a day until the permanent restorations were ready.

Figure 8 shows the marked improvement of the soft tissues before cementation. A dual-cured resin cement (Variolink II) was used to deliver the restorations (Figure 9). Due to the health of the tissues, there was no need to be concerned with contaminating fluids.

Case 2
A 62-year-old female presented with the desire to be mercury-free in a mercury-safe dental office and to have her dental health be considered as a part of her overall health. Her health history was unremarkable. She presented with generalized gingivitis. She was tested for the biocompatibility of dental materials using a blood serum sample processed by Clifford Research Lab (Colorado Springs, Colo). She tested well for Lava Ultimate (3M), Core Paste XP (DenMat), Variolink II cement, and Aeliteflo and Aelitefil composite resin.

Biocompatible dental care was to be provided for the lower right quadrant (Figure 10). This would include a DO composite resin on tooth No. 29; a crown on tooth No. 30; and a polymer ceramic onlay on tooth No. 3.

CASE 2
Figure 10. Pre-op photo of the lower right quadrant. Figure 11. Quadrant preps and gingival reduction for margin exposure.
Figure 12. Sculpted temporary resin for one-piece quadrant provisional.
Figure 13. Healthy tissues presented using the home-care protocol and excellent patient compliance. Figure 14. Final cementation was done using a dual-cured resin cement. Note the healthy gingival tissues.


Quadrant preps and gingival reduction for margin exposure were carried out with some associated minor trauma to the marginal gingiva tissues (Figure 11). Next, provisional restorations (Figure 12) were fabricated with Luxatemp A-2 and cemented using a temporary cement (Zone) and thoroughly cleaned. Oral hygiene instructions were given along with a 2-oz bottle of Tooth & Gums Tonic with directions to rinse twice a day with one cap full until the permanent restorations were ready.

Figure 13 shows healthy soft tissues upon the patient’s return for the delivery of the restorations. The final restorations were cemented (Figure 14) using a dual-cured resin cement (Variolink II).

CLOSING COMMENTS
In the author’s opinion, both of these cases clearly demonstrate the remarkable impact that biocompatible materials, a solid home-care protocol supported with all-natural products and clear instructions, and patient compliance have on the healing of tissues that become traumatized in the process of preparing the teeth. One added bonus is that most of the time, patients who are given Tooth & Gums Tonic and instructions with their provisional restorations during quadrant care continue to purchase 18-oz bottles of Tooth & Gums Tonic as their maintenance rinse. As a result, this becomes an additional and ongoing profit center in the hygiene department.

The Internet has given everyone access to the world’s knowledge, and people are becoming their own health advocates. Many patients are now coming to your office with expectations for their health. More than 68 million adult Americans are in the marketing category of LOHAS.

Dentistry for whole-body health is best achieved by starting with a perio­dontally healthy environment, providing biocompatible quadrant care. This progress will not just be taking your practice to the next level, it will be developing the next stage of your career in our noble and caring profession.


References

1. Mattila KJ, Nieminen MS, Valtonen VV, et al. Association between dental health and acute myocardial infarction. BMJ. 1989;298:779-781.
2. Mutter J, Naumann J, Schneider R, et al. Mercury and Alzheimer’s disease [in German]. Fortschr Neurol Psychiatr. 2007;75:528-538.
3. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. National health statistics reports; no 12. Hyattsville, MD: National Center for Health Statistics. 2008.
4. Derryberry J. Are you living LOHAS? Experience Life. April 2005. experiencelife.com/article/are-you-living-lohas. Accessed August 25, 2016.
5. Centers for Medicare and Medicaid Services. National Health Expenditure Data. cms.gov/Re­search-Statistics-Data-and-systems/Statistics-Trends-and-reports/NationalHealthExpendData. Accessed August 25, 2016.
6. Nahin RL, Barnes PM, Stussman BJ, et al. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. National health statistics reports; no 18. Hyattsville, MD: National Center for Health Statistics. 2009.
7. Natural Marketing Institute. Understanding the LOHAS Market Report. 6th ed. Harleysville, PA: Natural Marketing Institute; 2008:164.
8. Cortese A. Business; They care about the world (and they shop, too). The New York Times. July 20, 2003. nytimes.com/2003/07/20/business/business-they-care-about-the-world-and-they-shop-too.html. Accessed November 18, 2016.
9. Mochari H, Grbic JT, Mosca L, et al. Usefulness of self-reported periodontal disease to identify individuals with elevated inflammatory markers at risk of cardiovascular disease. Am J Cardiol. 2008;102:1509-1513.
10. Mealey BL, Oates TW; American Academy of Perio­dontology. Diabetes mellitus and periodontal diseases. J Periodontol. 2006;77:1289-1303.
11. Scannapieco FA. Pneumonia in nonambulatory patients. The role of oral bacteria and oral hygiene. J Am Dent Assoc. 2006;137(suppl):21S-25S.
12. Fresh Breath Study. Clinician’s Report (CRA). May 1999. dentalherb.com/pdfs/CRA-Fresh-Breath-Study.pdf. Accessed November 18, 2016.
13. Malmström H, Cacciato R, Yunker M, et al. Effects of essential oil mouthwash on gingival health. Presented at: University of Rochester, Eastman Institute for Oral Health; March 2007; Rochester, NY. dentalherb.com/pdfs/Malstrom-Study-2.pdf. Accessed November 18, 2016.
14. Malmström H, Cacciato R, Yunker M, et al. Effects of essential oil mouthwash on oral malodor. Presented at: University of Rochester, Eastman Institute for Oral Health; March 2007; Rochester, NY. dentalherb.com/pdfs/Malstrom-Study-1.pdf. Accessed November 18, 2016.


Dr. Evans earned a master’s degree in microbiology and immunology and a DDS from the Medical College of Virginia. He is a founding member of the American Academy for Oral Systemic Health. He is the president of the BioCompatible Dentist, LLC, a company that provides education and resources for dentists about whole-body dentistry. As a practitioner, author, speaker, and national dental coach, his expertise lies in his ability to research and bring innovative solutions to dentistry to include whole-body care and create value for your patient and your practice. He can be reached at (757) 220-1999 or at This email address is being protected from spambots. You need JavaScript enabled to view it..

Disclosure: Dr. Evans reports no disclosures.

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