The Promise of Microdentistry

When Kathy and I were in dental school, one of our first lectures was on what we call “Operative Dentistry”. To the layperson, this is “drilling and filling”. The professor commented that he had told one of his patients that he was giving a lecture on this subject, and her reaction was “I thought you just made a hole, and filled it up!”. Well, this certainly is not the case, as there are engineering rules to follow in any pursuit where physics is involved, whether it is a skyscraper, or a filling.
The rules for dentistry where invented in the late 1800’s by Dr. G.V. Black, the father of modern dentistry. Among the foremost of his “rules” was the concept of “extension for prevention”. This is the practice of drilling a cavity into ALL of the grooves on the biting surface of a tooth, just because ONE area is decayed. The idea was to remove the possibility of further decay in that surface of the tooth. The only problem was that a lot of HEALTHY tooth was destroyed in the process, and until we can actually grow enamel, we can’t replace healthy tooth, we can only restore it. The other problem with Dr. Black’s method was that the cavity preparation had to be shaped so that it would retain the filling material of his day, non-bonded, silver-mercury amalgam.
As dentistry advanced in the 20th century, we developed high-speed drills, fluoride treatments, and better treatment for gum disease. However, we continued to remove too much healthy tooth structure, which led to larger and larger restorations (including root canals and crowns) as the patient got older. In the late 1970’s and early 1980’s, composite resins began to emerge in dentistry, along with the concept of “bonding”. A mild acid is placed on the tooth, which causes microscopic irregularities in the tooth. The filling can then be locked into these irregularities (bonded) through the use of a bonding agent. When Kathy and I graduated in 1992, a new breakthrough was occurring called “dentin bonding”. This allowed dentists to not only bond fillings to the outer mineral layer of the tooth (enamel), but also to the inner, living layer of the tooth (dentin). This allowed the restorations to have a stronger bond, and also reduced post-operative sensitivity on the tooth. Unfortunately, even with the ability of the filling to simply stick to the tooth, many dentists are still removing too much healthy tooth. In addition, insurance companies still see fit to only pay for G.V. Black’s 19th century dentistry, because it is cheaper.

So what is this cutting edge concept of “microdentistry”, and why is it better? Microdentistry is just what it sounds like: making a dental restoration AS SMALL AS POSSIBLE. Because of the fact that we cannot replace your decayed tooth structure with healthy tooth structure, only an artificial filling, we want to remove only the decayed areas. We also want to catch decay as early as possible. If we catch it early enough, we may only prescribe a highly concentrated fluoride toothpaste to remineralize the lesion, so that it does not require a filling. However, for those times when a restoration is necessary, we want it to be as small as possible. This is where the Waterlase dental laser really shines. It cuts so microscopically and precisely that we are able to remove the decay, with very little removal of healthy tooth structure. I often wear magnifying glasses when I use the laser, it is so precise. In addition, because the laser sterilizes as it cuts, etches the tooth as it cuts, and does not leave an organic smear layer when it cuts, the fillings done with the laser should last longer than those done the conventional way.

What does this mean for the patient? It means a break in the traditional cycle of dental disease and restoration. What I mean is this: In the past, a child would get a small cavity in one section of the groove of his lower first molar. This decay would be drilled out, and all of the grooves on the biting surface of the tooth with it, to place a non-bonded, silver-mercury amalgam filling. In his late teens, the dentist would see a small cavity starting in between that tooth and another. Rather than fluoride therapy, the dentist would put a “watch” on that tooth. Sure enough, at age 20, that tooth would need another filling, this time involving two surfaces of the tooth, the biting surface, and the interproximal (in between) surface. Again, the tooth would be restored with a non-bonded, silver-mercury amalgam. At age 30, some cracks developed in the tooth as a result of the amalgam not being bonded. This time, the patient bites down into a slice of pizza, and fractures a portion of the tooth. At this time, the fracture goes into the nerve of the tooth, and our fictional patient needs a root canal, a post, and a crown. Everything is going smoothly until he hits 45, and the crown gets loose, and he bites down on something, and the post fractures the root. Now the tooth has to be extracted. The only decay he ever developed on this tooth was a small filling in the biting surface of the tooth, and a cavity between the teeth that might have been remineralized with the use of a concentrated fluoride. The eventual loss of the tooth really came about because our methods of dental restoration removed too much healthy tooth structure, and did not protect what was left.

Now think of a new scenario. An eight year old girl comes into our office with a small area of decay on her lower first molar. Using the laser (with no anesthesia) we remove ONLY the small area of decay, then we clean out the plaque and stain from the rest of the grooves in the biting surface of the tooth. At this point we place a very small, bonded filling in the decayed area, and a sealant over the rest of the tooth. The sealant is basically a bonded filling that seals the grooves of the tooth closed, so that cannot become decayed. When she is 16, we see a small area of decay starting in the enamel between her teeth. We prescribe a concentrated fluoride toothpaste (only available from a dentist), and we see that area of decay disappear by her next check-up. At age 20 we see a little bit of breakdown at the edge of the filling. The area is quickly roughened up with the laser, and re-bonded. Fast-forward to 40 years old, and that tooth still only has a small, one surface filling. No crack, no root canal, no crown, no fracture, no extraction. The less we take from your tooth, the better.

Microdentistry is the wave of the future. Probably by the time I retire in 30 or so years it will be considered to be the standard of care. We believe that it should be the standard of care now, and that our patients deserve only the best that modern dental technology has to offer. Ask yourself if you would rather be a part of scenario #1 or #2. I know which one I would pick for myself, my family, and my patients.
 

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