Angie Segatto

Photodam ® was inspired by artistic vision. My commitment to arts has determined my specialisation. It is a great challenge to restore things originally created perfectly by nature but damaged by external forces. For me, it is a vital need to deliver the gathered information, experience and knowledge to others. My mission is to give the passion for arts in dentistry for my students. My special fields are restorative dentistry, as well as orthodontics. I work in my private practice and I’m assistant lecturer at University of Szeged, Faculty of Dentistry. Currently I am doing my Ph.D. studies. Latest results of my research field are published in scientific congresses (Chicago, Istanbul, Seattle, etc.) and papers on regular basis. Segatto Dent’art Studio www.segatto.hu
Photodam ® was inspired by artistic vision. My commitment to arts has determined my specialisation. It is a great challenge to restore things originally created perfectly by nature but damaged by external forces. For me, it is a vital need to deliver the gathered information, experience and knowledge to others. My mission is to give the passion for arts in dentistry for my students. My special fields are restorative dentistry, as well as orthodontics. I work in my private practice and I’m assistant lecturer at University of Szeged, Faculty of Dentistry. Currently I am doing my Ph.D. studies. Latest results of my research field are published in scientific congresses (Chicago, Istanbul, Seattle, etc.) and papers on regular basis. Segatto Dent’art Studio www.segatto.hu

EVENTS BY THIS MEMBER

FRIDAY, April 8th, 2016 9.00- 17.30 Digital Smile Design- theoretic and practical course - DR. FLORIN COFAR (Romania) 17.30- 18.00 Registration 18.00- 18.10 Opening remarks 18.10- 18.30 Diamond Sponsor session 18.30- 19.30 Meet the Lecturers - GURREA, MAIA, MANAUTA, MONTEIRO SATURDAY, April 9th, 2016 7.45- 8.25 Registration 8.30- 9.30 Introduction to Contemporary Adhesive Dentistry - GURREA, MAIA, MANAUTA, MONTEIRO 9.30- 11.15 Sense and Sensitivity with direct restorations - DR. JON GURREA (Spain) 11.15- 11.35 Coffee break with Exhibitors 11.35- 13.20 Contemporary evidence based dentistry – light, bonding and action - DR. RODRIGO R. MAIA (Brasil/USA) 13.20- 14.20 Lunch break with Exhibitors 14.20- 16.05 The never ending simplicity in aesthetic dentistry - DR. JORDI MANAUTA (Mexico/Italy) 16.05- 16.25 Coffee break with Exhibitors 16.25- 18.10 Shape and texture on direct composite resins – The icing on the cake - DR. PAULO MONTEIRO (Portugal) 18.10- 18.55 Modern endodontics – a pillar of the restorative dentistry - DR. BENYOCS GERGELY (Hungary) 18.55- 19.00 Closing remarks 20.30 Gala dinner

ARTICLES PUBLISHED BY THIS AUTHOR

“Starting the daily use of the rubber dam is the beginning of wisdom. When the rubber dam comes through the door, slipshod methods go out of the window. It marks the beginning of better dentistry. “ J.M. Prime (1937) isolation the act of separating something from other things: the act of isolating something Isolation in dentistry. DEFINITION: Isolation of the treatment area from the buccal saliva, thereby protection of the dental tissue from the contamination during the dental treatment. OBJECTIVE AND METHODS: The objective of the isolation is complex: it provides a dry environment associated with the patient protection, establishment of an absolute visual and manual control as well as it helps improving the treatment efficiency. Literature divides the methods and tools of isolation into two groups: direct and indirect. Creation of a comfortable posture and relaxes, stress-free environment, the local anesthetic as well as the drug interventions are all considered to be indirect methods serving to reduce saliva production and to ease discomfort. Cotton-rolls, dry angles, retraction cord, lip retractors, different saliva ejectors and rubber dam are known as direct methods. Originating from the English term “cofferdam” meaning: “...a watertight enclosure ... to allow for construction or repairs; safety precaution in tankers ...” Cofferdam (rubber dam) in dentistry: ABOUT: This is a very thin, usually latex sheet of 12.5 x 12.5 cm in size used for isolating the operating field in the mouth. The places of the teeth to be isolated are marked on the sheet by using a template and are punched with a special punch, and then the sheet is fixed with clamps. HISTORICAL BACKGROUND: -1836 Rich uses a gold band that is placed around the tooth for isolation. This is described as “cofferdam” method. -1864 It has been used in dentistry since this year. Sanford Christie Barnum came up with the idea of using a punched sheet of rubber and pulling it over the treated tooth. In May of the same year in the course of a meeting at the Cooper Institute the solution to the problem of sustaining a “dry working area” is announced. -1867 Barnum’s method is described as “widespread”. -1882 S.S. White develops the cofferdam punch. - In the same year Dr. Delous Palmer launches a set of 32 clamps, a tool very similar to the one used nowadays. -1920 with the promotion of silver amalgam and the development of the suction methods, the demand for the rubber dam technique declines - The interest for rubber dam was reborn in the1990s. The use of rubber dam, unfortunately, is still not routine-like. ADVANTAGES: This improved isolation method has many advantages not only for the doctors but the patients. For patients there are two very important advantages: the protection of the oropharynx (aspiration) as well as keeping away and protecting the soft tissues. From the operating side it provides those essential conditions without which only a result with compromises would be reached as regards the treatment quality. Providing clean and dry environment and protection of the operative site from contamination during the entire treatment are some of these conditions, but the reduction of the communication ability of the patient and the protection of the dental personnel are also listed here. When evaluating it from both sides it is very important to mention the prevention of the cross infection control! DISADVANTAGES: No real disadvantages can be reported, but still we can recite some we have heard: “extra time”, “extra costs”, “problematic application” as well as “the patient rejects it”. INDICATIONS – CONTRAINDICATIONS: By examining the indication and contra-indication issue we have experienced that the use of rubber dam has been compulsory only in endodontics so far. We have found only the American official commitment concerning this question. On the contrary the list of contra-indications is far longer and airy contra-indications like the active orthodontic treatment are also included. The list of contra-indications is as follows: - If the patient shows allergic reactions to any components of the material (nowadays non-latex rubber dams are also available!) - asthma, certain upper respiratory infections and mouth breathing - psychosomatic intolerance - transient bacteremia - certain gingival diseases. PRECAUTIONS: Application of rubber dam requires precautions; however, the observable rules do not make usage more difficult. What should we consider while using rubber dam? - do not block the respiratory organs - use of rubber dam napkins to eliminate contact dermatitis - in order to avoid unwanted psychosomatic reactions, such as panic reactions, we should inform the patient about the application of the dam. TYPES AND FEATURES: Based on thickness a dam can be classified as thin, medium and heavy. The use of medium dam is the most widespread, but which to use depends mainly on a personal choice. However, the appliance of the thin dam is not recommended for endodontic treatments. I love using heavy dams in critical situation, it is easily adaptable and there is no risk of displacement. As regards the material the rubber dams are made of we distinguish latex and non-latex rubber dams and within this there are textured and non-textured surface rubber dams. Main features of the material: - elasticity - tearing strength - easy to clean and dry (tear resistance) What is it needed for a proper application? - rubber dam - a set of clamps - hole punch - punching template - clamp forceps - frame - accessories: rubber dam napkins, dental floss, removing scissors, etc. APPLICATION TECHNIQUES: Different application techniques are available. Its usage is custom-made and depends on the situation as well. - first the latex - first the clamp - the rubber dam and the clamp are placed at the same time. The successful placement of the later one depends mainly on how handy the operator is. In this case the use of winged clamps is recommended! When we talk about an “unsuccessful” application, we think about the fact that how the application of the rubber dam affects the result of the treatment or we consider the scope of the treatment. Common mistakes: - rubber gets nipped with the clamp - it is not adequately adapted in the sulcus - rubber tears alongside the perforation If the failure cannot be corrected, placement of a new rubber means the solution or we just do not take it into account if the failure does not negatively affects the treatment conditions. If it is a case to be published, there is no excuse for placement failure! I would like to mention in brief about the isolation variations at special situations, since Filippo Cardinali’s article on isolation of the prepared teeth has just been published on the StyleItaliano Endodontics website. He has described special situations in details. What is considered to be a special situation? - if the treated tooth is altered as a result of the anatomical/postural conditions or clamps that are not suitable for the given tooth type are used - the rubber sheet is used in an individual way due to the placement obstacles (split dam technique) - use of accessories, e.g. liquid rubber dam - use of altered isolation tools, e.g. OptraGate, OptraDam HOW ISOLATION SHOULD BE DONE? - as far as possible the teeth holding the clamps should be anaesthetized - the amalgam fillings should always be removed in isolation - it is useful the application of anaesthetic gel on the rest of the teeth because of the invagination (adaptation into sulcus) HOW MANY TEETH SHOULD BE ISOLATED? - Isolation of a single tooth is accepted in case of an endodontic treatment or in case of treating a class I. cavity - Isolation of three or more teeth is a must in case of class II. cavity - Isolation of a full quadrant is compulsory when it is a case-presentation or publication Recommendation: - In case of FRONT teeth the isolation of the entire frontal area is recommended, in most of the case I isolate teeth from 4 to 4. When I bond veneers, the clamp is always placed on the tooth which is treated in order to have the rubber adequately placed in the cervical area. - In case of PREMOLAR teeth isolation of only 2 teeth is rare when treating MO or OD cavities. In such cases the clamps should be chosen very carefully to prevent the placement of the sectional matrix. Basically, I prefer to work in quadrant isolation. - In case of MOLARS, the isolation of the entire molar area is the minimum isolation requirement! If it is not prepared for publication, isolation from 4 is enough! ISOLATION IN TAKING PHOTOS VS TAKING PHOTOS IN ISOLATION Basic requirements: - rubber dam should always be clean - replacement of rubber dam after sandblasting - acid, primer, bond cleaning with alcoholic cotton roll! The usage of contrastors has highly improved the aesthetic results of the dental photos. They enable the achievement of artistic level by a detailed focus on the optical characteristics and coloring effect. Their use in rubber dam isolation is sometimes difficult. The color of rubber dam and the black contrastor slightly bends the visual effect in the photos. But the contrast is very important! And PHOTODAM has been born……
The application of the incremental technique appeared together with the light-cured composites. This is important for two reasons: for the proper polymerization taking place and for decreasing the shrinkage and shrinkage stress due to the polymerization reaction. The incremental placement is used to help the adequate adaptation in the more sensitive areas (cavity wall, matrix), however, it involved the risk of contaminating the layers on the posterior areas requiring longer treatment period. Packable composites were launched in the late 1990s in order to meet the demands raised by the incremental placement. Besides their higher viscosity, they were capable of being bulk placed, that meant the placement and light-cure of 4-5 mm increments. The photo-initiators begin the polymerization in a proper wavelength of the light. If the light penetration is not sufficient, no reaction will be resulted, and this could lead to under-cured or uncured materials. Several factors like the wavelength, the light intensity, the distance from the light source, as well as the exposure time influences the effectiveness of the light. The monomers, the initiators and the shade/opacity of the material determine the depth of cure of a composite. Still, these materials were described as materials having high shrinkage and polymerization stress. The latest advancements in the field of materials science have led to appearance of bulk fill composites which correspond to the low polymerization shrinkage stress also seen and experienced in case of the composites used in the multi-layer techniques. Due to the decrease of the filler particles the volume of the resin matrix also decreases and as a result of this polymerization shrinkage decreases as well. The smaller the fillers are, the better the optical attributes of the material are. However, light scattering and gloss retention depend on the arrangement and distribution of the filler particles within the resin matrix. The most important advantage of these materials is its fast and easy one-step placement. During their use the higher viscosity can be beneficial in case of many operators. The good polish attributes improve the final aspect of the finished restoration. Although, for their aesthetic attributes they are recommended to be used mainly in the posterior area, efforts are made to have them manufactured in the several shades in order not to make big compromises in terms of shade effect. The 3M Filtek Bulk Fill Posterior material – used in the next restoration – is outstanding in this field.
The desire for having white teeth has been phrased for a long time. The light and bright tooth color has even been a very essential aesthetic aspect when the teeth alignment and symmetrical appearance was not of primary importance. A beautiful smile does not only reflect neatness but also helps people feel more confident and has a very significant role in socialization. The technical and technological development of the dental profession has enabled us to change the natural teeth color by non-invasive, chemical methods. Bleaching materials and techniques have gone through several generations and they are considered to be conservative and tolerant methods in fulfilling the desire for white teeth. Due to the above-mentioned circumstances tooth whitening has gained ground in the treatment profile of the dental offices. In the earlier times the “Nightguard”, later the techniques known as at-home tooth whitening systems used a gel of 10-20% carbamide peroxide with individual tooth whitening trays. Then lower concentration (6-8%) materials and absolutely universal tray setups appeared. The improvement in the tooth whitening home kits focused on increasing convenience and decreasing using time. Based on the achieved results these are considered to be the most tolerant kits nowadays. However, sensitivity attributed to these systems could not been successfully eliminated. As regards the individual structural distinctiveness of the dental enamel, sensitivity has been described from moderate to certain feel of pain character. Almost all the patients complained of sensitivity discomfort during the use of the tooth whitening home kit and some days after the treatment as well. The past tooth whitening products containing hydrogen peroxide have been replaced by products containing carbamide peroxide but this fact has not solved the problem. Unfortunately the aetiology of bleaching-related tooth sensitivity is neither well understood nor easily measured; however the hydrodynamic theory is a mechanism frequently cited to explain it. According to this model, peroxide solutions introduced into the oral environment contact available dentinal surfaces and cause retraction of odontoblastic processes, resulting in rapid fluid movement inside the dentinal tubules. This ultimately manifests in stimulation of mechanoreceptors at the pulp periphery, with the resultant feeling of pain when such teeth are exposed to cold or pressure, or even when they are at rest. As a result of the latest improvements a new bleaching product has appeared. Its molecule eliminates the tooth sensitivity problem. This is the WHITE DENTAL BEAUTY with an active ingredient called NOVON. This patented active ingredient has a novel inherent feature, in that it remains stable at neutral pH in the syringe, yet upon dilution a rapid pH increase occurs. This pH increase, from neutral to alkaline, produces an enhanced release of perhydroxyl ions resulting in a more effective bleaching action. Novon’s unique formula gives White Dental Beauty gel an unsurpassed accelerated bleaching action which is safe, effective and kind to the teeth. TESTING WHITE DENTAL BEAUTY: The testing procedure of this product was carried out among my patients under regular professional control in the office. The patients were asked to give detailed feedback related to the standardized application process. Ten patients participated in the testing process; all of them had in-office tooth whitening before. The previous treatment took place more than 5 years ago with a solution containing sensitivity assuasive effect material (35% H2O2). Half of the patients complained of acute tooth sensitivity while the other half considered the resulting pain as tolerable. When testing the new material I used bleaching material of 5%CP carbamide peroxide (White Dental Beauty WDB) and 6%HP hydroxid peroxide(WDB). The “sensitive” patients were treated with the 5% CP material, while the rest with 6% HP respectively. The tooth whitening procedure underwent using the StyleItaliano protocol. The change of tooth color was checked every third day in the dental office. The patients were asked to journalize the universal activities; they documented the frequency of the usage (every day or eventually the missed a day out) or whether they ran out of the time suggested as well as their own experience related to the wearing. Before the bleaching procedure I took extra- and intraoral pictures to document the basic condition and I recorded the teeth colors with cross polarization technique (Smile Lite). I repeated these steps under the same circumstances and adjustments after the tooth whitening treatment ended. In case of the test group the tooth whitening procedures carried out based on the same protocol resulted in the following achievements. Average wearing time: 10 days; average daily wearing time: 32 minutes; average change in tooth colour: 5 shades. The most outstanding result beside the general satisfaction of the subjects was the disappearance of the tooth sensitivity during the acting period and as well as during the days following the treatment.

Dentine hypersensitivity is a frequent problem in cases involving dentine exposition. The problem affects all ages, and its prevalence is the highest in the canines and premolars. Precise diagnosis and differential diagnosis are of the utmost importance. A frequently occurring mistake is that instead of concentrating on the cause, only the symptoms are treated, which, naturally, yields only temporary success. 

Today, several modern devices and techniques are available, both for home and clinical use, that make it possible to reach a long-lasting solution, provided that the indication was correctly determined. This article offers the clinician an up-to-date overview of the characteristics and importance of bioglasses, concentrating especially on Sylc (NovaMin).

THE STRUCTURE OF DENTINE

Dentine is a vital tissue, an organic matrix with a permeable, tubular structure embedded in crystalline apatite. Dentine is normally covered with hard tissue: enamel in the coronal region and cementum on the roots. Dentine is characteristically a sensitive tissue type. This is because of the odontoblast endings in the dentinal tubuli, and also because dentine is part of the dentine-pulp complex. Given that the pulp and dentine are so closely associated, harm to one will also affect the other. Odontoblasts located in the dentinal tubuli are the major cells of the dentine-pulp complex. The endings of odontoblasts are surrounded with fluid inside the tubuli. Dentinal fluid adds up to 22% of the entire volume of the dentine. The fluid itself is an ultrafiltrate of blood, which serves as a medium between the pulp and dentine along the odontoblasts. This anatomical fact led Gysi to hypothesise that it was the movement of this fluid that stimulated the odontoblast-associated nerve endings, causing pain this way. Decades later, Brannström revisited the hydrodynamic theory of dentine hypersensitivity and proved that removal of the fluid from the tubuli can alleviate the pain or stop it completely. The work of Brannström made the hydrodynamic theory the accepted explanation for dentine hypersensitivity.       

 

DENTINE HYPERSENSITIVITY

CLINICAL PRESENTATION

Dentine sensitivity and hypersensitivity are well known and frequent problems. It is characterised by brief, sharp pain triggered by thermal, tactile, osmotic and chemical stimuli. The pain originates in the exposed dentine, and it is not similar to any other kind of dental pain. 

EPIDEMIOLOGY

The prevalence of the condition has been reported between 4% and 74%, which reflects a large standard deviation due to methodological differences. The most affected are between 20 and 50 years of age, but there is another surge between 30 and 40 years. The canines and premolars are the most frequently affected, especially at their labial cervical area.  

AETIOLOGY AND PATHOGENESIS:

Dentine hypersensitivity develops in two phases, lesion localisation and lesion initiation. Localisation means the loss of the supradentinal protective layer (enamel or cementum) in a circumscribed area, whereby dentine becomes exposed to the external environment. The mechanisms include attrition, abrasion, erosion, abfraction or gingival recession. The latter may be the result of toothbrush abrasion or excessive flossing, but it can also be secondary to periodontal surgery (e.g. pocket reduction surgery) or tooth preparation for crown. However, localisation itself does not necessarily result in the development of hypersensitivity. For this, initiation has to happen, which means the removal of the protective smear layer, by which the dentinal tubules open up.   

In the oral cavity, demineralisation and remineralisation of the dental tissues are in a physiological balance, but organic acids produced in the dental plaque can shift this balance toward demineralisation. The resulting loss of minerals leads to damage to the dental tissues.

MECHANISM

There are three plausible theories regarding how sensitivity/pain develops, the most accepted of which, as said above, is the hydrodynamic theory. The three theories are:

the direct innervation theory

the odontoblast receptor theory

the fluid movement (hydrodynamic) theory

 

The first two of these, however, have fundamental weaknesses:

Ad 1. There is no proof that the external layer of dentine (which can become sensitive) is innervated at all.

Ad 2. Most of the studies conducted in this matter prove that odontoblasts are matrix forming cells, they are not sensitive to stimulation and they have no synaptic connection with the terminal nerves. 

 

Most of the evidence we have support Brannström’s 1964 hydrodynamic theory (see “The structure of dentine”). Scanning electron microscopic studies observed wide dentinal tubule openings on hypersensitive surfaces, which supports the hydrodynamic pain theory. The movement of fluid can be triggered by thermal, tactile, osmotic and chemical stimuli, and then it is the movement that activates the nerve endings in the dentinal tubuli or the dentine-pulp complex. The degree of pain depends on the intensity of stimulation. Stimuli that move the fluid away from the dentine-pulp complex cause more intensive pain (e.g. exhaustor).

 

DIAGNOSIS

A correct diagnosis based on a thorough diagnostic process is of key importance here. All other potential pain triggers must be excluded. The degree of pain must also be correctly determined (from mild to strong). It cannot be overemphasised how important it is to determine the cause of hypersensitivity, so that the trap of symptomatic treatment can be avoided. If we suspect increased acidity, it has to be determined if it stems from a systemic disease or some external factor is at play. It also has to be examined if there are any erosive agents that can damage the enamel or cementum, potentially leading to the loss of dentine protection.

 

TREATMENT

It has been attempted to treat dentine hypersensitivity in several ways. Based on the mechanism of action, these can be divided into 6 groups: nerve desensitisation, protein precipitation, plugging the dentinal tubules, dentine adhesive sealers, laser and homeopathic medication.

Temporary success may be expected from the following:

- chemical agents that penetrate the dentinal tubuli and block the depolarisation of the nerve endings (toothpastes that contain potassium nitrate).

- forming a protective layer by chemical or physical agents so that the flow of fluid in the tubuli is blocked (potassium/iron oxalate). This, however, is only a short-term solution, as the protective layer can be damaged, and after some time it disappears, and the hypersensitivity reoccurs.

Brannström’s results made it clear that any material capable of sealing the dentinal tubuli and preventing liquid movement can be used to reduce the sensitivity.

A long-term effect, however, can be only expected from a material that binds to the dental tissues not only physically, but also chemically, so that the chance of reopening is minimized. Based on the bioglass technology, researchers of OSspray (UK) developed a cleaning and desensitising powder that, by the emission of calcium phosphate ions, forms a surface layer and closes the dentinal tubuli.  

A multitude of in vitro studies proved that when used for air-polishing, this powder remineralises the demineralised dentine, while the calcium phosphate ions attach to the surface. Remineralisation can occur because the biomaterial is capable of reacting with the dentinal tubular fluid and/or saliva. As a result, carbonated hydroxyapatite is deposited along the demineralised collagen fibres and the tubuli are closed at the same time.     

 

BIOGLASS

Bioactive glass (Calcium sodium phosphosilicate – CSPS) was developed by Prof. Larry Hench at the end of the 1960s at the University of Florida. CSPS belongs to the large group of bioactive ceramics, which were developed to replace, enhance and repair hard tissues. The material was originally meant to play a role in bone regeneration, considering its excellent bioactive capability in forming hydroxicarbonate apatite, resultant in adhesion of cells to the glass when submerged in stimulated body fluid solutions. Later, in the mid-1990s, Leonard Litkowski, Gary Hack and David Greenspan further enhanced the material so that it became capable of remineralization by releasing calcium and phosphate ions from itself. The use of bioactive glass yields a longer desensitizing effect, and also more effective whitening results.

NOVAMIN

Bioactive glass capable of desensitizing dentine entered the market in 2003, under the brand name NovaMin. NovaMin is an inorganic, amorphous melt-derived glass compound that contains only calcium, sodium, phosphate, and silica. NovaMin offers immediate and long-lasting relief. Today various toothpastes and desensitizing pastes contain this material. 

The active ingredient of the prophylactic powder (Sylc) for the air-flow-based AquaCare is also NovaMin. Reacting with a salivary environment, the Sylc (NovaMin) releases calcium and phosphate ions. Sylc applied with air-flow forms a biologically stable, acid-resistant mineral layer (HCA), which is strong and resilient. The continuous release of calcium ions promotes both constant protection and a lasting sealing of the tubuli.  

It was proven in in vitro studies that the deposited smear layer allows mineralization in a calcium-rich fluid environment (such as saliva or the dentinal tubular fluid).  

It must be mentioned that NovaMin is also capable of remineralising enamel, and its antimicrobial and anti-inflammatory properties make it a promising candidate for gingivitis treatment.

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