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Covering both popular and advanced cosmetic procedures, Contemporary Esthetic Dentistry enhances your skills in the dental treatments. PDF | On Jan 1, , Yousef A. AlJehani and others published Current Trends in Aesthetic Dentistry. PDF | Welcome to the second article in the Vital Guide Series. Here, Irfan Ahmad points out the seven deadly sins of aesthetic dentistry and.


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Essentials of Esthetic Dentistry - Principles and Practice of Esthetic soundofheaven.info - Ebook download as PDF File .pdf), Text File .txt) or read book online. Contemporary Esthetic Dentistry, 1E () [PDF][UnitedVRG].pdf - Ebook download as PDF File .pdf), Text File .txt) or read book online. ESTHETIC DENTISTRY IN CLINICAL PRACTICE Editor Marc Geissberger, DDS, MA, BS, CPT Chair, Department of Restorative Dentistry Arthur A. Dugoni.

After establishing an appropriate size for the central incisors, the dentist can use various tooth-to-tooth ratios to help create a symmetrical and harmonious smile. In traditional film photography, 36 mm would fill a magnification ratio of 1: Frazier, G. According to Chalifoux,9 there are three categories of dental esthetic imperfec- tions that encourage patients to seek esthetic intervention. Lips It is important to assess lip morphology and mobility. J Orofac Pain 10 2:

Whatever the level at which you presently practise esthetic dentistry, my fellow authors and I believe that this book will strengthen, enhance and hopefully expand the scope of your work. I have learnt a great deal in the process of editing this book, and am confident that all those who read and study its contents will share my experience.

Your patients and practice will benefit greatly from you acquiring this book and becoming familiar with its contents. Introduction Esthetic dentistry is here to stay. It is a widely held belief that individuals who are beautiful are happier, have more sex appeal, and are more confident, kind, friendly, popular, intelligent and successful than their less attractive peers.

Who does not want to share some, if not all, of these perceived qualities? Having, or acquiring, an attractive smile Fig. Dentistry has changed dramatically over the past 30 years. Many have called it a revolution but this denotes sudden, monumental change. In contrast, it has been an evolutionary development, catalysed by various factors, including the following:. Dentistry, as now practised by an increasing number of practitioners, has moved from being a needs-based service, focused on treating acute symptoms and mechanistic operative interventions to manage disease, to a consumer-driven, wants-based service, treating patients presenting with various wishes and expectations, typically to maintain and, wherever possible, enhance oral health using minimal intervention approaches.

Patients have ready access to a wealth of information and are subject to media pressures in current society. This has increased the dental IQ and awareness of most patients, who, as a consequence, are more questioning and have higher expectations.

Dental attractiveness has increasingly become recognized as being part of looking youthful, vital and successful. Developments in tooth-coloured restorative systems and their application have created many new opportunities to enhance dental esthetics, increasingly using minimal intervention techniques as part of the drive to assist patients in having good-looking, functionally effective teeth for life.

Although patients have access to information, it stems from the media and not the dental profession. This raises issues of unreasonable expectations, based on Photoshopped images in the press and elsewhere.

Is what the patient is asking for really an achievable result? Do the media raise false expectations? Esthetics versus cosmetics What is the difference between esthetic and cosmetic dentistry?

The terms cosmetic and esthetic dentistry esthetic being used more widely on the international stage than the aesthetic spelling have been and continue to be employed interchangeably, causing much confusion in the profession and the population in general. The situation is compounded by the overlap between various esthetic and cosmetic treatments and by the fact that all esthetic and cosmetic procedures in medicine and surgery are considered to fall under the single umbrella of cosmetic practice.

In this introductory chapter of the first volume of a series of books on esthetic dentistry, it is important to discuss and clarify the use of the two terms. There are many different and varying definitions of cosmetics and esthetics. What is the etymology of these two words? As a noun, the word cosmetic comes from Greek kosmetike, which is the art of dress and ornament.

Esthetic Dentistry in Clinical Practice

As an adjective, cosmetic derives from the Greek word kosmetikos, skilled in adornment or arrangement or used or done superfi- cially to make something look better, more attractive, or more impressive http: The word esthetic comes from Greek aisthetikos, meaning sensitive and perceptive http: The Collins Concise English Dictionary provides the following definitions for esthetic: The same source defines cosmetic as having no other function than to beautify and designed to cover up a greater flaw or deficiency; superficial.

In essence, the way to differentiate between the terms cosmetics and esthetics is to consider esthetics as the theory and philosophy that explore beauty, while cosmetics refers to a preparation designed to beautify the body by direct applica- tion http: Aristotle stated that esthetics is the art of imitating ideal objects.

Winkler and Orloff1 describe the terms, as they pertain to the treatment of patients, as follows:. This encompasses reversible procedures to attain a so-called optimal appearance that is sociological, cultural, geographic and time-dependent.

Trends are time-dependent; what is acceptable and fashionable today can and will often- times be considered unacceptable and old-fashioned tomorrow. This demands tailoring and customisation to individual preference. It is a fluid and dynamic entity, but it is based on the patients expectations, psy- chology and subjective criteria. Others, including Touyz,2 have suggested that cosmetic dentistry, while improv- ing appearance, does not strive to achieve enhanced function, whereas esthetic dentistry incorporates biological considerations and measures to achieve ideal form, function and appearance, with a view to long-term performance and survival.

These authors consider cosmetic dentistry to comprise measures designed pri- marily to enhance dental attractiveness, without necessarily improving func- tion, whereas esthetic dentistry involves procedures on teeth and the associated soft tissues aimed at concurrently achieving ideal form, function and appear- ance. A useful distinction is considered to contrast a conformative approach to the enhancement of dental appearance cosmetic dentistry , with a modifying or rehabilitative approach with changes in function esthetic dentistry.

If the measures and procedures involve any changes to function, then the treatment should be termed esthetic rather than cosmetic dentistry. As a consequence, most of the procedures undertaken to enhance dental attractiveness with the exception, for example, of work such as bleaching that is limited to changing the shade of teeth, with no changes being made to form and function, including the replacement of any existing restorations and modifications to the adjacent soft tissues should be classified as esthetic dentistry.

A decision often has to be made either to work with the status quo and achieve a compromised result, or to carry out a complete rehabilitation. For the sake of completeness, two other terms also need to be considered: Dental decoration, including, for example, the bonding of a trinket or gemstone, possibly even a precious stone such as a diamond, typically to the labial surface of one or more upper anterior teeth Fig.

A dental decoration may be applied to cover a defect, such as. Dental mutilation, as undertaken in some primitive societies, albeit to enhance dental attractiveness in the eyes of the participants and their family members, friends and acquaintances, cannot be considered to be part of esthetic and cos- metic dentistry, nor to have any relationship with them.

Similarly, in present-day society, the mutilation and adornment of teeth Fig. Other forms of body art carried out in the mouth, such as tongue piercing Fig. Perhaps one of Fauchards most notable contributions, in particular in the field of prosthetic dentistry, was his work on the colouring and enamelling of denture bases.

His thoughts on colour and esthetics provided the foundations for subsequent developments in esthetic dentistry. Many of the ideals established and practised by Fauchard remain relevant today, nearly years after their introduction. Greene Vardiman Black, better known as G. Black the father of dentistry as practised in the 20th century was responsible for bringing dentistry into the modern world and putting it on a solid scientific foundation.

He is famously quoted as telling his students in The day is surely coming when we will be engaged in practicing preventive, rather than reparative dentistry and will so understand the etiology and pathology of dental caries that we will be able to combat its destructive and unsightly effects by systematic medication. The first porcelain crown systems, which preceded early direct tooth-coloured filling materials, were developed in the s by Drs M. Richmond and M.

Although these crown systems were a technological breakthrough at the time, they required the radical removal of coronal tissue, with devitalization of the tooth to be restored, and were ill-fitting and lacking in esthetic qualities.

Indeed, the completed crowns were typically considered to be unsightly. Also in the s there was the first known description of porcelain veneers, fixed in place with zinc phosphate cement. The esthetic qualities of these veneers, in common with the first porcelain crowns, were, at best, limited. Subsequent to the invention of the electric furnace and the development of porcelains fusing at low temperatures, Charles Henry Land came up with a transformational innovation.

Lands system for the provision of strong, esthetic porcelain jacket crowns was introduced in It revolutionized restorative dentistry at the time and is still used to this day, albeit in a greatly refined and modified form.

Between the early s and the s there were relatively few developments in esthetic dentistry, with the exception of advances in the esthetics of artificial teeth for dentures. Silicate cements were refined and marketed in a range of shades, and for the rich and famous, notably Hollywood film stars, various treat- ments became available that were the precursors to modern-day vital tooth bleaching, amongst other techniques.

The primary purpose of dentistry of the time was the treatment of pain and disease, including the replacement of teeth lost mainly as a consequence of caries and periodontal disease. In the s and s two major developments heralded a new era in esthetic dentistry: Rela- tively quickly thereafter, resin composite systems were introduced for the esthetic restoration of teeth. As an aside, it should be noted that Kramer and McLean published the first histological report on what is now termed a hybrid layer in Stemming from the initial work on the bonding of restorative materials to remaining tooth tissues, rapid developments in tooth-coloured restorative systems, notably the visible light-cured resin composites, and concurrent inno- vations in dentals materials science, including developments in porcelain fused to metal systems, there were many new opportunities for the provision of esthet- ically pleasing restorative dentistry in the late s and early s.

With the subsequent introduction of many other systems and techniques, including resin-bonded ceramic veneers and numerous other ceramic systems, dentine adhesives, innovations in osseointegration and implant dentistry, and new inter- ests in colour science in dentistry, as well as growing patient interest and expec- tations in respect of dental appearance, esthetic dentistry, as we know it today, began to emerge and evolve.

The profession now takes for granted a plethora of systems that may find application in the provision of esthetic dentistry, and remains anxious to see further developments and innovations that will facilitate easier, faster and better-quality esthetic dentistry, with increased patient accept- ance and longevity.

The smile It was not until the s and s that attention turned to defining and describing the dental smile, as forms the basis of present-day esthetic dentistry. As in most, if not all, procedures in dentistry, success in the management of the dental smile involves careful assessment and diagnosis, the application of all relevant art and science, tempered by clinical experience and acumen, and the ability to communicate effectively with patients to understand their concerns and wishes fully.

Although esthetically pleasing smiles include many common features and characteristics, no two smiles are the same. The wrong smile, albeit classical and ideal, in the wrong patient not only may look bizarre, but also may have adverse psychological and other effects on the patient. Conceiving, plan- ning and providing the right, esthetically pleasing smile for a patient is the challenge and professional fulfilment of high-quality esthetic dentistry.

Whats in a smile? There are many interactive components to an attractive smile: The scientific and artistic principles that link all these features together are often collectively referred to as the principles of smile design.

The successful application of smile design in the practice of esthetic dentistry is not, however, limited to optimizing the health, appearance, relationship and function of the oralfacial tissues and structures; it also involves consideration of the attitudes, motivation, expectations and personality of the patient, and in some cases the attitudes and expectations of the patients partner and family, and possibly even friends and acquaintances.

Giving an individual a smile that is beautiful, makes the patient happy, and encourages others to smile, is what esthetic dentistry should aim to achieve. The golden proportion If we delve into the belief that dental esthetics is both an art and a science, then we have to ask the question: While the age-old adage that beauty is in the eye of the beholder remains true, there is evidence that our perceptions of beauty are determined by a range of factors, including acquired, cultural and family values.

One of the earliest theories considered to underpin the science of beauty is that of the Golden Proportion a ratio of 1: Luca Pacioli and Leonardo da Vinci are held responsible for introducing the concept of Golden Proportion into art.

One of da Vincis best-known draw- ings, the Vitruvian Man Fig. The mans height is equal to the combined length of his arms, which, together with the extended legs, touch the circumference of the sur- rounding circle. The ratio of the length of the sides of the square formed by the hands and feet to the radius of the circle is 1: Biologists, botanists and other scientists have observed the Golden Proportion in many diverse natural forms,5 including flowers, sea creatures such as the nautilus shell Fig.

Natural structures that conform to the Golden Proportion, including faces and smiles, are invariably perceived to be esthetically pleasing.

Lombardi was one of the first to propose the use of the Golden Proportion in relation to dentistry. Ricketts developed Golden Proportion callipers to be used to evaluate and develop desirable ratios between the various elements of the face and dentition. It is widely accepted, however, that the use of Golden Proportion cal- lipers provides a useful guide rather than constituting any form of objective measurement in the assessment and planning of esthetic appearance.

Symmetry Symmetry is also important in perceptions of beauty; it suggests balance and the absence of discrepancies in growth and development. Edmund Burke, an 18th-century philosopher, highlighted the difference between classical beauty that which has symmetry and obeys the Golden Proportion , and the sublime art, a product of nature, or architecture that lacks symmetry and does not adhere to classical standards , indicating that the sublime may by no means be ugly, having its own esthetics and appeal.

Many beautiful faces and attractive smiles may be found to lack symmetry and not to conform to the Golden Propor- tion, but faces and smiles that are symmetrical and do conform to the Golden Proportion tend to be more esthetically pleasing.

Physiognomy In Western and Eastern cultures there is a strong tendency to apply physiognomy judgement. In recreating damaged faces and smiles, with no pictures or other likenesses of the face to use as a reference, the art is to develop a face and a smile that are considered to match the character and personal- ity of the patient. Such stereotyping can, however, lead to patient dissatisfaction, irrespective of the quality of the dental care provided.

The patient, together with family, friends and colleagues, must identify and be comfortable with the appearance created. A smile can be judged to be, amongst other things, friendly, seductive, reassuring, young, old or fake.

Planning and creating the smile that best suits the patient, let alone having certain patients agree and consent to the provi- sion of what is considered by the clinician and possibly others to be the most appro- priate smile, can be one of the greatest challenges in esthetic dentistry.

Ultimately, the decision rests with the patient, but the clinician must ensure that he or she is cognizant of all the relevant information and possible consequences before reaching a decision. Ethnic and cultural considerations To be successful in the provision of esthetic dentistry to patients of various ethnici- ties and cultural backgrounds, it is important to understand and be sensitive to different ethnic and cultural esthetic values and perceptions of beauty.

What is attrac- tive to patients of one culture or ethnic group may be unattractive, if not ugly, to others. As with physiognomy, stereotyping must be avoided. Such pitfalls may be best circumvented by spending time attempting to understand and appreciate what a patient really wants by way of treatment outcomes. Cases in which an individual wishes to change his or her dental appearance to look more like someone of a different ethnic or cultural group require special consideration and care.

Hollywood smiles In the Americas, a bright, white, wide, even, symmetrical smile is typically con- sidered to signify wealth, vitality, health and success. In Europe, and increas- ingly in other parts of the world, more emphasis is placed on the natural smile, leading Europeans and others of similar inclination to classify the preferred smile in the Americas as the Hollywood smile. It is interesting to note how the media represent both views: Esthetic perceptions and values vary greatly within and between different cul- tures and societies.

Perhaps this is best expressed by the Scottish philosopher Francis Hutcheson, who argued that beauty is unity in variety and variety in unity. Over time, many, including those who have contributed to this book, would hope that natural beauty, rather than some artificial construct of esthetics, might prevail, with minimal intervention approaches being applied, where indicated clinically, to achieve long-lasting and esthetically pleasing smiles.

Concluding remarks Prior to embarking on a journey to understand and appreciate the many different aspects of dental esthetics better, you may wish to reflect on the explanations and definitions of esthetics and the following eloquent and apposite quotation attributed to St Francis of Assisi: He who works with his hands is a labourer; he who works with his hands and his head is a craftsman; he who works with his hands and his head and his heart is an artist.

In the context of clinical practice, this quotation could possibly be expanded by adding and he who works with his hands, head and heart in the best interests of his patients is a true clinical professional.

Finally, in sojourning in the complex field of esthetic dentistry, it is best to remember, as stated in Sullivans pervading law, that in all true manifestations of the head, heart and soul, form ever follows function.

References 1. Winkler D, Orloff J. Ethics behind esthetics: Nordic Dentistry Yearbook. Quintessence; Touyz LZ. Cosmetic or esthetic dentistry? Quintessence Int ; Alterations in the staining reaction of dentine resulting from a constituent of a new self-polymerising resin.

Br Dent J ; Lombardi RE. The principles of visual perception and their clinical application to dental esthetics. J Prosthet Dent ; Hassin R, Trope Y. Facing faces: J Pers Soc Psychol ; Sullivan LH. The tall office building artistically considered.

Lippincotts Magazine ; March: Introduction The first time you compromise your ethics is always the hardest. After that it gets easier. Ewing, Dallas. It doesnt make a difference whether you are in business, or in politics, or in law [or in dentistry] ethics is ethics, is ethics, I still remember hearing Michael Josephson say in a National Public Radio broadcast some time in the s.

Josephson, the founder of the Joseph and Edna Institute of Ethics, and a frequent media commentator on ethics in the United States, was discussing ethics in the workplace.

The understanding of ethics as it applies to dentistry is fundamental to the professions vitality, and a vital cog in the continuance of the unwritten bond we have with the general public.

The professions autonomy is dependent on public trust a trust that is now under challenge, particularly in the fields of esthetic and cosmetic dentistry. What is ethics? Ethics is the study of what is good and what is bad, what is right and what is wrong. One can wonder if ethics can be taught or if it is somehow an innate standard of moral behaviour, drilled into us or not from our early years by our families and members of the wider community.

Growing up, it mortified me to hear of schoolmates who shoplifted for fun. Now, that did not necessarily make me a better person; it just made me believe I had better guidance from my parents. So, can we guide our dental students towards what is right and discour- age them from taking advantage of vulnerable patients for personal gain? Can we hope that dental manufacturers will provide us with the best products for our patients, or will they compromise their ethical standards in order to garner the highest profits at our expense, to the detriment of their ultimate customer the patient?

Dare we believe that our colleagues will refuse to mislead the public with unethical advertising or will they use the medium dishonestly in the pursuit of financial reward? Will the truth become the preserve of a minority while trust in dental professionals continues its downward spiral?

One of our most prolific writers on dental ethics, David Chambers, editor of the Journal of the American College of Dentists, believes that individuals cannot be con- sidered ethical in any meaningful sense unless they are part of a community:.

By analogy, dentists who materially mislead patients during informed consent, who upgrade dental insurance claims, and who practice so close to the stand- ard of care that mishaps are expected are all no longer professional. What makes their crime so heinous is that they continue to hold themselves out as belonging to the profession, while they operate outside it. Unethical practitioners claim the advantages of being a professional, while simultaneously damaging the credit the public extends to all professionals.

Unethical behavior means cheating in the game of building a community. Cheating Cheating is endemic in todays world. We are bombarded by major ethical break- downs in journalism and politics, such as the phone-hacking scandal in the UK, as well as other, more minor, travesties.

The pushing of the competitive enve- lope in the media phone-hacking cases eventually led to the closure of one of the UKs best-known newspapers the News of the World owned by Australian media giant Rupert Murdoch. At the time of writing, we are still awaiting the outcome of a number of criminal trials arising from the police investigations. In recent years we have also seen journalists such as Jayson Blair resign from prestigious publications like the New York Times for making up stories. We have witnessed all kinds of fakery being pushed on the Internet.

Some of our sports stars have been discredited, even Tour de France winners Floyd Landis and the once legendary Lance Armstrong, the latter eventually admitting to blood doping and the use of other illegal pharmaceutical supplements, subsequent to being stripped of his titles. Big Pharma has paid a radio host for giving their drug marketing lectures, a fact he did not disclose to listeners of his show.

Research scandals Perhaps some of the more serious instances of cheating in the healthcare world have involved the fudging of data, or their outright invention, in some of our scientific publications. A paper may not be exposed as flawed until it is with- drawn or retracted, too late in many cases to assuage the damage already done. Parents all over the world withheld vaccinations from their children based on the study of British medical researcher, Andrew Wakefield; in an article pub- lished in the prestigious Lancet, Wakefield claimed a possible link between the measles, mumps and rubella MMR vaccine and autism.

A General Medical Council inquiry found Wakefield guilty of serious professional misconduct on several charges relating to his research and struck him off.

The Lancet retracted the paper. How many children are now living with a disability or even died as a result of Wakefields actions? Then there was the study conducted by the Norwegian, Jon Sudb, who con- cluded that anti-inflammatory drugs reduce the risk of oral cancer; it emerged that his conclusions were based on fabricated data.

Equally seriously, perhaps, the Chronicle of Higher Education reports that many images used in research studies are faked, including those appearing in one paper on the role of cell growth in diabetes.

Big Pharma misconduct In , we saw the worlds largest drug company, Pfizer, plead guilty in court to criminal charges that it broke the law in marketing the drug Bextra. Pharmaceutical companies have vast sums of money riding on the outcome of clinical trials and there must be a real temptation to delay those that do not appear to be producing the desired results, to cherry-pick or massage data, and to send out stories based on incomplete findings.

Big Pharma has also, on occasion, buried results that fail to show its products in the best light. Pharmaceutical companies have been known to sue to prevent researchers from presenting or publishing data not seen as favourable. Ethics and legality The examples above are but a grain of sand in the desert of alleged and proven fraud and cheating through which we are struggling today. When a cheating scandal hit several US dental schools in and later, in one situation involv- ing half of the senior class of a large institution, it became difficult to see where it all would end.

Harvard University has recently announced that over a hundred students have been investigated for cheating. Will our children grow up thinking that this is simply normal behaviour? As Chambers says, We have reached a critical mass of chronic low-grade cheating. In his excellent book, Profit with Honor, Daniel Yankelovich notes that, Every viable society depends on ethical norms to guide and restrain conduct. For most forms of conduct, norms are far more important than legal constraints.

The law only sets minimal standards of conduct. Yankelovich continues, one can act legally and still not act ethically. Codes of ethical conduct in dentistry Most countries have ethical codes or standards of professional conduct for dental practice. These guidelines, such as the American Dental Association ADA Prin- ciples of Ethics and Code of Professional Conduct, outline the principles that an ethical practitioner of dentistry is expected to uphold.

In return, the profession makes a commitment that its members will adhere to high standards of ethical conduct. In essence, the ADA code is a written expression of the duties and obligations inherent in the implied contract between the dental profession and members of society.

This implied contract supports the autonomy that is granted to the pro- fession by the public. These five principles are all intertwined. However, they are guidelines only, and in practice there is nothing that the ADA, or any other body not involved with issuing the licence to practise, can do in instances of violation, other than expel- ling a member from the organization.

Patient autonomy The dentist has a duty to respect the patients right to self-determination and con- fidentiality. The situation today is very different. Patients are better educated about dental health and expect, and in most cases receive, multiple options for treatment, laid out by the dentist in an open and honest discus- sion.

Dentistry pdf esthetic

There are, however, clear examples in the published literature of induced consent rather than informed consent. Guiding choice in this way, for any reason other than a genuine concern for the long-term interests of the patient, is in violation of the first principle of patient autonomy. Non-maleficence The second principle is non-maleficence doing no harm.

Dentists have a clear duty to heal, not harm, the patient guarding the patients welfare, recognizing the scope of their own skills and knowledge, and seeking advice or referring the patient to a specialist or another practitioner if the problem lies outside their area of expertise. If a patient is denied the appropriate information about, say, an elective esthetic procedure and consents to significant tooth structure removal to improve their smile when another less invasive procedure would have suf- ficed, that patient has been harmed, particularly in the long term.

As Bader and Shugars put it, An implicit, if not explicit, assumption covering any treatment is that the benefits of the treatment will, or at least are likely to, outweigh any negative consequences of the treatment in short, that treatment is better than no treatment. Beneficence The third principle is one of beneficence doing good. Professionals have a duty to act for the benefit of others and to promote the patients welfare.

As a treating dentist, one should always consider whether the patient will be better off after treatment than if nothing had been done. The British author Martin Kelleher has written eloquently about this serious problem from the European perspective. Tongue-in-cheek, he invented the terms hyperenamelosis to describe the imagi- nary condition of a patient with too much enamel to justify the gross over- removal of enamel seen in many cosmetic treatments and porcelain deficiency disease to describe the imaginary condition of a patient who thus requires the brutal removal of natural enamel so that it can be replaced with porcelain.

This phenomenon has been documented by me over the years. Justice The fourth principle is justice or fairness. Professionals have a duty to be fair in their discussions with patients and in their actions.

If dentists do not put the patients interests first, they are not fulfilling this obligation. This principle is most frequently violated in the form of advertising and treatment planning, where the dentists willingness to push the ethical boundaries of propriety can lead to the promotion of short-term profit rather than long-term health.

Veracity The fifth and final principle is veracity or truthfulness, which applies to any communication between dentist and patient. Violations are most common in advertising and can be found en masse on dentists websites. Dentists may attempt to promote unproven science, such as that of neuromuscular den- tistry, which some are said to favour as a justification for carrying out unneces- sary full mouth reconstruction.

Or they may argue against the use of amalgam for restorative dentistry, in an effort to persuade patients to have all their old amalgam alloy restorations replaced. Such statements are in direct violation of the ADA position statement on the use of dental amalgam.

And while dental amalgam has lasted much longer than I incorrectly predicted in the early s,25 there is no justification for removing otherwise adequate amalgam restorations, other than in a very small minority of allergic patients. Ethics in esthetic dentistry In , Michael Buonocore published the first article on the etching of enamel.

In restorative dentistry, etching of enamel heralded the arrival of mini- mally invasive preparations, determined by the extent of caries and not by the principles of G. Black Fig. The sealant at 5 years old. The same sealant, now 15 years old.

It would be ethically inappropriate to carry out a conventional class I G. Black cavity preparation outline form in dotted lines on a molar with incipient caries in two confined areas such as this when a conservative preparation removing only the carious tooth structure can be used Preventive Resin Restoration.

Indeed, Buonocores original research may be the key that opened the door to the modern practice of esthetic dentistry, as well as other clinical tech- niques that utilize the acid etch technique, especially, perhaps, in orthodontics. With these changes have come opportunities. On the positive side, dentists now have the ability to provide conservative options to address a patients esthetic concerns.

For example, whereas it used to be necessary, just a few decades ago, to place a full crown or, in the case of children, a basket crown to repair a fractured central incisor, today a bonded composite resin can accomplish the same functional and esthetic task, while removing virtually no tooth structure Fig. On the negative side, there has been an upswing in over-treatment, pandering to some patients vanity. Lured to the surgery by glossy media images of that super-smile, such individuals are easy prey for the minority of dentists who threaten the ethical standards of the rest of the profession.

A minimally invasive treatment option may not be considered by the unethical dentist, or is quietly discouraged. This can be devastating to young patients and their parents.

It is ethically appropriate to provide informed consent for all treatment options. The fracture can be quickly and conservatively treated with the acid-etch technique and composite resins. Conservation of tooth structure is ethically appropriate. Greed and vanity can be powerful motivators. Over-treatment We must remember that the vast majority of dental practitioners serve the public in an ethical manner.

Most enter the profession with a sense of wanting to help people, whether by relief of pain or correction of a life-affecting cosmetic concern. Some, however, violate their ethical obligations by pursuing the path to riches via unethical choices and taking advantage of their sometimes gullible patients in a most egregious manner. Dentists are sometimes placed in an uncomfortable position. They have one foot in the world of healer and provider of care, and the other in the commercial world.

While many hold salaried positions and have made no personal financial investment in the surgery or in costly equipment and supplies, others have put in large amounts of money and must cover these costs from the remuneration they receive from patients. Without a sufficient flow of income the practice would go bankrupt, and patients in the neighbourhood would lose their surgery. Running a dental practice like a business is, therefore, a necessary evil to some degree. Chambers notes:.

Dental practice is inherently a profession only; it is a business in an accidental and derivative sense Quality in dentistry should be determined by what it means to practice oral health care and not by looking for good economic returns in pandering to the wants of a small segment of patients. It must be clear that the ethical standards relating to a patients treatment cannot take into account the business needs of the practitioner.

Connected to this is how the dentist chooses to advertise the practice. Ethical standards governing health- care promotion are frequently violated by those who would take advantage of patients for financial gain. This leads to appearance being put before health, anec- dote before evidence, and profit before public interest. Those who follow such a path are putting the autonomy of the dental profession at risk.

Neuromuscular dentistry Neuromuscular dentistry is an approach that is promoted by fringe elements of the profession and is often used, in my opinion, as a means to justify full-mouth reconstruction. Such actions make the evidence-based scientific community react with shock and dismay. No dental school of which I am aware teaches neuromuscular dentistry as part of the dental curriculum, let alone as a recommended treatment. No legitimate expert in oral pain, prosthodontics or temporomandibular joint science that I have ever asked for an opinion has indicated that there is any scientific method behind neuromuscular dentistry.

A recent page textbook on the subject of temporomandibular dysfunction gives it not a single line. So, it really puzzles me how certain colleagues can base their work on this disputed practice. However, the Las Vegas Institute LVI , a for-profit, private continuing dental education centre, makes claims of changing lives while placing neuromuscular dentistry at the core of its programme.

It uses terms like graduates, alumni and faculty, which invite comparisons with universities, and describes itself as a postgraduate institute, but the requirements for gaining a qualification are far fewer than those demanded by a university. The programme has been exported globally and dentists in many countries now claim affiliation. A significant pro- portion of the LVI programme is focused around how to increase office produc- tivity.

Thus neuromuscular dentistry is presented as a substantial source of income. It describes itself and its mother organization as world-renowned, yet the majority of the full-time faculty listed on their website as of September seem to lack any recognized academic postgraduate qualifications beyond their primary dental degrees. As has been noted on their website over the years, It wont be long before LVIM after the name of a doctor will indicate superior skills and training to the public.

What would the ADA code say in such a case? The use of abbreviations to des- ignate credentials shall be avoided when such use would lead the reasonable person to believe that the designation represents a quality assured professional qualification or academic degree, when such is not the case.

One could write a whole book on the over-treatment seen in the pages of dental magazines over the past years. It is unfortunate that the success of one very fine minimally invasive procedure, that of porcelain veneers, has been turned to the benefit of some clinicians in the name of esthetic dentistry. Done properly, por- celain veneers are highly successful in terms of retention and esthetics, but even minimally invasive porcelain veneers may be classed as over-treatment when they are placed in situations where simple bonding composite resin would suffice.

Indeed, any treatment used where a less invasive option is available can be regarded as over-treatment. One particularly troubling example illustrates this ethical minefield. It involves the treatment of a young lady in her early twenties, judging from her photo- graph , whose only esthetic issue was a discoloured proximal-incisal class IV composite resin on her maxillary left central incisor.

The rest of her teeth were impeccable and restoration-free. The dentist, who brazenly entitled the paper Conservative Elective Porcelain Veneers,13 proceeded to cut into and treat no fewer than eight teeth for maxillary veneers from central incisors to first bicuspids. Each veneer, of course, adds to the cost of the procedure, removes enamel from a virgin tooth, and creates a restoration that will require constant follow-up and possible replacement in future decades.

The author puts the onus on the young patient, saying:. After discussing the options of vital bleaching and direct bonding with composite resin or porcelain veneers, the patient opted for porcelain veneers because she [my italics] considered them the longest lasting, most durable, and most stain- resistant option. It was still possible, however, to maintain most of her natural tooth structure for the future by using stacked porcelain and performing minimal preparation of the specific teeth involved.

The purpose of the seven veneers that performed no useful function was presum- ably the result of the domino effect wanting the neighbouring teeth to match the one tooth that did need treatment. Esthetic improvement using composite resin would have been minimally invasive and equally attractive, albeit lacking the longevity of porcelain. So was this informed or induced consent?

I do not know the details of the advice given to the patient, but I find it hard to believe that any normal human being, presented with the pros and cons, would choose the more invasive and much more costly option.

If there is no such benefit, it is difficult to see any advantage, other than an economic one for the dentist. If that was the motivation, it would, of course, have been unethical. Ethics of advertising in dentistry Advertising serves a useful purpose for consumers, providing information about individual businesses that offer services the public may wish to purchase.

One could argue that the more information is available to patients, the better pre- pared they will be to make what is, in reality, a purchasing decision about their health. So, why should they not have information about the training and skill level of the clinician they are considering using and which treatment option they should choose? Isnt that a part of informed consent? Certainly, the US legal system has recognized that advertising can play a large role in providing the information patients may need.

The problem comes when advertising becomes deceptive or unfair, such that the consumer is faced with a false choice.

Ever since the US Federal Trade Commission FTC started to break down the self-imposed restrictions on advertising by dentists brought in by the various State Boards of Dentistry , the role of advertising in the profession has been fraught with emotional and political issues. On one side, the State Boards gener- ally made up of a large majority of practising dentists are trying to protect the interests of their constituency. On the other, the FTC and the courts aim to protect the public from the potential self-interested actions of some State Boards and some dentists, who may choose to walk the fine line between ethical and unethical advertising.

The promotion of competition is also a goal of advertising and of the FTC, while the profession of dentistry prides itself on collegiality. In an article called Ethics and Advertising. Geoffrey Klempner wrote that three charges can be levelled against advertisers They sell us dreams; entice us into confusing dreams with reality.

They pander to our desires for things that are bad for us. They manipulate us into wanting things that we dont really need. Would we wish any of these characteristics to be associated with our profession?

I think the answer is very clearly, No! The battle over advertising in the United States was fought and lost by its oppo- nents when the FTC ruled that dentists should be allowed to advertise, providing the advertisement is not false or deceptive. State Boards then tried to regulate but found that the bar had been placed quite low. Advertisements are permitted that are self-aggrandising and unprofessional.

They lure consumers by appeal- ing to their vanity. Some manipulate patients by making them want something that they do not need, and that in many cases is harmful to their long-term oral health.

Yet its all still legal. In the early days of dentistry, advertising took the form of harmless self- promotion on business cards and free give-aways imprinted with the name of the practice or dentist.

There followed a long period of essentially minimal advertising before we reached the point we are at today, most dentists carrying out some form of practice information delivery. Examples of Victorian-era trade cards can be seen in Figures 2. These date from circa and some depict claims that would be considered. Courtesy of Dr Theodore P. Croll, Doylestown, PA. Another card talks with apparent hope of pain- less extracting while perhaps coming closer to the truth with Decay removed and fillings inserted with the least pain possible.

Apart from word of mouth, such cards were the only way to advertise ones services during this period. While dentists no longer produce trade cards, I have seen advertisements for dentists in the present day that employ questionable professional standards, such as those printed on the back of grocery store receipts or on the sides of an advertising van Fig.

Today, the most popular form of advertising is surely a well-designed and well- managed website. However, many exaggerate a dentists cre- dentials and are misleading and deceptive. It seems there is a blurring of the for- merly sharp line between a profession and a trade, at least in terms of advertising standards, and this is especially noticeable in glossy magazines sporting advertise- ments for cosmetic dental spas placed between those touting tummy tucks and tattoo artists.

Is that really how we wish the public to visualize our profession? Promoting a practice in this manner does nothing to enhance the image of the profession in the public mind. Trust At the core of ethical advertising for the dental professional lie three issues, the first of which is trust.

Trust is the most fundamental building block of any practice and should be the basis on which the relationship between dentist and patient rests. Without it, an adversarial relationship, such as that seen during the purchase of a car, for example, is set up and there can rarely be a truly happy outcome as each side tries to gain an advantage.

The buyer wants the best possible car for the lowest possible price, while the seller is trying to pocket as much money as he or she can. It is trust that enables the dentist to complete the best treatment plan for the patient, who, in turn, is happy to receive such treatment, trusting that it has been delivered with their best interests in mind.

And yet the adversarial relation- ship is also creeping into dental practice, as many office managers and staff are trained to up-sell additional treatments, or the patient tries to bargain for extra services to be included. This is the inevitable outcome of advertising for example, free teeth whitening with examination and has been going on since the early trade cards No charge for Extracting when Teeth are ordered see Fig.

This can only lead to an erosion of our pro- fessional autonomy.

Misleading claims After trust comes the responsibility to refrain from making claims that can mislead an extremely problematic area.

Often the intent seems to be to mislead the patient deceptive advertising into believing that Dr X is better than any other dentist at a particular procedure or in a particular community Fig. This leads us into a grey area where the FTC would probably rule that it is accept- able to say that one is good, but not to draw comparisons with colleagues that are impossible to prove. Any attempt to claim superiority is fraught with colle- gial issues and is certainly unprofessional and, to my mind, unethical.

Titles The third core component of ethical advertising is to stay within ones area of professional competence and abilities, and not to imply that one is a specialist if not qualified to do so.

Unfortunately, in a rush to follow the business principles that really should not be applied to a healthcare profession, many colleagues stray over this ethical boundary. The unsuspecting public is not familiar with the accredited specialty areas and it is easy to deceive by exaggeration. Saying one is better than ones colleagues is unprofessional and shows a lack of collegiality. The key is to ask the question: Is a member of the general public likely to be misled into thinking that the dentist in question is a specialist in the area advertised?

If so, the advertise- ment, in the form of the practice name, is, in my view, unethical. Being truthful and honest The onus is on dentists to present their skills and qualifications truthfully and honestly, and not even to hint at any claim that might stray into questionable ethical territory.

Subjective claims concerning the quality of the services pro- vided or the relative quality of the treatment should be avoided. For example, many practices try to set themselves apart by claiming to provide advanced dentistry. And one has only to search the Web to find general practitioners who call themselves the best cosmetic dentist.

How do we, or they, know they are the best? And what are your colleagues down the road, also general dentists, going to call their practice? While it may be true that the level and quality of care provided in any particular surgery is of a higher standard than that of others in the vicinity, how can that be proved without objective evidence?

In its policy on advertising, the American College of Dentists ACD puts the onus on the public to verify the claim, noting in a list of points that an advertise- ment is deceptive if it contain[s] a representation or implication regarding the quality of dental services which would suggest unique or general superiority to other practitioners which are not susceptible to reasonable verification by the public.

In order to properly serve the public, dentists should represent themselves in a manner that contributes to the esteem of the profession. Dentists should not misrepresent their training and competence in any way that would be false or misleading in any material respect Although any dentist may advertise, no dentist shall advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.

Qualifications and degrees The use of letters after ones name that represent unearned or non-health degrees is another way in which we can potentially mislead the public. Thus MD is acceptable, but MA would only be acceptable if dentally or medically related. Similar rules exist elsewhere in the world. The reasons are obvious:. The use of a non-health degree in an announcement to the public may be a repre- sentation which is misleading because the public is likely to assume that any degree announced is related to the qualifications of the dentist as a practitioner.

It should almost go without saying that one must only utilize degrees profes- sionally awarded in healthcare, in a healthcare practice, and not in diploma mills. Some years ago, a regular contributor to the Journal of the American Dental Association listed a Masters degree after his name and dental degree on the title page.

This MBA suddenly disappeared when its legitimacy was ques- tioned but the publications continued. The degree had been purchased from a diploma mill and seems to have been used to bolster the authors qualifications and ego. It appears that the transgression, major as it was, was not serious enough for the journal to consider losing a potential source of a column. The American College of Dentists The ACD, a highly respected fellowship organization, has been at the forefront of promoting ethical standards in the profession.

Its position on advertising is straightforward: The College does, however, recognize that advertising is here to stay and, when properly done may help people to better understand the dental care available to them and how to obtain that care. The ACD states that advertising should be designed to increase public confidence in the dental profession and in the indi- vidual practitioner, and should not be misleading or false in any way.

In particu- lar, advertising should avoid creating any false expectations for a favourable treatment outcome and should not primarily target a lay persons fears. Advertising in dentistry has its good and bad points. On the plus side, dentists can get their message across, and patients can benefit from extra information concern- ing the dentists education, training and interests.

On the minus side, advertise- ments can make the profession look like all the trades that advertise in a non-professional manner. Advertising should be professional, honest, informational and accu- rate, so as to convey the sense of a profession communicating its goals of service to the general public. Anything else chips away at the unwritten laws of trust and autonomy, hard earned by the generations of colleagues that went before us. Dental publishing While much has been noted about the dishonest and unethical researchers who fudge, manipulate or even invent data, there is also a trend that attempts to make pure hype and sales-oriented publications look and feel like scientific reports.

Authors throw in a few references to make an article look scientific and format the report just like a peer-reviewed paper to disguise its real intent. Also, many papers in the trade magazines I refuse to call them journals are ghost- written by dental product manufacturing companies. Serial endorsers are paid to add their names to a paper that they have not written or participated in, other than to approve the content.

Another source of dental advertising, particularly for esthetic dentistry and implant surgery, is airline magazines. Certain of the advertisements are spon- sored by some of the most self-promotional dentists you will find anywhere. Each one appears to be the only cosmetic or esthetic dentist with real credentials.

Since there is no such specialty as cosmetic or esthetic dentistry, what are these real credentials? Does this mean that everyone else has fake ones? This sort of advertisement certainly implies that impossible scenario. Plagiarism Plagiarism and the stretching of one study into multiple publications are sig- nificant ethical problems in dental publishing today. Removal of plaque, tartar, and the margins of the restoration and could result in parts of bacterial toxins from root surfaces can be carried out the restoration being torn off and the restoration, with its manually or mechanically.

After the first examination, which is executed by the dentist A simple modification of this scaling technique is to move i n collaboration with the dental hygenist, an individual the scaler along and parallel to the restoration margin.

By treatment plan is drawn up. The plan is developed for the doing so, less damage is caused in the marginal area. Scaling patient, based on the seriousness and type of the patient's and root planing at the margin of bonded restorations must disease. Gracey curets Manual Scaling -Working direction: Manual scaling performed using metal curets does not dam- age a bonded restoration to the same extent as ultrasonic scales, assuming that the therapist takes certain precau- tions.

These precautions include first identifying the margins of the restoration. Dentists and the dental hygienists have 15 Using curets on nonrestored teeth The usual curet technique i nvolves the curet being inserted i nto the sulcus and pulled in a coronal direction, with the cutting edge along the tooth surface. The tooth surface can thus be scaled and planed. This action can only be recommended for nonrestored teeth, as other- wise there is a danger of restora- tion margins being damaged.

This pre- vents damage to the margins of the restorations. The risk Many dentists and dental hygienists use such scalers, since of injurying a restoration margin decreases. At the same they can remove calculus more quickly. At the same time, time, it is possible to check and detect secondary caries le- therapeutic irrigation of the sulcus can be performed with sions at an early stage.

If handled improperly, ultrasonic devices can damage all Air Polishing Devices types of restorations. They can chip ceramics, cause abra- sion of composites, increase the surface roughness of all Discolorations are usually removed by polishing, conducted restorations, and destroy the adhesive joint between tooth with rotating instruments, brushes, and rubber cups.

Addi- and restoration. Because of these drawbacks, sonic and tionally, air-powered abrasive devices are also available. The ultrasonic instruments should be avoided in patients who air polishing abrasive appliances CaviJet, ProphyJet, Air- have several bonded restorations.

If necessary, however, the Flow, and AirScaler are very efficient at eliminating dark appliances should be used with great caution, and margins stains in concave tooth surfaces and in areas that are diffi- of tooth-colored restorations should not be touched. However, their abrasive power prohibits them from being used near restorations of any types. Their use Consequently, it is necessary to inform patients with aes- should be exclusively restricted to natural, unfilled tooth thetic restorations that they should have their teeth cleaned surfaces.

If the patient visits the practice at shorter recall i ntervals, less tartar will accumulate and, consequently, less aggressive methods are needed to remove it. Thus, manual 17 Ultrasonic devices and composites This composite surface has been destroyed by an ultrasonic de- vice.

The result is discoloration and accelerated degradation of the restoration. Professional Oral Hygiene 13 Polishing Teeth Fluoride Treatments The best method of polishing tooth surfaces is with rotating At each recall, the patient's teeth should be fluoride treated. It should be noted that For this purpose the dental hygienist uses stannous, and the prophylactic pastes to be used should have low abrasiv- sodium fluorides. Stannous fluorides should not be used ity. Any rubber cups that are used should be made of a very with tooth-colored restorations because they can etch their soft, low abrasive material.

Many of the relatively hard rub- surfaces. The problem with such etching is especially pro- ber cups and most commercial prophylactic pastes are too nounced with ceramic surfaces. If an IPS Empress veneer abrasive for composite surfaces and resin cement margins. Finishing strips and disks must also solved.

Therefore, as a general rule, neutral sodium fluorides be used with great caution. Since, ideally, a good composite restoration is invisible, the Recommended fluorides: Abrasion of the ceramic surface using air abrasive equipment.

Abrasion of a microfilled composite surface with a Prophy- Jet. Patients should be informed that gel toothpastes to perform oral hygiene at home. Given the quantity of are less abrasive than pastes. A toothpaste with low abrasiv- products offered in drug stores, it may be difficult for ity should be used.

Often, pastes that make teeth white are patients to select the right toothpaste and toothbrush for more abrasive and should therefore be avoided. Toothpastes their home care. Colgate Gel is an example of a gel tooth- Toothbrushes paste that has a low abrasivity and contains sodium fluo- Patients with many tooth-colored restorations must use ride.

The toothbrush can easily abrade composite restorations in particular. Mouthwashes Many mouthwashes have a very high alcohol content. The Some patients have difficulties with plaque control and alcohol can soften resins and after some time they can cause therefore need to be recalled more frequently.

Pdf esthetic dentistry

Therefore, nonalcoholic prod- ucts should be used. If patients have problems with their oral hygiene, it may be helpful to recommend an electric toothbrush. Electric tooth- Generally, two groups of mouthwash are recommended: Tooth- pastes are available as pastes or gels.

Most toothpastes 21 Etched ceramic surface This ceramic surface was treated with an amine fluoride gel. Amine fluoride and stanuous fluoride with a very low pH value are pres- ent in many toothpastes and prophylactic pastes. A sodium fluoride toothpaste with neutral pH value should preferably be used on ceramic restorations. The dentist or dental practice staff must give clear advice to patients with aesthetic restorations on how to choose suitable oral hygiene products.

Oral Hygiene at Home 15 Mouthwashes containing chlorhexidine are not recom- Smokers mended. Chlorhexidine causes discoloration of the tooth Cigarette smoke leads to a pronounced discoloration of the surface. This discoloration increasingly appears at the bond- tooth surface, particularly of resin surfaces. Smokers should ed sites and on resin surfaces and is very difficult to remove. If mouth rinses containing chlorhexidine must be used, local application of a gel is recommended to minimize the Oral Habits discoloration.

Bruxism, chewing of ice cubes, and chronic biting on objects such as toothpicks, fountain pens, etc. The patient must be made aware of this. Many patients use dental floss, proxabrushes, and tooth- picks. The use of dental floss is usually completely harmless If the patient cannot break these habits, damage can occur if the patient has been taught a proper technique by the not only to natural dentition, but also to any restorations.

The use of toothpicks is not recommended. The patient should be informed, verbally and then in writ- An oral irrigator is quite safe, as long as no chemicals are ing, of the necessity of attending recall sessions at the prac- used that discolor or dissolve resin surfaces. Diet The patient should receive nutritional advice including a list of foods that often cause tooth surface discolorations or dis- solve ceramic surfaces.

Patients will only rarely change their diet. They should, nevertheless, know which nutritional parameters may change the color of tooth surfaces, particu- larly resin surfaces or cement joints.

Many patients with high aesthetic claims show pronounced abrasive defects. A suitable power tooth- brush can prevent further pro- gression of such abrasive defects. Additionally, a low abrasive toothpaste with neutral pH value containing sodium fluoride should preferably be used.

Mouthwashes containing chlorhexidine should be avoided because of their strong tendency to stain the teeth. There are various reasons for taking photos in the dental -Photographs are very helpful when used for both patient office: Photographs document what can be achieved with modern dentistry.

They make it possiblbe to demonstrate a planned treatment to the patient. It is particularly con- -Dentists document their work and monitor their skills. A satisfied patient will recruit and the dental laboratory. Accompanying photographs new patients. Excellence is and will remain the best adver- greatly facilitate the work of the dental technician. The tisement for your practice.

What, after all, is marketing? There is about it. A good illustra- -Photographs are also helpful in communicating with tion of the situation helps the technician to succeed. But it can also be extremely helpful to have good photographs in cases involving legal disputes.

The photographer stands in front of the patient. A long, slightly conical mirror makes it possible to photograph the posterior teeth with occluded mandibular and maxillary teeth. Basics of Photography 19 Basics of Photography Modern mm cameras are constructed so that very limit- Lenses ed technical knowledge is needed for their use. Most of For intraoral photography the dentist uses a macro lens with these cameras have automatic film-speed detection, auto- a focal length of mm.

Such lenses produce a 1: Nevertheless, some basic photographic knowl- Type of Film edge is indispensable. One can select between slide or negative films. Slides can be used for lectures; prints are suitable for patient education Exposure Time and Aperture and communicating with laboratories. Exposure time and aperture size restrict the amount of light to which the film is exposed.

The photographer should set Film Speed the size of the aperture. The recom- enables a large depth of field. Therefore, the aperture should mended film speed for the case under discussion is ASA. However, this necessitates a sufficiently strong light source. As long as one Light Sources works within a reasonable range of magnification 1: Resolution The dentist chooses the desired magnification for example 1: The photo- graph is then taken.

Digital cameras are discussed on page In the case of con- For intraoral photography-macrophotography-SLR cam- ventional film systems, the choice is between: The APS film is exposed conventionally and then developed.

The In certain situation, instant cameras have their advantages, laboratory can later produce identical color prints by using for example, if neither an intraoral camera nor a digital the stored data. Furthermore, the APS system allows photos photo system is available and a quick photograph is needed with classic, wide, and panoramic picture formats.

If the dentist now takes a Polaroid photograph, Because of its highly developed periphery, it is possible to the patient can immediately be shown the importance of transfer the pictures stored on photographic film via a video the proposed treatment and the method of procedure can signal to a conventional TV screen for viewing.

The picture be explained. Polaroid pictures are also useful as a fast can also be transferred via a digital connection to an APS marketing instrument. The patient can receive "before and player, processed by the computer, and be printed out. This after" treatment photographs, which can be shown to fami- could affect the dentist's decision in favor of the APS when ly, friends, and colleagues.

Consequently, Polaroid pictures deciding which new camera equipment to buy. A mirror of optimal size is placed against the lower tooth arch.

The photographer stands behind the patient and photographs the patient's maxillary teeth using the mirror.

The mirror used for photographing the upper jaw is also used here and is placed against the upper tooth arch. The photographer stands in front of the patient and indirectly photographs the tooth arch of the lowerjaw using the mirror. For -Photographic film, for example, with standard ASA each brand, matching lenses macrolenses at focal lengths speed, of mm by companies such as Sigma, Tamron, Toni- -Cheek retractors and intraoral mirrors.

It is difficult to decide which is the system that allows for the use of a small aperture usually best system. It is probably still the best photographer who f in order to obtain maximum,depth of field with the takes the best photographs, regardless of the system!

However, relatively affordable appliances have been a film but on an electronic memory chip. These pictures can available for some time, whose pixel density still does not be processed further on personal computers or shown on compare with that of professional cameras.

The possibilities the monitor. Using a color printer such digitally recorded of the digital cameras are enormous. They are most suitable pictures can also be printed immediately. This converts the picture into electric impulses digital data. The image is stored in the memory chip, even when Resolution the camera is turned off. The image can be downloaded The CCD sensors of a digital camera process information, from the camera to the computer via a direct connection which is expressed in pixels.

The resolution is defined by between camera and PC. Using a driver and image process- the number of pixels per inch ppi or per centimeter ing software, usually included in the purchase of such a ppcm. The maximum picture format and the quality are camera, the photograph can be downloaded from the camera determined by the pixel number.

The quality of the picture Bit-depth depends on the pixel density of the chip, which determines The bit-depth defines the maximum number of colors that whether the digitized picture is in focus or true color. It not only determines the individual colors but also the hues and the shades of gray. If A few years ago, only professional photographers used the the gray is only divided into a few shades, an effect known new technology because digital cameras were very expen- as "posterization" will result.

Digital Camera Systems 23 Technical Prerequisites for Digital Photography No more than 8 bits shades of gray can be used by the For processing digital pictures in the dental practice the fol- usual computer programs during picture processing. Most lowing equipment is needed: They dismantle the analogous data into 10 bits , 12 bits , or 16 -Camera Figs. The computer then reduces the quantity of -PC with fast graphic card and a large RAM preferably i ncoming data. The most frequently used image-processing For dental applications, a "light" version is available.

However, the complexity of Lenses these programs should not be underestimated. The quality of a picture is also determined by the quality of -Color printers: Most color printers by Canon, HP, Citizen, the lens.

High-resolution, professional cameras with inter- or Lexmark are suitable for printing the pictures immedi- changeable lenses e. These modified nent of the entire digital system. Only powerful computers with a large RAM can process this amount of data. Normally, affordable digital compact cameras are sufficient for use in the dental practice. Figures 33 and 35 give an overview.

If there is Within a few years we will see the film as a medium for only a 1-hour development photo laboratory nearby, the photography become a relic from the early days of photog- conventional film is more advantageous. The decision to raphy. Digital photography offers fantastic possibilities: However, the biggest advantage of processing the images It is important to develop experience of photography.

A directly is at the same time associated with some major patient education album with one's own exposures can be risks: Such documentation has great power of guished from an original picture. Today, many dental pre- persuasion. For example, the photos can be printed in a sentations in the international continuing education circus patient newsletter. The future of a successful dental practice are already using digital images. Hardly a printed medium lies in which treatment alternatives the practice can offer to still contains unmodified original pictures.

The pictures are patients. An active marketing of the performance spectrum digitized when they are scanned into the computer and of the practice is necessary. An important prerequisite is an then they can easily be reworked using image processing extensive archive with one's own, good-quality pictures.

The gingiva from one tooth site can be spliced electronically and inserted at another tooth site, tooth color Dentists also can determine their own quality performance can be altered By regularly review- cheaters, and it is appropriate to be doubtful when the ing their own treatment cases, critical observers can assess results are all too perfect.

Therefore, digital technology may the regular ups and downs of normal human capability and also be a great danger for photography. When one decides to buy a system for the practice, one Finally, dental photography is used for documentation in should not automatically decide in favor of digital photogra- forensic cases.

In the United States, the oversupply of phy systems. One must be familiar with such solutions and lawyers has turned into the "lawyer plague" for physicians want to solve problems associated with the computer and and dentists. A similar development is occuring in other their programs.

The existing image processing programs are countries. That means that digital photography can soon become frustrating. At the moment, therefore, the com- Thus, to successfully integrate photography into the dental puter lay person should stick to conventional photography. However, it also requires a particular film devel- 36 Further example of a digital camera: It can be used for photog- raphy in the macro range.

This change is, to a great extent, due to the longer life expectancy of people see also: The Future of Dentistry, p. The transition from symptomatic treatments to patient-preferred treatments requires extensive patient education by dentists and their staff.

Practices in which there is no active patient education have recorded a decline in treatment activity; this is because of the general decrease in caries activity that has occurred in the population. In contrast, practices that provide extensive patient education have demonstrated fast and impressive growth and an increased use of new treatment techniques. For each tooth defect there are various restorative methods that have different prognoses and prices.

Therefore, it is important that the dentist shows patients the status quo of their teeth and demonstrates the different treatment options. I ntraoral cameras are imperative for these presentations. Video tech- ogy-endoscopes have been used for many years.

The first nology with close-up images was used to demonstrate intraoral video camera, the Fuji DentaCam, was developed treatment methods.

Nowadays, video technology has from these endoscopes in Even though interest in the become both a teaching and learning tool in all areas of edu- camera disappeared soon after its introduction, there were cation and training.

Numerous training programs-used also some dentists who realized the potential of intraoral minia- in dentistry-are nowadays supported by instructional ture cameras. Since then, many manufacturers have made videos. Dentists are somewhat restrained in their use of video tech- Simultaneously, so-called imaging systems were being used nology in patient education.

A possible reason is that the in many areas of industry and medicine, with which digital pain-oriented dentistry practiced earlier, which was pri- pictures of houses, cars, faces, etc.

This imaging con- patient education. However, because of the changes that cept was also introduced into dentistry in the late s and have occurred in dentistry, new methods are needed for was used to change electronic images of anatomical, oral patient education, including video technology. Since the outlines to be used in treatment planning and in patient s, many health-related organizations have developed education. Although many users assumed that this imaging films targeting patient education.

This method of education concept would be an extraordinarily successful method for is meaningful and should be used by all dentists. One can demon- strate the status quo by means of this picture. Newsletters are not only brochures forthe practice, but are also useful for informing patients about certain treatments or as a marketing tool.

However, it must be remembered that brochures distributed by the industry are often of questionable value. The dentist can then determine whether it is possible to do justice to the patient's ideas using the available methods. If this is not possible, the dentist can demonstrate a more realistic treatment goal to the patient before treatment starts. Patient Education 27 Patient Education Dental practices that are equipped with intraoral cameras Intensive patient education with the use of intraoral images use them, first and foremost, to show patients their own is recommended because these images show the necessity intraoral images.

Video films, watched in the practice or at of a treatment or a particular, selected treatment method. These The intraoral camera is a simple, easy-to-use medium for two ways of using video technology predominate in den- educational purposes. The areas of the mouth requiring tistry today. This relatively self-explanatory method How Can the Intraoral Camera Be Used to Educate usually leads to acceptance of the proposed therapy.

A diagnostic session which also uses an intraoral camera Diagnosis and Treatment Planning takes only a little longer than a regular session. Patients tak- Each dentist uses different methods to modify patient ing advantage of such a diagnostic session alter their behavior and acceptance of treatment plans. The intraoral behaviour and develop, often spontaneously, an astonishing camera allows the patient to directly observe the intraoral interest in the condition of their oral health.

The advantages situation for the first time. Thus, the patient can participate for the dentist lie in having an increasingly active practice directly in the decision-making process as far as the treat- and the introduction of new clinical techniques. The dentist or staff can use an intraoral camera to explain any relevant details to the The intraoral camera is used primarily for patient education patient.

In a dental office with well-trained staff, patient in the dental practice. The integration of an intraoral camera education is usually performed by the staff.

This is cost-sav- in the diagnostic session necessitates neither radical admin- ing and, furthermore, the staff are often more thorough than istrative changes nor other serious alterations. Generally, many patients cannot dentistry. Moreover, they open up new possibilities for the accept this. The intraoral camera can substantially improve dentist in aesthetically-oriented therapy.

After images of the the patient's acceptance. If, whilst restoring a cavity, a full oral structures have been made, they can be modified elec- crown becomes necessary, the reason for the altered treat- tronically.

For example, a diastema can be closed, tooth ment plan can be explained to the patient on the spot with color can be lightened, the visible gingiva can be increased the help of the intraoral camera.

The result is an improved or reduced, a chin remolded, class-III malocclusions altered, dentist-patient relationship and increased acceptance. These results can consequently be seen by both the den- tist and the patient. After Treatment Nowadays, it is especially important to gain patients' trust, If "before and after" pictures are shown, the computer-pro- so that they accept the chosen therapy.

By using "before and cessed electronic image becomes particularly impressive for after" pictures after treament has been completed to tact- patients and often results in behavioral changes. However, fully demonstrate differences to the patient, the dentist has use of intraoral images results in significantly greater a reliable way to build up trust and improve the dentist- changes in the routine of the practice than use of intraoral patient relationship. The intraoral camera is also an out- camera does.

More time is required for a diagnostic session. Normally, a separate room must be available, and highly motivated and well-trained staff are needed who have suf- ficient time and creativity to demonstrate the different therapeutic options to the patient. Documentation 29 Documentation The following section gives examples of situations in which Dental Picture Archives it is necessary for the dentist to take pictures of oral condi- tions.

The pictures generated by an intraoral camera are excellent for clinical research documentation, patient information, or I nforming Family Members for documentation of situations that do not yet require treatment, but need to be observed further.

Some dentists Frequently, it is not the patient to be treated child, spouse also prepare patient portraits that are attached to the or the patient alone who decides how the therapy will be patient records. Many intraoral camera systems now offer printouts of the oral conditions displayed on the The storage of digital image data requires a large memory monitor. These printouts can be given to the patient to be capacity. As well as the normal disks Compaq , special ones take home, thus facilitating the decision as to whether or are available, namely, Zip and Jaz drives, streamer, inter- not to execute the treatment plan.

I nsurance Companies Prints of intraoral conditions, showing the necessity of a proposed treatment, are invaluable for dentists when they are negotiating with insurance companies. An excellent example of this is a patient with a root fracture, of which no radiographic image is submitted, but instead a picture of the current condition in the mouth.

Insurance companies can be positively influenced by such pictures. Despite the dentist's efforts, the patient, in general, neither recognizes the problem correctly nor understands it. On the screen, the defective amalgam fillings can be demon- strated much more clearly and digitalized radiographs can be used to give added weight to the arguments previously put for- wa rd. Therefore, certain area which is being treated. The intraoral camera enables procedures are more difficult to execute with indirect the dentist to see the area or to freeze a specific image on vision.

Simple procedures suitable for learning the method the monitor which can then be used for guidance during the i nclude adjustments of occlusion, which is of a two-dimen- treatment. Although learning how to manipulate the camera in order to The advantages for the dentist are: I n some areas of medicine, doctors have already used mon- It is expected that the indirect procedure will develop fur- itors for some time to perform surgery and other treat- ther in the future and gradually become routine in dentistry.

Some dentists have also gone through this transition, The intraoral cameras of the future will probably be located at least regarding certain procedures. Under these conditions, the dentist is often forced to adopt a very unhealthy posture that can result in early wear and tear of the spine. Today, certain methods are already available to dentists as well, enabling them to treat patients via a monitor. The use of an intraoral video camera is a prerequisite for this. It has already become standard the intraoral camera, imaging system, or patient education practice for a large number of dentists to show short video- by use of video technology.

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At first, the cost of purchasing tapes in the treatment room. These films can be shown in the technical equipment and the tapes appears high, and the following ways: However, dentists should not be discouraged by this. Those -on the monitor connected to the intraoral camera who have already beeen using these concepts in their prac- -on a standard VCR monitor, similar to a regular TV tices for some years confirm that the expense and effort -on a special monitor located on the ceiling of the involved pays off within a short period due to the patients' treatment room increasing acceptance of the proposed treatment plans.

In order to reduce the noise level typical for a dental prac- The following three priorities emerge from the concepts tice, the patient is given headphones. There are numerous i ntroduced in this chapter: Videos for patient education ment sessions, or during treatment. Intraoral cameras 3. Imaging If patient education using video films takes place during treatment, the best place to install the monitor is just below Some systems are available that combine video technology the ceiling.

By doing so, the patient can be informed during and intraoral cameras; other complete systems combine all less demading treatment. If patient education is to be three concepts in one single system. Video glasses and glasses with an i ntegrated monitor help fulfill such a wish. This is the concept of virtual reality in dentistry. They are: An intraoral camera that can be sterilized Manipulation: Only one hand should be needed to operate would be desirable.

However, sufficient disinfection is guar- the camera. Wide observation field: The camera should be able to view Printing the pictures: A high resolution is necessary for several teeth a quadrant simultaneously. This provides documentation. The printer should be equipped with a large better orientation for the patient and makes it easier for the RAM 16 MB. The ideal Rotation of pictures: It must be possible to rotate a picture by i ntraoral camera should be easy to adjust from close-up pictures of the teeth to pictures of the entire dentition.

Small camera hand-pieces: These should allow distal tooth Activation of the appliance: The intraoral camera should surfaces and posterior teeth to be visualized. An intraoral camera should have high reso- up period. Size of the unit: The smaller the better. It should be possible to take stills with an intraoral Further aspects: Multifunctional applications are advanta- camera at high resolution.

A still picture is helpful when analyzing and discussing a particular intraoral condition. Accurate color reproduction: Poor color reproduction is con- fusing for both patient and dentist.

New developments are constantly taking place in intraoral cameras, which means that we will see new, improved fea- Automatic light regulation: Additional light sources to tures on a regular basis.

Uses-Summary 33 Using Intraoral Cameras Summary While some dentists use only one treatment room, others Different recording techniques are now available, which use several simultaneously. Ideally, one monitor should be enable dentists to provide patients with information in a available in each room. Some systems allow the camera to manner which was previously not possible.

This obviously be connected to the monitor or printer in each treatment contributes considerably to improving patient education. Portable complete systems, easily transferred, can The best known concept in dentistry is the educational use also be used.

The integration of both techniques in a practice should be recommended to every Many dentists start off with a simple portable system and dentist. This increases patients' acceptance of different then later progress to installing a monitor in each treatment treatment alternatives that are now offered by modern den- room. The four most important applications of the intraoral cam- I maging systems allow dentists and patients to visualize era include: Imaging systems are less -Showing the present condition of the teeth common than intraoral cameras, but they can be of great -Describing the condition of the teeth after treat- value when properly applied.

The use of video technology ment, using an imaging system can also be expected to spread in the future in indirect den- -Explaining different treatment methods by means tistry, i. This enables the camera to be used in several rooms with i ntegrated systems.

They all have the required characteristics out- lined on p. The following appliances represent the spec- This intraoral camera system is relatively new on the mar- trum of developments in intraoral cameras that are ket. The manufacturer mainly produces endoscopes for var- currently available. Three of them Acucam, Reveal, and ious uses in medicine. Reveal was one of the first companies Cygnascope have a relatively wide depth of focus and only to make sterilizable, lightweight camera systems that could one lens.

This enables the camera to be used in all four of be combined with an easy-to-use, multifunctional concept. It is also available as a mobile standard unit. However, the technological advances in this area are so Cygnascope rapid that it is recommended that all available appliances on the market are checked for the desired characteristics. This is the smallest intraoral camera system available on the market.

It can be carried by hand from one treatment room Acucam to another. In addition, the camera is currently the smallest available.

This camera system has been the market leader for several years. It has been improved continuously. Acucam can be I nsight installed as a mobile unit, but it is also available as a multi- functional appliance, so that this camera can be connected This company is one of the pioneers in the field of digital to the monitor installed in each treatment room.

It is very useful for both patient education as well as for documentation. He examined the effect of Gly-Oxid Marion , which his young patients used during the night in a remov- At the end of the 19th century, dentists began to bleach vital able appliance.

This treatment resulted in a close-to-healthy teeth. Westlake used a mixture of peroxide and ether. Ames earned his fame with a mixture consisting had disappeared. In Ames Indeed, a treatment lasted approximately 30 he experimented with the somewhat thicker Proxigel Reed minutes and the sessions were repeated up to 25 times.

Zack and Cohen were the first to conduct a scientific The periodontist Wagner, a colleague of Klusmier's, evaluation on how the effect of the source of heat affected explored the use of the method in adults and subsequently the pulp. They found no pulp damage. The results were later discovered that the gingiva was somewhat less inflamed confirmed by Nyborg and Brannstrom Slowly the method spread and was adopted in by Haywood at the Univer- Since Arens has also tried to bleach tetracycline disco]- sity of North Carolina.

Home Bleaching Carbamide peroxide has been long known among periodon- tists as an oral antiseptic substance. Munro described in The orthodontist Klusmier from Fort Smith, Arkansas, had, that as a side effect of using carbamide peroxide in a like so many other orthodontists, patients with problematic splint, the teeth became whiter.

Haywood published his first studies in Extracted teeth were bleached for 5 weeks in the usual manner. Examina- Vital and nonvital tooth bleaching has not been around for tion of the teeth using the scanning electron microscope very long, which is reflected in the list of commercial prod- revealed no changes in the enamel.

The type of bleaching ucts being introduced on the market: Carbamide peroxide disassociates into H, C02, urea, and The sales figures during the past 4 years have more than NH 3. H 2 0 2 is the effective agent here as well. Bleaching with quadrupled. Bleaching is popular: A survey conducted by the Clinical Research Associates in Murchison examined the effect of carbamide peroxide on gave an extremely positive trend: A natural enamel sur- face exhibits well-defined periky- mata with irregular contours.

It was used as a control and placed in saline.

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Right above: I t is relatively porous and has poorly defined perikymata. Left below: It was not damaged by bleaching.

Right below: This method is called external bleaching and can Advantages thus only change the discoloration of enamel. A requirement is that the dentist has a dental Bleaching Nonvital Teeth assistant or hygienist who has the necessary qualifications To bleach nonvital teeth, the chemicals are placed in the needed for instructing the patient about the home bleach- pulp chamber. In this way the coronal dentin is changed. The process is called internal bleaching.

I n-Office Bleaching -The patients bleach their teeth whenever they wish to do so. They do not have to come to the dental office to do this. These are very aggressive bleaching methods that were -In home bleaching, in contrast to in-office bleaching, no used previously when bleaching was done in-office: Damage to l atex allergy and cannot tolerate the rubber dam.

The technique has -The bleaching process takes longer and is therefore safer been named power bleaching. Bleaching teeth in the dental practice continues to play an Disadvantages i mportant role. For example, when front teeth are treated -Patients must collaborate actively. If they do not wear the with veneers, the cuspids can be brightened up by in-office bleaching tray, no therapuetic effect will occur. If they use bleaching. If one wants to achieve results very quickly, then their tray too much each day, the result is often hypersen- i n-office bleaching is preferred to home bleaching.

Stronger sitive teeth. In most cases, by the dentist or dental staff, even if this is means higher three bleaching treatments are necessary. Side Effects of the Bleaching Agent -Bleaching agents contain peroxides. These enhance muta- -A common adverse effect that occurs during bleaching is genic effects of other chemicals, such as those present in temporary hypersensitivity.

This disappears in almost cigarette smoke. Based on present scientific knowledge, every case when the bleaching process is interrupted and patients should not smoke while wearing a bleaching tray. If fluoride. If the gingiva is not protected it can be etched. How- ever, the damage is temporary and disappears after a few -Power bleaching changes the structure of the hard tooth days. Bleaching Methods-Effects and Side Effects 39 -When bleaching nonvital teeth, root resorptions may -The patient should be informed that the bleaching result occur.

Since the teeth are prepared internally, crown frac- will decrease with time and it may be necessary to do a tures are also possible. This change in color has several causes coffee, red wine, -No restorations should be bonded directly after bleaching fruit juices, soft drinks, and other drinks with low pH- because the bonding ability of the adhesive material is values, smoking, etc.

As long as these external factors are greatly reduced. A period of approximately two weeks present, the teeth will become darker. Despite these potential risks, bleaching of vital and nonvital teeth is the most conservative therapy available in dentistry.

After a cer- tain amount of bleaching time, the enamel surface is saturated with the bleaching agent. When this happens, the bleaching pro- cess must be stopped, because otherwise the enamel could be damaged. Tetracycline Discoloration The first tetracycline compound was purified in , and wood and Heymann Yellow discolorations are due to the first tetracycline-induced tooth discoloration was Ledermycin, Terramycin, or Achromycin Bailey and Chris- described in Only some of the tetracycline accumulates ten Yellowish evenly discolored teeth can be success- in the enamel, while a much larger proportion accumulates fully bleached Bevelander After light-induced oxidation, a red quinone compound forms 4-a, a anhydrooxo The three categories of tetracycline discolorations are: Different bleaching agents can reduce this dye.

Category 1: Slight yellow, brown, or gray discolorations that extend Tetracycline discolorations can be brownish, grayish, or evenly over the whole tooth. They can usually be removed bluish. They usually occur bilaterally and can involve several after three to five bleaching treatments in-office or through teeth in both upper and lower jaws.

If the anterior baby a 4-week bleaching treatment at home. However, if the permanent A strong, but even discoloration that can normally be front teeth are discolored, the tetracycline medication most removed after five to seven in-office bleachings, or after likely occurred between the third month after birth up to four to six weeks of treatment with the home bleaching the seventh year of age.

The strength of the discoloration depends on duration and Category 3: The type of color Strong discolorations using horizontal strips. This requires change depends on the type of the tetracycline derivate.

Gray-brown discolorations are due to Aureomycin Hay- 54 Causes and therapy of tooth discoloration The best results with bleaching are achieved with color changes caused by the aging process, l i ght fluoroses, and tetracycline discolorations of Category 1. All other discolorations should be treated using restorative methods. Types of Discoloration 41 Fluorosis White Spot Lesions Dental fluorosis can be induced between the second These discolorations are innate or acquired during enamel trimester of pregnancy and the ninth year of age, i.

The fluoride level of the drink- illness. Acquired white spots are incipient carious lesions ing water should be checked before fluoride medication is caused by plaque. They are often found around orthodontic prescribed. The degree of tooth discoloration-which varies brackets. The cause of innate acquired white spots must be from slightly chalky to strong yellow-brown spots due to removed first.

That means that good oral hygiene must be precipital accumulations secondary after the eruption of established and low bacteria caries activity must be the teeth-correlates directly with the fluoride uptake. The achieved. Teeth become darker with age. Thus, a youthful tooth color of, for example, Al, becomes A2, A3, and A4 with age. This is Bleaching is only successful when the enamel discolorations a natural process which is enhanced by the presence of are superficial. A combination of micro abrasion and bleach- certain components in spicy food, alcoholic beverages, ing two to four bleaching treatments , followed by facets or cigarette smoke or tobacco.

Color changes caused by aging reconstruction of the enamel with microfilled composite is are ideal for bleaching. Alternatively, veneers can be made. B Mild tetracycline discoloration. C Strong tetracycline discol- oration bleaching time: D Fluorosis with brown color changes. E White spot discolorations after orthodontic treatment. F Nonvital tooth. Courtesy of Van B. The patient should register and vitality must be clarified.

Existing restorations must be tight report pain reactions e. Bleaching Effect on Restorations Acid treatment: The enamel of single, strongly discolored Patients should be informed that only enamel surfaces will teeth can be locally etched with phosphoric acid.

This be bleached and not existing restorations. That means that i mproves the penetration of the bleaching agent and accel- crowns and fillings may appear darker after bleaching treat- erates and reinforces the bleaching process. A general etch- ments. In the case of fillings, one can remove the outmost i ng of enamel is not recommended.

The result can be a layer of the filling and replace it with a new filling layer in a rough enamel surface which later changes color more suitable tooth color. In the case of crowns, it may be neces- quickly. In principle, tooth color should be determined before each Swallowing the Bleaching Agent treatment. Many patients wish to have snow-white teeth.

I n the stomach, carbamide peroxide is broken down into Those beyond A1 tooth colors are also marked as "Holly- H and urea. H then disintegrates into water and reac- wood toilet white. A tive oxygen. Urea is produced naturally in the body and is tooth color change of about two shades is more realistic. Usually it is possible to reduce a tooth color of A3. The bleaching treatment should not proceed after A1 color has been achieved, because an uncontrolled, long bleaching treatment can damage the tooth structures.

Here, the color is found to be A3. Courtesy of Ultradent Prod. Home Bleaching 43 Home Bleaching This bleaching method has been available since It is Treatment Procedure most effective when treating orange-brown and age- 1. Professional tooth cleaning, polishing of all tooth sur- i nduced discolorations age-induced staining. Most bleach- faces. Consequently, it is possible 2. Determining the tooth color with the patient.

There- 3. Radiographs of the teeth to be bleached to detect possi- fore, patients with exposed root surfaces should use desen- ble internal damage.

Photographs with the shade tabs. Diagnose and determine the causes of the tooth color changes describe external factors. Possible side effects of home bleaching are: Make a dental impression. Fabricate a bleaching tray. Hand the bleaching agent over to the patient. Demon- -Temporomandibular joint disturbance carrying the tray strate how to use the tray and the bleaching agent and during the night hand over written instructions.

Recall and check the progress of treatment. The patient takes the tray and sufficient bleaching agent home. Then, the patient can increase the time step-wise until a maxi- mum of five hours per day is reached.

Also teeth with a mild form of fluorosis or a slight -patients with a serious systemic illness tetracycline discoloration can be bleached. According to -patients using strong medications newer studies by Haywood , the success of bleaching -pregnant or breast-feeding women tetracycline-induced discolorations increases if the patient -patients who suffer from allergic reactions to bleaching is ready to wear a bleaching tray for half a year.

The bleaching tray is not a bite splint. In fact, the bleaching Home bleaching is ideal as a part of preprosthetic therapy. If tray can temporarily reinforce existing joint disorders. Chemically-induced strong discolorations are a possible contraindication for home bleaching. Here the tooth colors are are usually blue or grayish. Patients with very sensitive teeth are another contraindication. Teeth that already exhibit hypersensitivity to tooth polishing should not be bleached.

Home Bleaching 45 Bleaching Agents The newest bleaching agents for home bleaching contain oxide. One of the first products on offer was BriteSmile. A carbamide peroxide. Carbamide peroxide is a must be stored in the refrigerator. During decomposition, hydrogen peroxide splits off and dis- Home bleaching products must be applied to the teeth by integrates into reactive oxygen and water.

There are incidentally also home bleaching products that are purely hydrogen peroxide-based. These bleach 2. However, up until now only few have been given a CE certifica- tion. They are a reservoir is created on the tooth surface by means of a made of soft plastic. It is important that the trays adapt well to prevent the bleaching agent from being quickly diluted light-cured plastic. The tray material is available in thick-nesses of 0. The thicker tray material is by saliva, which could reduce its effect.

The bleaching agents should only and exclusively be located The illustrations Figures show the procedure for on the teeth and not on the gingiva. If the tray adapts insuf- malting a bleaching tray. The technique can also be used to ficiently, allowing the bleaching agent to leak, it can lead to manufacture a medicament carrier. The reservoir extends to within approx. Light-cured blocking resin is placed where the reservoirs are going to be located.

The overextended tray is cut to its right extension. The tray margins are readapted with a flame in order to enable optimal marginal adap- tation. Prod- 1. Diagnosis and treatment planning as in the case of the ucts with a higher concentration of bleaching agents e. H2O2 are mainly used. Because of their aggressivity, one 2.

Color determination together with the patient. Preoperative photographs. Placing the rubber dam. Place bleaching agent and replace after minutes. A The drawback of in-office bleaching is the expensive treat- treatment lasts 30 to a maximum of 60 minutes and ment time. I ndications 6. After the rubber dam has been removed, remineralize the teeth with a fluoride gel.

Let the patient rinse for a few minutes. Contraindications Most gingiva irritations disappear after two hours. Raised level of sensitivity usually vanishes within a -Patients with large fillings few days. Use toothpaste for hypersensitive teeth as a possi- ble accompanying treatment.

Fresh bleaching agent is placed on the teeth at minute i ntervals. The bleaching process can be accelerated by exposing the tooth being bleached to the li ght of a polymerization lamp. The patient's face and, above all, the eyes must be pro- 7.

The power bleaching process should be stopped after 10 tected since one is working with aggressive chemicals. If Dentist and patient should wear goggles; cover the pain is registered, the treatment must be stopped imme- patient's face.

Protect the gingiva with Vaseline or Orabase in case the 8. Remove the source of heat and wait five minutes so that rubber dam leaks. Then, the remaining bleaching agent is rinsed away using plenty of water and sucked 3. Position the rubber dam. The holes should be made small away. Invert the rubber dam. Finish the procedure by treating all teeth with a neutral 4.

Clean the teeth with pumice and water; do not use a sodium fluoride gel for two to three minutes, whereupon polishing paste containing fluoride.