ISSUES IN P E D I AT R I C DENTISTRY
SPRING 2019
FIRST, DO NO HARM
WHY PREFABRICATED PEDIATRIC ZIRCONIA CROWNS MIGHT BE THE WRONG CHOICE FOR PERMANENT DENTITION
MAKING LEMONADE TURNING A SOUR CLINICAL SITAUTION INTO A SWEET RESULT
DIGITAL ASSETS are they for
MAKING
A PERMANENT DIFFERENCE A DENTIST FROM ROMANIA PLACES ZIRCONIA CROWNS TO LAST A LIFETIME
JOURNEY OF THE SCRUBS
HOW SERVING OTHERS IN AFRICA HELPED ME GROW A PASSION FOR DENTISTRY
STAYIN’ ALIVE
BIOCERAMICS AND THEIR IMPACT ON VITAL PULP THERAPY IN IMMATURE PERMANENT TEETH
ICING ON THE
REAL?
CAKE A TRUE STORY ABOUT ONE FAMILY’S SEARCH FOR WHAT WAS BEST FOR THEIR CHILD
SPRIG UNIVERSITY DESTINATIONS FOR 2019
August – Boston, MA
September – Napa, CA
Simple Solutions to Real Challenges. Register for one of our upcoming Zirconia hands-on workshops today!
October – Las Vegas, NV
December – Miami, FL
CONTENTS SPRING ISSUE 2019
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LETTER FROM THE EDITOR
By chance or by choice?
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CONTRIBUTORS
Without whom this issue would not have been possible
18 HEALTHY CORNER Five ways to reduce stress
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ON THE SCENE
Spending good times with friends at all the Sprig-attended events throughout 2016 & 2018
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22 FIRST, DO NO HARM Why prefabricated pediatric Zirconia crowns might be the wrong choice for permanent dentition
28 MAKING A PERMANENT
DIFFERENCE
A dentist from Romania places Zirconia crowns to last a lifetime
36 MAKING LEMONADE Turning a sour clinical situation into a sweet result
DOCTOR TO DOCTOR
Hear from a colleague how attending Sprig University improved the way she practices
Prefabricated Zirconia Crowns PRIMARY DENTITION PERMANENT DENTITION
Discussing When NOT to use Zirconia Crowns on Children
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36 Making Lemonade
Turn the crown you have, into the crown you want. Unrivaled results. Clinically proven. Change your world with EZCrowns, the esthetic upgrade helping you create beautiful smiles faster and easier than ever before.
LEARN MORE sprigusa.com/ezcrowns
CONTENTS SPRING ISSUE 2019
42 ICING ON THE CAKE A true story about one family’s search for what was best for their child
48 THE CASE FOR
CRYPTOCURRENCIES
Wall Street is beginning to pay attention— Are you?
54 STAYIN’ ALIVE Bioceramics and their impact on vital pulp therapy in immature permanent teeth
64 JOURNEY OF THE SCRUBS How serving others in Africa helped me grow a passion for dentistry
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ON THE COVER PEDIATRIC DENTIST JOELLE SPEED, DDS AND HER BEAUTIFUL LITTLE PATIENT ELLA COVER DESIGN BY JEFFREY P. FISHER, DDS
This issue of Shift magazine features Ella and her pediatric dentist on the cover. On page 42, Ella’s mother shares her family’s story and the happy ending that truly was like icing on the cake.
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64 42 www. sp r i g u sa.co m / S p r i n g 2 01 9
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Dentistry by Joelle Speed, DDS The Smile Gallery—Roseville, CA
Restorations by Sprig Oral Health Technologies, Inc. EZCrowns—S4 and L4
Dentistry by Joelle Speed, DDS The Smile Gallery—Roseville, CA
Restorations by Sprig Oral Health Technologies, Inc. EZCrowns—S4 and L4
LETTER
from
THE EDITOR
BY CHANCE OR BY CHOICE?
Dr. Fisher and his son Tanner
It was one of the most amazing things I had ever seen. My family and I had just finished a construction, dental/medical mission trip in Kisi, Kenya, and were enjoying a day of safari adventure just outside Nairobi. After all the hard work of laying block and treating long lines of patients in a tent clinic, we were enjoying a little bit of down time before our 30-hour return trip to Northern California. Rare because they are extremely shy creatures, leopards are one of the “Big Five” sightings on an African animal safari. Our guide told us that even he had not seen one in about four years. But there she was, right in front of us—not more than 30 feet away— a magnificent leopard. Fascinating to watch, her skin pattern blended perfectly with the natural surroundings. Then, in the blink of an eye, she was gone. Our driver had radioed all the other Land Rover drivers in the vicinity. Soon they all arrived, with visitors expectantly hoping for an opportunity to view one of Africa’s rarest sightings. But for most of these other spectators, it was too late. The opportunity had vanished. Life is often like that. Circumstances in our lives occasionally place us in the right place at the right time enabling us to experience something truly amazing, while someone else might face nearly the identical circumstances, yet miss out on an opportunity of a lifetime. On the other hand, most often it is the sum of the choices we make (rather than a mere fleeting moment of luck) which determines how our lives will unfold. Every day we face the necessity of making choices—choices that will dictate how our future will unfold and what type of circumstances will confront us. We have the choice of “playing it safe” or “swinging for the fences.” Life often unfolds as a result of the choices we have made. Our everyday decisions, made one after another, in large part determine where we will end up in life. In this issue of Shift magazine, you will read about choices. Choices like how to treat a fractured Zirconia crown in Making Lemonade or how to deal with poor prognosis primary molars with no permanent successor in Making a Permanent Difference. First, Do No Harm discusses the topic of restoring hypoplastic six-year molars with prefabricated Zirconia crowns and why you might want to think twice before choosing that option. Stayin’ Alive discusses the many options of using bioceramics in the restoration of young permanent molars with deep decay. The Case for Cryptocurrencies might give you an entirely new perspective on blockchain and distributed ledger technologies. Icing on the Cake and Journey of the Scrubs, two real-life stories, will challenge you to be a better doctor, a more caring person. Choosing to go on an annual mission trip with my son has proved to be very rewarding. As Tanner’s interest in dentistry has grown deeper with each trip, our foreign adventures serve to draw us closer together through service. The choice to participate in these international excursions has enabled us to encounter multiple jointly shared, lifealtering experiences which I will always treasure. My hope for each of you as you read through this issue is that you will be challenged to make bold decisions—decisions that will change your life and practice for the better and enable you to develop into the person you want to become.
Je rey P. Fisher, DDS Editor-in-Chief editor@sprigusa.com
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EyeSpecial C-III THE DENTAL CAMERA THAT MAKES IT EASY
WATCH NOW! EYESPECIAL C-III
MEET THE
CONTRIBUTORS TO SHIFT MAGAZINE
Daniel McGlynn Daniel McGlynn started covering cryptocurrencies in 2014 as a magazine journalist. He now works as a writer for Abra, a global app that uses the power of cryptocurrencies to make investing around the world more accessible.
Victoria Sullivan, DDS Dr. Victoria Sullivan practices pediatric dentistry in Houston, Texas. She is a graduate of University of the Pacific and completed her specialty in pediatric dentistry at the University of Southern California. She is licensed in both California and Texas. Dr. Sullivan has been involved in both private and group practice settings as well as in affiliation with university and hospital training programs for over 20 years. She has a master’s degree in education from Rutgers University which she utilizes to further her interest in instructing a new generation of dental students. In addition to working at Shriners Hospital with the cleft palate team, she also has participated in test development for the American Dental Association. In her free time, Dr. Sullivan enjoys fun runs and half-marathons, Marvel movies, traveling, and reading. She has two children—a sophomore at Tulane University and a junior in high school.
Roger D. Gallant, MD Dr. Roger Gallant graduated from the School of Medicine at Loma Linda University in 1994. He currently practices emergency medicine part time at John C. Fremont Healthcare District, a small critical access hospital in Mariposa, Calif. Dr. Gallant is also the medical director of the NEWSTART Lifestyle Program at Weimar Institute in Northern California. NEWSTART is an 18-day residential lifestyle program where patients are taught lifestyle principles designed to improve their health. NEWSTART is an acronym for Nutrition, Exercise, Water, Sunlight, Temperance, Air, Rest, and Trust in God.
Ana Vinau, DDS Dr. Ana Vinau works as a pediatric dentist at Dent Estet 4 Kids and is currently practicing at a clinic in Timisoara, Romania. She is a member of numerous pediatric dental teams, founded by Dr. Oana Taban in 2008. Dr. Vinau received her dental degree from the Victor Babes University of Dental Medicine and Pharmacy, Timisoara, and recently completed her master’s degree in periodontology. She is also currently studying for another master’s degree in orthodontics.
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Yolanda Bradley
Mayanne Quion
Born in San Francisco and now a Sacramento resident, Yolanda is the true definition of an entrepreneur. As the creator, owner, and operator of Sacramento’s favorite ice cream truck, The Meltdown, Yolanda spends her days bringing smiles and memories to kids and nostalgia to their parents! When not serving up sweet treats on summer days, Yolanda enjoys spending her free time with her husband (a Sacramento police officer) and their two daughters, Emily and Ella.
Mayanne Quion is a junior in high school studying at Weimar Academy in Northern California. Born in Central California, she lived for a time with her family in Southern California where they enjoyed the sandy beaches. Currently, she enjoys exploring the mountains of Northern California. Her father, a physician, and her mother, a nurse, have inspired her to pursue a career in dentistry. The highlight for Mayanne each year is the annual mission trip she participates in. So far, she has traveled to Nepal, the Philippines, Belize, Bolivia, and most recently to Kenya.
Evelyne Vu-Tien, DDS Dr. Evelyne Vu-Tien is a board-certified pediatric dentist who completed her dental training at the University of California, San Francisco in 2003 and her specialty training at Rady’s Children’s Hospital of San Diego in 2006. She opened Kidz Place Dentistry in 2008 where she is the solo practitioner in a private pediatric dental practice in San Diego. Now, she enjoys volunteering at local dental events as well as internationally in Mexico and Vietnam. In her spare time she serves on the Oral Health Advisory Board for San Diego and is a speaker for the American Dental Association Success Seminars. Outside the office, she enjoys spending time with her husband, an activeduty Navy dentist, and her two daughters, Reagan and Josephine.
Jarod Johnson, DDS Dr. Jarod Johnson received his DDS degree from The University of Iowa College of Dentistry in 2013 and his certificate in pediatric dentistry from the University of Nevada, Las Vegas, School of Dental Medicine. He is also a diplomate of the American Board of Pediatric Dentistry and holds a position as an adjunct assisting professor in pediatric dentistry at The University of Iowa. Dr. Johnson is the owner/manager of Artic Dental in Muscatine, Iowa and is an active member of the community, serving on the board of Musser Public Library. Dr. Johnson and his wife, Laurie, have two children, Lydia and William. Together they enjoy cooking, grilling, and exploring the outdoors.
… without whom
THIS ISSUE would not be possible.
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Issues in Pediatric Dentistry Previously published biannually as EZPEDO Magazine 2015—2016.
Vol. 5 No. 1 | Spring 2019
JEFFREY P. FISHER, DDS Editor-in-Chief TIMOTHY SHAMBRA Layout Designer
JAMES R. FISHER, MSPH, PhD Senior Consulting Editor
RICKY QUINTANA Issue Coordinator
STACEY SCHOELLERMAN Graphic Designer
ANN FISHER, MAT, MMus Copy Editor/Proof Reader
Contributing authors Daniel McGlynn / Victoria Sullivan, DDS / Roger D. Gallant, MD / Ana Vinau, DDS / Yolanda Bradley Evelyne Vu-Tien, DDS / Jarod Johnson, DDS / Mayanne Quion
Contributing photographers Stacey Schoellerman / Timothy Shambra / Garrett Hanes
Special thanks to Jody Wrathall, DDS, MS
SPRIG ORAL HEALTH TECHNOLOGIES, INC. Publisher RICKY QUINTANA Advertising Sales
LYUBA KOLOMIYETS Finance & Accounting
STEPHEN SMITH Advertising Contracts
For editorial enquiries please email: editor@sprigusa.com For advertising enquiries please email: ricky@sprigusa.com Subscriptions are available online by visiting: www.sprigusa.com/magazine For additional enquiries please call: 888 539 7336 / Int. (1) 916 677 1447
SPRIG ORAL HEALTH TECHNOLOGIES, INC. 6140 HORSESHOE BAR ROAD, SUITE L LOOMIS, CALIFORINA 95650
Shift magazine, a contemporary dental publication highlighting relevant topics of interest for busy practitioners in private practice, publishes scientific articles, case reports, and human-interest stories focusing on current issues in pediatric dentistry. Pediatric and general dentists will learn about new concepts in restorative treatments and the latest innovations in techniques and products, all available in the one magazine that helps them keep pace with rapid changes in pediatric dentistry. © Copyright 2018 Shift magazine, a subsidiary of Sprig Oral Health Technologies, Inc. All Rights Reserved.
SOCIAL NETWORK
How AAPD attendees plan to grow (AAPD 2018)
PEOPLE, PLACES AND PARTIES
The next generation (AAPD 2018)
A guest at the Sprig Booth (AAPD 2018)
BLAST FROM THE PAST
Every AAPD Meeting holds the warmest memories, and the friendliest attendees we’ve ever had the pleasure to meet.
Dr. Rosalynn Crawford (AAPD 2018)
Charging Station (AAPD 2017)
A future AAPD member (AAPD 2016)
Dr. James Forester, Mrs. Linda Shannon and Dr. Andrew Jason Shannon (AAPD 2017) The auxilary team from Tina S. Merhoff & Associates Pediatric Dentistry (AAPD 2017)
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5
CHOICES
HEALTHY CORNER
WAYS TO REDUCE STRESS.
The Stress in America Survey shows that people report high levels of stress in adulthood. Seventy-five percent of adults reported experiencing moderate to high levels of stress in the past month, and nearly half reported that their stress has increased in the past year. Stress seems unavoidable in our world today. by Roger D. Gallant, MD
So, what can you do to decrease stress in your life? 1. Eat a healthy diet. Stress creates oxidative stress for our bodies, which drives our immune system crazy. Emotional stress especially suppresses our immune activity. Decreasing the amounts of fats and processed sugars in our diet helps our bodies handle stress better. Moving from a high-protein meat diet to a plant-based diet provides us with better antioxidants which help our immune systems to function better. Lower levels of folate in the diet contribute to greater stress and depression. Folate is commonly found in green leafy vegetables, lentils, other legumes, and oranges. 2. Get regular exercise. When we are stressed, our bodies produce a substance called EDLF (endogenous digitalis-like factor), which has an effect similar to the drug digitalis in our bodies. EDLF strengthens the heart’s contraction and increases the amount of blood pumped with each heartbeat, thus stressing the heart. Exercise neutralizes the effects of stress in our lives, including the effects of EDLF. Exercise outside in the fresh air helps us to relax and improve our circulation. 3. Get eight hours of sleep per night. When we sleep, our bodies heal and repair themselves. We need to strive to get eight hours of sleep each night, and the earlier we go to bed, the better our rest will be. Going to bed earlier helps us to get more deep sleep (Stages 3 & 4) which provides our bodies with more time for healing and repair. When we are in those deep stages of sleep, 18
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our EEG shows slow delta waves, signifying that our brains are resting and doing less complicated tasks. 4. Drink plenty of water. Drinking more water hydrates each cell in your body, helping to keep them healthy. When we are better hydrated, our bodies are more alkaline instead of acidic. That helps to keep all of our enzymatic processes and hormones working normally. A better hydrated brain thinks more clearly and does not get stressed as easily. 5. Simplify your life. Look for ways to simplify your life and thereby decrease stress. Try cutting back on your time commitments. Let go of material things or drop that second job. Live within your means or even below your means. Peace of mind may be worth more than a new car or the latest gadget.
HELPFUL HINT:
Try applying the Serenity Prayer to your life:
“God grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.”
SHARPEN YOUR SKILLS
EARN 8 CES Discover fast, easy, and proven clinical techniques at a Sprig University hands-on workshop with pediatric Zirconia crown co-inventor, Dr. John P. Hansen. register online at sprigusa.com/university Boost your confidence
Manage over reduction
Increase your speed
Minimize tissue trauma
Simplify complex multi-unit reconstructions
Place 9xs more crowns after attending
Sprig Oral Health Technologies, Inc. Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 5/1/2018 to 4/30/2022 Provider ID# 358727
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DOCTOR-TO-DOCTOR TESTIMONIAL
CONFIDENCE. Why I chose Sprig University
I thoroughly enjoyed every aspect of Sprig's Zirconia Crown C.E. course. Prior to this, I had only placed eight Zirconia crowns and found it was taking too long to prepare the tooth and fit the crown. Now I don’t have any concerns, and it only takes me a few more minutes than seating a stainless steel crown. I really appreciated having Dr. John Hansen at the course as well as a couple pediatric dentists as co-instructors. I also enjoyed the intimate environment of only having about 30 attendees total. Taking the Sprig Zirconia Crown course has enabled me to o er my patients an esthetic, highly durable choice that will last the life of the tooth.
Jody Wrathall, DDS, MS PORTAGE, MICHIGAN
Shortly after completing her pediatric dentistry residency at the University of Michigan, Dr. Jody returned to her hometown of Portage in Southwest Michigan and took over the practice of a retiring pediatric dentist. In 2017, she built a brand new office two golf course holes down from her childhood home. Dr. Jody's husband, Doug, is a middle school Spanish teacher. DR. WRATHALL has three young children: Dougie, Clark, and Penny.
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IMPORTANT TO KNOW
FIRST, DO NO HARM JOIN THE DISCUSSION & DISCOVER WHY PREFABRICATED PEDIATRIC ZIRCONIA CROWNS MIGHT BE THE WRONG CHOICE FOR PERMANENT DENTITION.
When and when not to use Zirconia crowns on children
Shift magazine shares an interview with Dr. Victoria Sullivan, a pediatric specialist, and Dr. John P. Hansen, a cosmetic and restorative dentist, regarding the challenges faced when restoring the teeth of a patient with amelogenesis imperfecta (AI). The following unique discussion addresses issues of an AI patient’s primary teeth and the especially challenging considerations when dealing with their permeant hypoplastic dentition.
Prefabricated Zirconia Crowns PRIMARY DENTITION
A candid conversation between pediatric dentist Victoria Sullivan and cosmetic and restorative dentist John P. Hansen.
PERMANENT DENTITION
Discussing When
NOT to use Zirconia Crowns on Children
THE QUESTION “Zirconia crowns offer pediatric dentists a new and beautiful alternative for treating patients. The field of pediatric dentistry, however, is not known for rapidly adopting new advances in practice. In many cases we are using techniques that were taught in the 1800’s. G.V. Black’s concepts of “extension for prevention” is still in our lexicon even as it has disappeared from most of our colleagues’ conversations. Improvements in Cad/Cam technology, precision work, and fancy esthetics simply have not been adopted in pediatric dentistry as commonly practiced. We value the world of speed, bulk, simple-but-functional, “good-enough” dentistry. Our successful outcomes are measured in grins and giggles not crowns and veneers. However, with the introduction of pediatric Zirconia crowns, it is now within the arena of esthetics where we can display the best of our techniques and strengths, while addressing the realm of precision and beauty not previously open to us. I am delighted to now offer the Zirconia crowns option to my patients. It is natural, then, to wish to extend the potential value of these procedures to challenges with permanent dentition. Can prefabricated Zirconia crowns offer our patients a beautiful, durable, and functional solution for crumbling painful, and damaged permanent molars affected with amelogenesis imperfecta?” VICTORIA SULLIVAN, DDS
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“If I had to guess, I would foresee all kinds of potential complications resulting from using prefabricated Zirconia crowns on adult teeth. These would include endo issues, chronic inflammation, and eventually tooth loss for many patients.” John P. Hansen, DDS
“ John P. Hansen, DDS and Victoria Sullivan, DDS discuss some important differences between primary and permanent dentition and the potential clinical effects of using Zirconia crowns on permanent teeth, 24
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Shift magazine HOW COMMON IS AI IN YOUR PRACTICE, AND WHAT HAS BEEN YOUR EXPERIENCE IN DEALING WITH PATIENTS HAVING AI? V Sullivan In my clinical practice, I have not encountered a full manifestation of AI. However, I had one case in residency and see enamel errors requiring full-coverage crowns on a weekly basis. In these cases, I first try to remove the damaged portion of the tooth. Then the decision to use a full-coverage crown is tied to two factors: 1) patient discomfort, and 2) structural compromise. J P Hansen In my 20 years of practice, I have restored four of these cases on kids that were in their mid to late teens. They were all full-mouth reconstructions. Two cases were done all at once, and the other two were completed over a period of time. The decision to complete the treatment over time versus all at once was based on two factors: 1) was the child done growing? and 2) the cost of the reconstructive treatment.
Shift magazine WHAT HAVE BEEN THE CHIEF COMPLAINTS FROM PATIENTS THAT COME INTO YOUR OFFICE WITH AI? V Sullivan Generally, children with extensive enamel errors complain of sensitivity to hot and cold. I also notice discoloration of their teeth and that the enamel present on their teeth is inconsistent. J P Hansen I usually see these patients in their mid teens when all the primary teeth have exfoliated and the permanent dentition has already been restored long ago by their pediatric dentist—so the pain has already been managed. Most of these kids have a mouth full of silver in the posterior and stained and breaking-down composites in the anterior. Having their smile restored to normal is the main concern for these teenagers.
Shift magazine BEYOND THE PAIN AND DISCOMFORT ASSOCIATED WITH AI, WHAT HAVE YOU SEEN AS THE SOCIAL IMPLICATIONS FOR PATIENTS WITH AI? V Sullivan This is really obvious. The children with these conditions have misshapen, odd-looking teeth that are frequently broken and look stained. In a culture hyper-obsessed with an individual’s visual image, these children are not as socially adept as their peers. They cover their mouths when they laugh or smile, and they are hampered in reaching normal emotions, academic, and social milestones.
J P Hansen I have two daughters not far past their teenage years and one son that is now 18. I can tell you kids do get teased and picked on and this can have a significant impact on their social well-being. When parents bring their kids to my office, they are distraught over the appearance of their children’s teeth. They just want them to fit in with the other kids and not look different. Because of the hereditary nature of AI, many of the moms have already gone through their school years and have themselves struggled emotionally with AI.
Shift magazine HOW HAS THE INTRODUCTION OF THE PEDIATRIC ZIRCONIA CROWN BY SPRIG ORAL HEALTH TECHNOLOGIES, INC. IMPACTED HOW YOU PRACTICE AND THE LEVEL OF ESTHETIC CARE YOU PROVIDE TO YOUR PATIENTS? V Sullivan Zirconia crowns have changed the quality of my practice immeasurably. Before I could only offer my patients a bulky, bright “white chicklet's” which obviously looked fake and chipped frequently. Now I am able to offer a restoration people cannot detect. I have parents raving about the results and sending me full glossy photos of their children. These crowns don’t chip or break, and they look incredibly real. Now that I am able to offer such attractive results, parents are happy and my practice is flourishing. J P Hansen I love using Zirconia crowns. Having a largely adult esthetic practice, I always used to hate placing SSC’s on anybody. With a Zirconia option now available, I feel good placing these crowns because they rival the esthetics of what I do in the adult realm. EZCrowns are the only prefab Zirconia crowns on the market that are not monochromatic so there is no bulky “chicklety” look as with some of the other crown options. Just like custom adult crowns, they are hand characterized to blend in with the surrounding teeth. Plus, I know they are going to last and that the tissue response will be better than any other option. And it is a bonus to know I am not going to have to deal with parents complaining about a silver crown on their kid after just finishing what I thought was a good job.
Shift magazine FROM A CLINICAL STANDPOINT, WHAT ARE THE MAIN CHALLENGES OF RESTORING THE PERMANENT TEETH OF AN AI PATIENT? V Sullivan There are probably three main issues that need to be addressed. The first and most important one is anesthesia. These teeth are frequently difficult to numb adequately. The children often require double the usual amount of anesthesia to be comfortable. www. sp r i g u sa.co m / S p r i n g 2 01 9
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The second factor is removing the decay and damaged structure while preserving as much of the sound tooth as possible. My effort as a pediatric dentist is directed toward completing a restoration that will act as a spaceholder. In so doing, it is necessary to ensure clearance for the crown. However, I know my restoration is temporary and will need to later be the foundation upon which the final restoration will be placed. I know no matter how little tooth structure I remove it will end up being too much and make the final restoration more difficult. The final issue is esthetics. Zirconia crowns are undoubtedly the best esthetic option for primary teeth. Sadly, this is not the case when it comes to adult dentition. One of the most disappointing realities from a pediatric dentist’s perspective is that in pediatrics we do not yet have a satisfactory temporary esthetic solution for dealing with adult dentition—one that does not potentially compromise the future health of the tooth. J P Hansen By the time I see patients with AI, most often their teeth have already been restored with stainless steel crowns in the posterior. I never know what I am going to find when I pop these off. There can be gross recurrent caries, and many times the preps will be undercut. Because most of these margins are wide open and very sub-gingival, the tissue is a bloody mess. This situation makes it very difficult to refine the margins and take an impression. I usually will take the SSCs off, remove the decay and refine the margins enough so I can seat a well-fitting composite temporary crown. Then we come back later and do the final refinement and impressions once the tissue is healthy. Also, many of these cases have lost vertical dimension due to the SSCs being too short. I almost always have to re-establish the vertical in the provisionals before proceeding with the permanent restorations.
Shift magazine
WHERE DO YOU SEE PREFABRICATED ZIRCONIA CROWNS FITTING INTO THE TREATMENT PLAN FOR RESTORING PERMANENT DENTITION? V Sullivan It is a tempting "honey-trap" to apply Zirconia crowns to adult molars. We enjoy being the hero and delivering not just functional results but beautiful ones as well. However, there are two key principles to remember when applying a Zirconia crown restoration: 1) the vital importance of ensuring a sub-gingival reduction, and 2) the absolute necessity of prepping for a passive fit. Both of these principles involve the use of techniques which are diametrically opposed to the techniques required to reach the goal of stabilizing painful and dysfunctional adult molars with a permanent restoration. Given this dilemma, minimizing tooth reduction for the purpose of 26
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ensuring a later adequate margin placement is all but impossible when using a Zirconia crown. Thus, we must unfortunately conclude that prefabricated Zirconia crowns are an inferior option for the restoration of permanent molars. J P Hansen I can't tell you how many times I have had pediatric dentists ask for Zirconia crowns for permanent molars. This would be a huge market for us. Some of our competitors offer them. We made them many years ago, but we decided not to sell them; it was an ethical issue for us. Both Jeff and I did not want to be responsible for potentially thousands of people loosing permanent teeth down the road because of prefabricated Zirconia restorations placed early in their lives. Let me explain the reasons why. The prefabricated Zirconia crown makes a great temporary crown and works fantastically on primary teeth. It only has to last until the tooth exfoliates, plus it has better tissue response and is far more durable than the standard SSC. In my opinion, the esthetics of Zirconia crowns together with their greater durability compared to SSCs make Zirconia a preferred option for treatment of AI in the primary dentition. For an adult tooth, however, at some point that prefab Zirconia crown will have to be removed and replaced with a permanent restoration. The passive-fit preparation required for a prefabricated Zirconia crown leaves no margin for a permanent crown later—the prep is basically a cylinder. How can you make a permanent crown fit where there is no margin, no chamfer, no shoulder? Maybe if you are lucky you will have a remnant of a knife edge somewhere, but most teeth will not have enough margin suitable for placing a permanent custom crown. Furthermore, the margin is way sub-gingival which further complicates things. As a restorative dentist, I cannot even imagine having to restore adult teeth in this condition and then hoping they will last the rest of a patient's life. When it comes to using prefabricated crowns to restore the adult dentition, this is one situation in which I clearly see stainless steel as being a better restorative option.
Think Smart by Thinking LONGTERM
YOUR PATIENTS ARE COUNTING ON YOU TO MAKE THE RIGHT CHOICE.
Why doesn’t Sprig make crowns for permanent (adult) molars? EZCrowns are designed with the patient in mind. And that is still the case today. The answer to the above question is quite simple—it’s not the right thing to do for your patient. The passive-fit preparation required to seat a prefabricated pediatric Zirconia crown extends subgingivally all the way to the CEJ. As a result, the amount of subgingival permanent tooth structure required to be removed will compromise your ability to create an adequate margin when attempting to seat a permanent restoration in the future. Thus, we cannot recommend a temporary solution (good as it may be) that will jeopardize the longterm stability of permanent teeth. Would it work in the short term? Absolutely. But it would exact a price down the road, and that’s a risky path we’re unwilling to take.
Jeffrey P. Fisher, DDS Owner / Co-founder
John P. Hansen, DDS Owner / Co-founder
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Making a Permanent 28
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Difference
A dentist from Romania places Zirconia crowns to last a lifetime by Ana Vinau, DDS
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Patricia first came to our clinic with her
mother when she was 7 years old. She was quite shy,
and I could tell that she felt very uncomfortable. Her mother told me, “My daughter has experienced dental pain before and has to take medicine in order to calm the symptoms.” Patricia had experienced a lot of pain during prior treatment at another dental clinic and didn’t want to endure a similar experience again. When I proceeded to examine Patricia, I could see several ofher teeth were decayed. She told me her lower molars weregiving her a hard time. I could see that teeth K and T were the most affected with evidence of massive dental destruction. I noticed that T also had a vestibular abscess. To be honest, I was nearly convinced we would need to extract those teeth due to the extensive damage. Furthermore, lesions had alreadyled to infection.
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For the next appointment I asked her mother to bring me a panoramic X-Ray so I could see all Patricia’s teeth and assess the amount of root resorption in order to know how to treat her teeth. When I received the X-Ray, I was surprised, disappointedand challenged all at the same time. I saw that the adult permanent teeth were missing and noted accompanying extensive bone damage. Patricia’s parents were shocked and discouraged when they found out that she was experiencing hypodontia in addition to having decaying second primary molars. I knew right away that I needed a second opinion on this case, so I asked my friend, Dr.Teodorina Secara, our Orthodontic specialist, for some advice. She advised me, “Try to keep the two damaged teeth in Patricia’s mouth if at all possible, given the fact that she already has too much space between her teeth.”
The loss of these two primary molars would disrupt the elationship between the rest of her teeth, and in the end, impact her entire entire occlusion. I took on the task of resolving this case as a personal challenge. Because the permanent adult teeth were missing, I couldn’t afford losing the second primary molars. I didn’t know how this casewould end up, so I started by taking it one step at a time. In the beginning, I treated the root canals of those two damaged and infected teeth with MY FIRST THOUGHTS antibiotics and anti-inflammatory medications. I was nearly convinced After 10 days, I filled the root canals of both we would need to extract teeth using the standard procedure for permanent those teeth due to the teeth. On K, I also encountered a furcal perforaextensive damage. tion and although it was very difficult to stop the hemorrhage, we managed eventually to FAST FORWARD place MTA I took on the task of on it. We filled K with Equia GC and T with Gradia resolving this case as a Direct GC. Everything was going well so far. personal challenge. Two weeks later, while I was treating the rest of Patricia’s teeth, I spotted through the enamel that K had begun to turn black underneath the Equia filling. Also, T, due to the extensivenature of the filling and the small remaining healthy dental structure left after removing the decay, had begun to exhibit fissure lines. It was just a matter of time until that tooth would break, requiring an extraction, in spite of all the hard work done to save it. This was not a scenario I was willing to accept.At that point, I knew I had to come up with an alternative idea in order to help Patricia retain her second primary molars, and I had to do it fast. At the time, we only had SSCs available in our clinic, and I had used them in the past. I knew I had to reinforce these damaged molars if we wanted to keep them. But, what I most wanted for Patricia was an esthetic solution for her situation that would prove durable over time, because these primary molars would
Tooth T was missing its permanent successor and compromised by a vestibular abscess.
I was surprised, disappointed, and challenged all at the same time. Tooth K showed massive decay and was complicated with a furcal perforation during endodontic treatment.
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never be replaced by permanent teeth. In addition to being esthetic, the ideal restoration would also need to be extremely strong, able to withstand all the bite forces over a lifetime. SSCs were not an option for me or for my patient. I refused to believe that I had reached the end of the road, so I began doing some research on the Internet to find what other esthetic pediatric options were available. That is when I discovered that such a restoration option did in fact exist, having all the characteristics that I had been hoping for. Sprig EZCrowns also seemed to satisfy both the needs of my patient and the desires of her parents. Usually,when you diagnose a young patient with hypodontia and talk to the parents about it, they perceive the diagnosis as a handicap; or they feel ashamed for having done something wrong that led to the situation. Now, however, it was such a joy and a relief to be able to share the option of using Zirconia crowns when faced with such a difficult circumstance. After assessing Patricia’s situation, I shared the good news of my discovery with her parents and proposed using Sprigcrowns. They were excited about the fact that the crowns had the same color as natural teeth and gave me permission to proceed. I told Patricia that she would no longer feel any pain. She was excited to learn that instead of two “injured” teeth, she would be getting two beautiful “pearl-like” teeth. Anticipating the case, I was nervous because this would be the first time I had ever used Zirconia crowns. However, I managed to seat both crowns in the same session. In the end, Patricia was extremely excited with the result. During the entire process of discovering Zirconia crowns and preparing for the case, I found the Sprig team to be most helpful andresponsive in communicating with me. At Patricia’s two-week check-up, I was surprised to see how beautifully the gingival margin had healed andto discover that the crown
It was such a joy and a relief to be able to share the option of using Zirconia crowns.
Tooth T : 1) Initial exam 2) Interim 3) Immediate post-op crown placement. 4) Clinical follow-up after one year and six months.
HYPODONTIA IS THE AGENESIS OF SIX OR LESS TEETH.
OLIGODONTIA IS THE AGENESIS OF SIX OR MORE TEETH.
ANODONTIA IS THE AGENESIS OF ALL TEETH. Reported worldwide prevalence is 2.6 –11.3 percent. Women are affected more than males at a ratio of 3:2. Both genetic and environmental explanations for hypodontia have been reported.
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Tooth K : 1) Initial exam 2) Interim 3) Immediate post-op crown placement. 4) Clinical follow-up after one year and six months.
contour was nearly perfect. I was impressed by the fact that both crowns looked so natural that you could barely notice any difference between the Zirconia crowns and Patricia’s natural teeth. I was thrilled with the result and so were her parents! But what I most anxiously wanted to see was how well these crowns would perform over time. Would my patient be able to use these two crowns à la longue (over the long term)? Therefore, I determined to monitor the Sprig EZCrowns to see how they would hold up after prolonged use. I saw Patricia regularly for follow-up exams and carefully examined her. At six-month and one-year and six-month follow-up appointments, I took photos and x-rays of her teeth. They still looked impeccable. Her first permanent molars erupted in their right places. I couldn’t detect any wear of the opposing teeth, and the crown margins were subgingivally placed, revealing healthy surrounding tissue.
One year and six months post-op X-rays and clinical photos
The x-rays showed that the bone had re-mineralized and healed. In summary, Patricia uses these new “teeth” as if they are her own natural ones. After we placed the Zirconia crowns, Patricia began taking personal responsibility and paying more attention to proper dental hygiene. She now enjoys coming to her appointments because she knows we will take pictures every time. I think Zirconia crowns are a necessity in this kind of situation when you have to deal with missing permanent teeth. When I promote these crowns to parents, I now feel confident recommending Zirconia crowns. At the same time, I am able to honor the trust which parents have placed in me by providing the best available solution when treating special dental conditions such as hypodontia. By incorporating all the benefits of Zirconia crowns into your practice, you, too, will increase your chance for success. Above all, you will live with a strong feeling of professional satisfaction knowing that you can overcome even the most difficult situation.
I was surprised to see how beautifully the gingival margin had healed and to discover that the crown contour was nearly perfect.
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A Five-year Followup Every time a patient revisits our clinic for a checkup appointment after a long absence, I feel a sense of excitement. I’m eager to check each patient’s dental status to see how the treatment plan we adopted has impacted their quality of life. Let me share with you the story of Patricia, a patient with two congenitally missing permanent second premolars. This story began five years ago when Patricia first came to our office as a timid, shy child with serious oral-health issues. When Patricia first came to our office, her second inferior primary molars were severely damaged. Our initial inclination was to extract them; but, fortunately, we chose to cap teeth K and T with EZCrowns (Sprig Oral Health Technologies, Inc.) Now, almost five years later, our choice to use Zirconia crowns has been rewarded, and her teeth continue to look astonishingly natural. Patricia, who is almost 12 years old now, is no longer shy, and I can tell by the brightness of her smile that she is full of confidence. Since her initial visit, she has developed into a young girl with abundant enthusiasm. Initially, tooth K had extensive decay complicated with a furcal perforation as a result of root canal treatment. Tooth T also had massive bone demineralization complicated by a buccal abscess. Nevertheless, based on the latest X-rays taken during a recent follow-up exam, we can now confirm that the final results continue to look amazing. The Zirconia EZCrowns (Sprig Oral Health Technologies, Inc.) have literally demonstrated their quality reputation as la pièce de résistance. Although both second primary molars have been treated endodontically as if they were permanent teeth and the mesial root of tooth T shows evidence of resorption, Patricia has experienced no clinical symptoms. The contour of the gingival margin is still placed at a physiologically appropriate height. Compared to her natural teeth, you can see only insignificant signs of gingival inflammation, likely due to the still superficial personal dental hygiene habits so commonly practiced by preteens in Romania. One of my biggest concerns when I initially placed Patricia’s Zirconia crowns was how they would hold up over the long term. Would they be abrasive and damage the opposing natural teeth?
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Although Zirconia crowns are glazed and smoothly polished, they still have a harder surface than natural teeth. However, to my surprise, every time Patricia arrived for a clinical exam, I was unable to observe any notable pathological sign of dental abrasion on her opposing teeth. Today Patricia experiences no issues with her mastication or occlusion. Furthermore, and most importantly, she enjoys the amazing aesthetics of a beautiful smile. She is experiencing excellent oral health, and when I talk to her, I sense her feeling of wellbeing at having a beautifully restored smile. Although both molars had a guarded prognosis, five years later, Ana Vanau, DDS and Patricia are still pleased with the results of her Zirconia restorations.
Making Lemonade Turning a sour clinical situation into a sweet result. by Evelyne Vu-Tien, DDS and Je rey P. Fisher, DDS
I reach for my phone. The voice on the other end is calm and collected, but I can tell something is wrong. There’s an urgency in the voice, and I know it must be something important. It’s one of many calls I receive each week as the co-owner of Sprig —an innovative pediatric healthcare technology company. Each call is unique. Each call is important. Each call provides me an opportunity to communicate with our customers— sharing advice with them, discussing treatment-plan options, or just letting them know we’re here for them. This particular call stuck out in my mind because it involved a situation every pediatric dentist dreads —getting a call from the parent whose child’s case was performed under general anesthesia (GA) saying something has gone wrong with treatment. Maybe it’s a crown that came off, or a spacemaintainer that came loose. Whatever the case, the first thing that goes through our minds is, “What am I going to do? Do I need to put the child back under GA? Are there any other alternatives?” This was the nature of the call I had just received from Dr. Evelyne Vu-Tien, a pediatric dentist in San Diego, California. In the conversation below, Dr. Vu-Tien and I discuss a case done under general anesthesia, after which a crown fracture was noticed post-operatively. We explore options regarding what to do when the patient is a young child whose cooperation is limited. — Jeffrey P. Fisher, DDS
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“
What are my options when I have a crown fracture during or after seating?
Dr. Fisher
WHAT IS YOUR USUAL RESTORATION CHOICE WHEN RESTORING LOWER CUSPIDS, AND HOW HAVE PEDIATRIC ZIRCONIA CROWNS AFFECTED THAT CHOICE?
Dr. Vu-Tien When I find large interproximal decay in a cuspid or decay involving a cuspid incisal edge, I use Zirconia crowns because they are the most durable restoration out there. Especially in children where bruxing and lateral excursive forces constantly fracture large class III composite restorations, I find that Zirconia crowns are the fastest to place and are the strongest restoration available. I used to perform large strip-form type crowns. It would take me a long time to polish them down into proper occlusion. Also, they would frequently fracture after a few months or inevitably fail within one to two years after placement. In younger children under 5 years of age, placing a Zirconia crown gives me the peace of mind knowing that it will last them at least the next three to four years. Prior to this case, I had completed about a dozen cases using canine Sprig EZCrowns, each with success and without incidence. So what happened next surprised me.
Dr. Fisher
TELL US ABOUT YOUR PATIENT, JULIE, AND THE PARTICULARS OF HER CASE.
Dr. Vu-Tien I saw Julie in November 2015, when she presented for her first initial exam at age 5. We discovered she had 12 cavities. She was extremely apprehensive and anxious, and it was difficult to coax her to open her mouth for a visual examination. Due to the severity and amount of decay, as well as her level of apprehension, her mother and I
discussed monitored-anesthesia care for her treatment. We ended up placing six crowns and six posterior interproximal restorations. We placed EZCrowns on teeth E, F, M, and R with no pulpotomies required. I decided to substitute upper canine crowns for the lowers, using a smaller size (Size 1 of C and H). I also used Fuji Cem for cementation instead of the recommended Ketac Cem. I did not hear any “snap” or “breaking” sounds upon seating the crowns, nor did I notice any fracture lines after the treatment was completed.
Dr. Fisher
IN JULIE’S CASE, WHEN DID YOU FIRST NOTICE THE FRACTURE IN THE CROWN, AND WHAT WENT THROUGH YOUR HEAD IN THE MOMENTS THAT FOLLOWED?
Dr. Vu-Tien I received an evening call from Julie’s mother one week after the surgery, alerting me that a piece of the “tooth” had broken off on the lower right area of the crown. I did not believe her at first. I had never had a canine crown fracture before. I immediately wondered if it was a piece of excess cement that I had failed to remove, or if it was a chip off a neighboring tooth. I tried to recall if I heard any “snap” or felt any “break” during cementation, but I could recall nothing. I asked her to text me a photo of the tooth right away. Sure enough, a diagonal piece of the crown was missing. Julie’s mother said her daughter had been eating soft foods at the time and handed mom the chipped piece. I was worried how I would be able to restore the fragment chair side and wanted to look up what materials bond to Zirconia. Luckily, the cement under the crown was still present, and Julie was not having any pain or sensitivity. I did not want Julie to undergo anesthesia again to repair just one tooth, so I was trying to brainstorm ideas on how to “patch it” until she could tolerate a chair-side removal of the crown or until the tooth would exfoliate naturally in two to three years.
Dr. Fisher
WHAT ARE YOUR THOUGHTS ON WHY THE CROWN MIGHT HAVE FRACTURED?
Dr. Vu-Tien It was puzzling, because I had placed two lower canine EZCrowns, only one of which chipped. At the time I performed the case, I did not have the SL cuspid sizing, so I placed regular canine crowns instead. The other canine crown (M) did not fracture. I suspect that I may have twisted the lower right crown (R) upon cementation, which led to the failure and fracture of the crown. The regular-sized cuspid Zirconia crowns are more ideal for placing on maxillary primary cuspids, while the SL-sized cuspids—being somewhat narrower—are more suitable for use on lower canines. I also wondered if by using the Fuji Cem, which was less viscous than Ketac Cem—if it somehow contributed to decreased retention of the crown, resulting in failure where the chip occurred.
Dr. Fisher
WHEN YOU CALLED ME, YOU HAD A GOOD IDEA OF WHAT YOU WANTED TO DO TO FIX THE PROBLEM. WHAT WAS YOUR IDEA?
Dr. Vu-Tien When I called you, I wanted to review my options with you and discuss what experience you may have had with this type of fracture. Because of Julie’s anxiety level, the idea of removing the crown with a high-speed
Fractured Zirconia crown
Repaired Zirconia crown
“ I decided to repair
hand piece, requiring water, suction and recementation of a new crown was something highly unfeasible given her level of anxiety. Julie barely spoke any English, and it was challenging trying to communicate with her. Typical “tell-show-do” methods and voice control had not proved effective. Rather, I opted to repair the tooth with composite to buy us some time until she was older and could better tolerate more definitive treatment. I did not want Julie to have to undergo anesthesia an additional time for repair of a crown fracture that was neither symptomatic nor carious.
Dr. Fisher
WHAT WERE THE PROCEDURES YOU USED TO FIX JULIE’S BROKEN CROWN?
Dr. Vu-Tien When Julie returned to the office, she was still very anxious. It was difficult to place the nitrous mask on her. Upon inspection of tooth R, we discovered the remaining unchipped area of the EZCrown was intact and well cemented. Since cement still covered the exposed portion of tooth, I opted to bond composite to this exposed area. I first cleaned the area with chlorehexidine and used a size-2 round bur to roughen the cement and clear out any debris. I used a mouth prop and cotton roll isolation in lieu of a rubber dam because of Julie's behavioral issues. After placing a sectional matrix, I applied 35% phosphoric etchant and Adper bond (Scotchbond) to the cleaned surface. I applied A1 flowable composite (Shofu) to the interface between the crown and tooth
Like many dentists, Dr. Vu-Tien used her training and a splash of common sense to manage a di cult clinical situation— turning an otherwise disappointing result into a manageable situation.
the fractured Zirconia crown with a composite restoration.
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and followed up with Filtek Supreme color B1 over the open area. I then polished using football and flame-shaped carbide burs to contour the composite. Finally, I polished with a Shofu white point to achieve smoothness and shine. I advised Julie's mom that the composite restoration possibly could chip and stain and may need revisions in the future, but at this time it was a viable option we had chosen instead of replacing the entire crown while Julie is still young and apprehensive. Julie's mom was very happy with the result.
Dr. Fisher
WERE THERE ANY CHALLENGES WITH THE “ZIRCONIA REPAIR,” AND WHAT DID YOU LEARN FROM THIS CASE?
Dr. Vu-Tien Julie’s mom was very happy with the results and with the fact that we could achieve them without additional monitored anesthesia care. That joy was short-lived, however, because one month later, I got a call from Julie’s mom telling how the crown had fractured again. This situation allowed me an opportunity to reflect yet again on how I might have repaired the tooth better. I requested Julie to return, and we removed all the old cement to expose the dentin. I then followed the steps outlined above to ensure a good bond. This time, I took the tooth out of occlusion by 1–2 mm and rounded the edge of the canine with a new diamond and lots of water to prevent heating the tooth. Julie’s mom was pleased with the second repair. I contacted mom again one month later to check on Julie. I learned she was doing great, experiencing no issues and with the filling still intact.
Dr. Fisher
HAVING REPAIRED A FRACTURED ZIRCONIA CROWN NOW IN YOUR OWN PRACTICE, WHAT WOULD YOU ADVISE YOUR COLLEAGUES TO DO IF THEY WERE TO ENCOUNTER A SIMILAR SITUATION?
Dr. Vu-Tien First off, I would pause and reflect back on the steps taken to complete the crown. Could the error
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have been caused by one of the following factors? 1) inadequate tooth preparation, 2) crown choice (SL vs. regular sizing), 3) cementation process, or 4) type of cement. Answering these questions allows you to critically evaluate each of the steps taken. You can then more accurately deduce how you might have performed the procedure better. This process also allows you to review how you could have given more careful attention to the materials used or steps taken, possibly ensuring a better outcome. I am thankful for humbling experiences such as this because I am able to learn and grow from my mistakes. I am so appreciative that you, Dr. Jeff, were always available to speak with me and offer support, guidance, and mentorship throughout the process. Sprig is the only company I know of that is owned and managed by dentists with a passion for educating their dentist customers and ensuring that their product improves a patient’s overall health and well-being.
Dr. Vu-Tien
FINAL THOUGHTS LOOKING BACK FOUR YEARS LATER. My patient, Julie, received her composite repair when she was one day shy of 4 years old. Now that she is 8 1/2 years old, the tooth is beginning to show signs of mobility due to normal exfoliation. The restoration served its purpose well—to maintain space and promote healthy tooth structure. She was able to continue eating, smiling, and thriving with the treatment she received. Nearly two years after the repair, a portion of the composite chipped, and Julie’s mother reported that her daughter experienced no sensitivity or pain as a result. We decided to monitor the situation since her daughter was comfortable with the chip, and it did not interfere with her eating.
Overall, the Zirconia crown, even with the small facial fracture, withstood the test of time and continued to serve its purpose for four plus years. Both Julie and her parents were happy with the outcome. The portion of the Zirconia crown that was unchipped did not show signs of becoming mobile and continued to display great retention. The restoration showed no signs of recurrent decay or staining around the surfaces or chipped edges.
Space-loss Shape Sprig EZCrowns
Dr. Fisher
OUR COMMITMENT TO DOING WHAT IS BEST FOR OUR PATIENTS.
Often in the practice of dentistry we are presented with situations that are less than ideal. It’s just the nature of the profession, and we as practitioners need to be able to use critical thinking to solve these challenging situations. The above mentioned case is just one example of any number of situations—many of which you might decide to resolve differently. That’s the beauty of private dental practice. Our education has equipped us with tools to use in the treatment of our patients. It is up to us, as individual dentists, to use that knowledge to offer the best treatment we can to those seeking our help. As the horizon of pediatric dentistry continues to expand, we will be faced with more and more situations requiring us to exercise our criticalthinking skills. I want to encourage all of us to think outside the box. Think with a critical mind. Use the “tools” you have to evaluate every new product and technique that you encounter. Learn and decide for yourself how you will respond to the most important question you face every day in practice ... “What is best for my patient?”
Having problems fitting your posterior Zirconia crowns? With narrower mesio-distal dimensions, Sprig’s spaceloss EZCrowns allow you to restore crowded cases faster and easier than you ever imagined. 6140 Horseshoe Bar Road, Suite L Loomis, California 95650 USA
888.539.7336
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COVER STORY
ICING ON THE
CAKE A TRUE STORY ABOUT ONE FAMILY’S SEARCH FOR WHAT WAS BEST FOR THEIR CHILD by Yolanda Bradley
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D
ental hygiene has always been a priority for my husband and me. We take pride in preserving our smiles by brushing at least twice a day, flossing, and even going the extra mile by investing in products that will better our oral care. We use topof-the-line toothbrushes, toothpastes, water flossers, and whitening regimens. We regularly visit our dentist and follow recommended procedures. You name it, we do it.
We have two daughters, who have now doubled the number of teeth we are responsible to take care of. Teaching our oldest daughter good dental habits has been a priority for 11 years, and she has never had a cavity. We began to feel as if we were pretty seasoned at this whole parenting thing and continued to implement the same habits with our 5-year-old, Ella. When our older daughter spotted Ella’s first tooth, we were all excited. Later, we took her to the dentist for her first checkup at age 2. Like the rest of our family, Ella has continued to receive routine checkups every six months for the past three years. As Ella grew older, her smile continued to light up our world. Recently, while I was brushing and flossing her teeth, I noticed a discolored mark on one of her back molars. It was in between two teeth, so it was hard to see, but it definitely was there. I immediately scheduled a checkup and felt heartbroken to learn that Ella had ten cavities. To say that I was in shock, confused, and devastated is an understatement. My 5year-old is more compliant and consistent than my 11year-old when it comes to brushing her teeth, and I kept asking myself, “How can this possibly be?” We were referred to a local pediatric dentist who presented us with a treatment plan. Upon viewing the x-rays, we learned that Ella had a mouthful of cavities. Not only that, the dentist was recommending that many of her molars be capped with stainless-steel crowns. I was beside myself in tears. Nothing could have prepared me for this news. To be honest, I needed time to process the news; but being a busy mom, I was not given the luxury of having time to assess the situation. Immediately, the dentist started to review her treatment plan, explaining that naturallooking crowns were not an option since Zirconia crowns are essentially unsustainable at Ella’s age. He presented silver crowns as our only option. Plagued by “mom guilt,” my only thought was this. “How is this treatment going to impact my sweet little girl’s confident, fearless smile?” Yet, I didn’t want to put off necessary treatment. My main goal was simply
to get Ella’s teeth back to a healthy state. So, I booked her appointment and paid for the full treatment in advance. As we waited, I recalled having seen kids with silver teeth and naively feeling sad for them while judging their parents. Thinking about my judgmental attitude now, I feel awful. So that’s the reason I am choosing to share our story. For days after agreeing to the treatment plan, guilt continued to consume me. I realized that this decision is something that could have a permanent effect on my beautiful girl. I decided that we had to explore other options. As we researched like crazy, we came across Sprig EZCrowns! We examined the claims of the dentists that invented the crowns by watching YouTube videos. We saw techniques performed using EZCrowns and also listened to stories told by parents whose children had undergone the same procedures. We heard testimonials of doctors who have used EZCrowns and have taught at the Sprig University. What impressed me the most was the testimony of one pediatric dentist who had previously been unsuccessful in using aesthetic crowns. He even stopped using aesthetic crowns altogether, stating that it was his own lack of knowledge about the proper techniques required when using the crowns that led him to conclude they were an inferior product. However, after receiving training at Sprig University, this originally skeptical dentist now feels confident that EZCrowns are indeed the future of pediatric dentistry—making them the “perfect restoration choice.” After watching every video we could find, I was convinced these dentists using EZCrowns cared deeply for their patients, used the highest quality materials, and ensured their staff were trained to the highest standards.
“Had we not sought out a highly trained dentist with progressive ways of thinking that align with our values, we likely would have accepted a di erent outcome for our little girl.” www. sp r i g u sa.co m / S p r i n g 2 01 9
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It’s unfortunate our family had to go through this experience, but one thing has now become clear to me. We would have settled for the basic traditional treatment plan if we had not taken that extra step to find a dentist offering an alternative, innovative treatment program. Had we not sought out a highly trained dentist with progressive ways of thinking that align with our values, we likely would have accepted a different outcome for our little girl. It breaks my heart to think that our failure to make a correct decision might have caused our sweet and confident Ella to compromise her smile throughout childhood and possibly thereafter. So, as parents, we have turned our nearly devastating experience into a success story. We live in the Sacramento area and reached out to Dr. Joelle Speed at Smile Gallery Dentistry in Roseville. She is absolutely amazing! We cancelled our previous
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appointment and booked with the Smile Gallery immediately. Her staff was accommodating, knowledgeable, and confident in their practice. These qualities put us at ease throughout the entire treatment process, and Ella’s restored smile is now delightful. In retrospect, I realize that sometimes, as a parent, you do your best, and that is the most that can be expected under the circumstances. We hope that our experience will encourage more parents to seek out pediatric dentists who are willing to implement innovative improvements in their practice and offer cutting-edge products and procedures to their patients. Had we found such a dentist early on, it would have made our experience a more positive one from the outset. We are most grateful to Dr. Speed and her team at Smile Gallery for providing an aesthetic alternative to silver crowns and preserving Ella’s natural, captivating smile.
cover story
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The Case For Cryptocurrencies Over the past ten years, cryptocurrencies have grown from cypherpunk ideal to become a massively valuable global market. Way more than magic internet money, cryptocurrencies like bitcoin show signs of becoming a new investable asset class. by Daniel McGlynn
WALL STREET IS BEGINNING TO 48
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A
little over ten years ago, the idea of having a form of digital cash was laughable. Up until the birth of bitcoin, early versions of digital money were plagued by the double-spend problem. Without some kind of middleman, it was hard to be able to trust and verify transactions — much in the same way that if someone emails you a photo you have no idea how many copies of that photo exist, or who else has one.
CURRENT Market Cap: $113,463,358,748 (May 10, 2019) coinmarketcap.com
Without solving for double-spend, money would forever be stuck in the analog world. Sure, things like direct deposit and paying bills over the internet were possible. But that’s not really digital money. That’s just digital functionality added to old money. In the end, you would still need a bank, or a credit card company, or a payment service provider to vouch for the legitimacy of the transaction. Having layers of middlemen costs time and money. There are also other tangibles involved with the middleman model related to privacy, censorship, and trust. And then bitcoin came along. It was first proposed in late 2008 to a popular cypherpunk email list by the mysterious Satoshi Nakamoto (we still have no idea about the true identity of the person behind bitcoin) as a way to conduct peer-to-peer cash-like transactions. Building on decades of work in public key cryptography, Nakamoto claimed to have solved the double-spend problem. In early 2009, bitcoin launched and early adopters started using the network. At the time, one bitcoin was worth pennies. Early bitcoin adopters existed at the fringes: free-staters, gamblers, etc. Bitcoin has never been run by a company and it is not under the control of any kind of official company. Instead, it exists as an open-source network that anyone can join, run, and improve. These attributes kept driving the growth and adoption of bitcoin for people looking for alternatives to traditional finance, and for a better way to store, send, and share value. In the ten years since bitcoin’s launch, it has gone from a novelty pitched on a niche forum in the remote corner of the internet, to the anchor of a new global financial movement. Along the way, the idea of bitcoin — of digitally-native money that can exist without needing a trusted (and costly) middleman — matured into an entirely new sector based on the principles of decentralization and global accessibility. What’s become apparent in the last ten years is that bitcoin solved a larger problem than the vexing double-spend issue. By combining the power of computer code with the basic rules governing currency (portable, divisible, fungible, etc.), bitcoin 50
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By combining the power of computer code with the basic rules governing currency (portable, divisible, fungible, etc.) bitcoin can be made into programmable money, which can be used for tomorrow’s sophisticated applications. PUT ANOTHER WAY, SOFTWARE IS EATING MONEY!
TOP 10
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Bitcoin
Ethereum
XRP
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Cardano
113.46 BILLION
18.43 BILLION
12.69 BILLION
5.09 BILLION
4.70 BILLION
4.38 BILLION
2.71
BILLION
2.77
BILLION
can be made into programmable money, which can be used for tomorrow’s sophisticated applications Put another way, software is eating money. The full value of bitcoin and other cryptocurrencies is yet to be realized or even fully understood for that matter. By now, there are more than 2,000 different kinds of cryptocurrencies, hundreds of companies supporting the new decentralized economy, and an addressable market of seven billion people and growing daily. At the most recent high water mark at the end of 2017, bitcoin reached the price of $20,000, while the entire crypto market hit $795 billion in early January of 2018. Future forecasts of the crypto market cap reaching many multiples of where it is today sometimes feel like over-exuberant speculation. But looking at the data from the past decade, and overlapping some basic market fundamentals, paints a different picture of unprecedented opportunity.
Investing in cryptocurrencies While cryptocurrencies are still volatile in terms of market movements (the price of all cryptos have retracted massively from the all-time highs in 2018 in what insiders call crypto winter), the growth in value of the entire industry is happening at a pace unrivaled by anything else in history. As bitcoin and other cryptocurrencies continue to mature, there are several high-level, long-term investment ideas developing. One of the biggest ways that cryptocurrencies get their value is by the size of the network they are able to create. In the case of bitcoin, the network is designed to gain strength and value as it expands and becomes more distributed. Game theory and other tactics are baked into the underlying protocol to help it become more resilient and robust as time goes on. The networks also have their own economies that grow with use. Tokens or coins are created for services such as maintaining and verifying the network, and users pay transaction fees in native tokens, which essentially creates a flywheel effect as the networks grow, the coins become more valuable, which encourages more adoption.
BILLION
In the digital age, the size and integrity of a network are the basis for unicorn-level valuations. In some ways, cryptocurrencies are growing like the early internet, only this time people are able to invest in the underlying protocol or infrastructure and not just the applications being built on top of those protocols.
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Another major investment thesis for bitcoin is that it is a digital store of value. In many parts of the world, having a place to keep assets outside of the control of a government or centralized financial institutions is a
1.78
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major breakthrough and extremely valuable. In more stable economies, having a portable and extremely liquid place to store assets and wealth also has its advantages. Before bitcoin, there was no secure storeof-value digital asset. It should be noted that gold has a market capitalization of about $8 trillion and exists largely as a store of value with no significant use for commerce. So even if cryptocurrencies like bitcoin were able to capture part of the market share, the potential crypto market valuations have very significant room to grow. Bitcoin and other cryptocurrencies are also being used as a form of digital collateral as more traditional or physical assets become “tokenized” or digitized. Some
FACTS: [Crypto glossary]
BITCOIN: Bitcoin is both a network and a cryptocurrency. The network is open source and globally distributed, and acts like a public ledger that registers transactions. The currency is created through a process of computation and is designed to reward the confirmation of transactions and maintenance of the network. Launched in 2009, Bitcoin is the first massively adopted cryptocurrency. ALTCOIN: An altcoin is any
EASY TO USE
FAST
FLEXIBLE
MOBILE
SAFE
cryptocurrency other than Bitcoin. In the early days of cryptocurrencies, there were only a handful of altcoins. Today there are more than 2,000 altcoins that serve different functions.
BLOCKCHAIN: A blockchain is the data structure that makes public, permission-less cryptocurrencies like Bitcoin work. A blockchain consists of groups of confirmed transactions (blocks) that are linked (chain) forming a record that would be costly in terms of computation and energy resources to go back and undo. Blockchains allow people to interact and share data (or in the case of Bitcoin, share value) without the need for a centralized data gatekeeper such as a corporation or government. CRYPTOCURRENCY:
WHAT IS ABRA? Abra is the world’s first global investment app. Unlike other investment apps, cryptocurrency exchanges or wallets, Abra’s non-custodial model is backed by the Bitcoin blockchain using smart-contract technology, which means it’s secure, private, and gives users full control of their money. The company empowers consumers to invest in 30 crypto assets, and soon US stocks and ETFs across the world, all within a single, easy-to-use app. Abra users can also quickly exchange multiple crypto or fiat currencies and instantly transfer currencies to other Abra users. Founded in 2014 and headquartered in San Francisco, Abra is available in over 155 countries. For more information, visit https:// www.abra.com/
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Cryptocurrencies, crypto assets, or just crypto most often refers to a system of creating and accounting for value on a blockchain using public key cryptography. Public key cryptography means that users hold a private key, which is used to access the assets stored on a blockchain, while a public key exists so that certain transaction details are publicly auditable.
MINING: A process of using complex
computation to maintain a public blockchain in a proof-of-work network.
WALLET: A cryptocurrency wallet
contains the details necessary to access blockchain-based assets. Wallets contain a public key and a private key. Private keys need to be secured and properly stored. A public key can be shared and can act like an email address for sending and receiving funds from others.
companies are doing this with real estate. The global investment app, Abra, for example, enables users across the world to get access to top US stocks and ETFs like Apple, Tesla, S&P500, etc. all using bitcoin as collateral. Such a use case was never possible before bitcoin. Crypto-collateralization opens up access and investment potential to a range of assets by making things like micro and fractional investing possible. Considering that the US stock market alone contains an estimated $34 trillion in value and the value of the global real estate market is $8.5 trillion (2017) — if small fractions of those markets became collateralized by bitcoin or cryptocurrencies, that would represent orders-of-magnitude crypto market growth. There are a number of other key potential uses for bitcoin and other cryptocurrencies that are fueling today’s valuations. People are building everything from a decentralized, a-political reserve currency of the future to platforms capable of instantaneously brokering complex business transactions with multiple inputs via smart contract functionality. Crypto is being used for the backend of what people are calling Web 3.0, which, if the Web 2.0 movement is any indication, will generate new products, services, and create value for entrepreneurs and investors.
Role of cryptocurrency in a traditional portfolio So this might be a good time to temper all future science-fiction-sounding investment speculation with some real-world analysis of how crypto can fit into a traditional investment portfolio that is made up of stocks and bonds. One interesting takeaway is that even small allocations of crypto to a traditional investment portfolio can have noticeable impacts. One way of evaluating how crypto performs in the context of a traditional investment portfolio is to look at how it performs at the asset class level. (For the analysis that follows, bitcoin was used as a proxy for the crypto sector more broadly). The most popular traditional asset classes for investors have been stocks (equities), bonds (fixed income), commodities (such as gold and other metals and oil), and real estate. All of the asset classes are attractive to investors because they behave differently during times of economic growth and contraction. Using the characteristics of these assets, investors optimize portfolios for upside, but also for risk, which requires diversifying across a number of assets to make sure the portfolio is slightly insulated from major economic movements.
Modern portfolio theory provides a handful of benchmarks for making decisions about how to compose holdings consisting of diversified investments. Two of the major concepts, as they apply to crypto as a new investment class, are correlation and the Sharpe Ratio. Correlation looks at how different asset classes compare in comparison to one another. Ideally, a portfolio consists of low-correlation assets, so that major market movements in one sector are covered by another. The development of cryptocurrencies as an independent asset class gives investors another option for hedging their portfolios with uncorrelated assets. Diversifying across different and uncorrelated asset classes can not only have an impact on overall portfolio returns, but it can also serve to reduce overall exposure risk. Another aspect of the cryptocurrency asset class is that for the last six of the past nine years, crypto has had a higher Sharpe Ratio when compared to traditional asset classes. The Sharpe Ratio is a measure of risk-adjusted return. Since crypto has traditionally been a volatile asset, investors need a way to understand the net effect of that volatility. So using tools like the Sharpe Ratio, show that despite its volatility, crypto still has positive returns when compared to risk a majority of the time. Assets with a higher Sharpe Ratio are beneficial to overall portfolio health because they indicate the opportunities that might lead to higher upside. The properties that make crypto somewhat of an outlier in terms of an asset class are the same reasons why it is also a great addition to a traditional portfolio. Even the addition of small percentages help impact the overall risk/reward profile and returns.
The future will be decentralized Cryptocurrencies are often over-hyped or else poorly understood. But somewhere in the middle of those two extremes exists a unique financial and technological opportunity. Cryptocurrencies represent a shift in the foundation of finance. A simple analogy is that cryptocurrencies will do for money what the internet did for information. Eventually, cryptocurrencies could become the basic financial infrastructure of the future, playing a role as the transport and settlement layer for everything from payment and credit to loans and investments. The greatest news is that despite the enormous growth across all facets of the emerging crypto sector, it is still very early in terms of investor opportunity.
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Well, you can tell by the way I use my walk, I’m an MTA man, no time to talk…
STAYIN’ ALIVE BIOCERAMICS AND THEIR IMPACT ON VITAL PULP THERAPY IN IMMATURE PERMANENT TEETH by Jarod Johnson, DDS
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STAYING ALIVE AND CURRENT IN THE WORLD OF PEDIATRIC DENTISTRY CAN BE CHALLENGING, ESPECIALLY AS WE ENCOUNTER RAPIDLY CHANGING TECHNOLOGIES AND MATERIALS.
When I competed dental school in 2013, MTA was a topic of discussion in the endodontic department. However, as students we were told it was too expensive, too hard to handle, and turned teeth black. Just a few years later, the market has been flooded with new bioceramics that are less expensive, easier to handle, and don’t stain. While this is great news, I wasn’t taught how to use MTA in dental school, and some of the things I was taught we’re finding out are not true. Fortunately, I’ve been able to further my education and have learned to work with these materials to achieve more favorable clinical outcomes. As a practitioner, my goal is to provide the best care possible to my patients, and that means keeping vital teeth alive. Reaching this goal helps me achieve three things: 1) improve access to care for underserved children (patients with state-funded insurance are less likely to have the opportunity to see an endodontist), 2) prolong tooth life, and 3) avoid the cost of more expensive and time-consuming procedures such as non-surgical root canal therapy. Patients presenting with dental trauma or deep carious lesions in permanent teeth can greatly benefit from the use of bioceramics. The goals of treatment for these teeth should be to maintain a vital, healthy pulp, and conserve tooth structure. The development of bioceramics has provided practitioners treatment options based on sound evidence, and allows them to utilize more conservative treatment modalities to treat these carious or damaged teeth.
Dental Trauma A common use for bioceramics in treating dental trauma involves dealing with a complicated fracture or a fracture where the pulp is exposed. In such cases, a partial pulpotomy can be performed to preserve pulp
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vitality. Using bioceramics can be extremely advantageous in cases where the apex of the tooth has not closed, allowing apexogensis to occur. Complicated fractures or fractures that expose the pulp may be accompanied by other dental injuries such as luxation, but can still be treated with a partial pulpotomy. A partial or Cvek pulpotomy is a procedure that removes a portion of the coronal pulp to help maintain vitality of the radicular pulp. Success rates have been reported to be 81–96 percent. The procedure can be performed days after the trauma occurred, if healthy radicular pulp is apparent (see Figure 1).
Understanding Caries Progression It is well established scientifically that dental caries is caused by the presence of a biofilm on tooth structure fueled by a substrate. The most commonly associated bacteria are Streptococcus mutans, Streptococcus sobrinus, and Lactobacillus acidophilus. 2 As the bacteria utilize the substrate for fuel, they produce lactic acid and demineralize tooth structure. Should the environment remain favorable for their proliferation, they begin an onward march toward the dental pulp through dentin tubules. What practitioners must ascertain is what pulpal response occurs in relation to this invasion. Studies have shown that the presence or absence of bacteria is key to determining if it is possible to maintain a vital pulp. 3 Thus, if bacterial incursion can be stopped or prevented, the pulp will be able to respond favorably. Two terms, “affected” and “infected,” are key to our understanding of lesion progression. 4 Both terms are used to describe dentin and the pulp. At any given point in the development of a lesion, areas of tissue may have bacteria present (be infected). On the other hand, some areas may not have bacteria present, yet may still demonstrate physiologic changes (be affected). The areas with bacteria present are known as infected, and those that have changed but do not yet have bacteria are affected. The “million-dollar question” is this. At what point in the progression of a carious lesion does the pulp become irreversibly inflamed? One may ask when treating deep lesions, “How can we ensure that the pulp has not been infected?” A key study by Stanley, et al, analyzed extracted teeth to determine how much remaining dentin is required in order to categorize a pulp as maintaining a healthy status. They found that less than 0.5 mm of remaining dentin thickness was associated with pathologic pulpal changes. 6 While this thickness can only be measured histologically, it may play an important role in a practitioner’s clinical decision making process and in reaching a proper diagnosis which will serve as the basis upon which to make a treatment recommendation.
Figure 1: Technique: 1. Local anesthetic 2. Rubber dam isolation 3. Shallow pulpotomy with diamond bur and copious irrigation. 4. Hemostasis controlled with NaOCl 5. Rinse and dry 6. Calcium silicate material placement (1.5—3 mm) 7. Glass ionomer base 8. Final restoration
TRAUMA CASE: Luxation and root fracture A 9-year-old female presented with luxation and a complicated enamel-dentin-cementum root fracture of her permanent maxillary right central incisor (#8). She presented two days after trauma, and presented with healthy pulp tissue. Tooth #8 underwent a partial pulpotomy to a point below the fracture, SmartMTA (Sprig) and a Glass Ionomer Base (Ionostar Plus, Voco GmBh) were placed, and the tooth was restored with Filtek Supreme (3M). Her tooth was then splinted with a non-ridged splint. At subsequent recall, the tooth was restored. The tooth remains positive to vitality testing and is asymptomatic. It will be monitored per the IADT guidelines and will likely need orthodontic extrusion pending the response to pulpal therapy.
Pre-op periapical, partial pulpotomy with MTA and splinting, post-op restoration.
A PARTIAL OR CVEK PULPOTOMY IS A PROCEDURE THAT REMOVES A PORTION OF THE CORONAL PULP TO HELP MAINTAIN VITALITY OF THE RADICULAR PULP.
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Diagnosis Diagnosis is derived from the Latin word dia, meaning “through,” and the Greek verb ginoskein, meaning “to know.” To reach a diagnosis, in the words of a respected radiologist at the University of Iowa, Dr. Axel Ruprhect, “You might actually have to know something.” Currently the American Association of Endodontists recognizes the following seven pulpal diagnoses 7:
Normal Pulp: A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing.
Reversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
Symptomatic Irreversible Pulpitis:
A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain.
Asymptomatic Irreversible Pulpitis:
A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma.
Pulp Necrosis: A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing.
Previously Treated:
A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments.
Previously Initiated Therapy: A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy) Vital pulp therapy focuses on the first four of these diagnoses: normal pulp, reversible pulpitis, and both asymptomatic and symptomatic irreversible pulpitis. In order to have the best chances at reaching the proper pre-treatment diagnosis, it is imperative that practitioners gather reliable evidence to reach an accurate diagnosis. To obtain the most accurate diagnosis, clinicians must gather information from subjective and objective evaluations. The subjective evaluation should involve information that the patient provides the clinician. It includes the patient’s medical history, the chief 58
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complaint, prior history of the tooth (trauma, caries, treatment), type of pain the patient is experiencing, and what causes the pain (i.e. biting, hot, cold). A thorough clinical exam will provide the clinician’s objective findings. The exam should include charting of restorations and decay on the tooth, visualizations of any fractures or cracks, sensibility testing such as cold and electric pulp tests, a soft tissue exam, radiographic exam, and periodontal exam. By combining the subjective and objective findings clinicians, should be able to reach a pulpal and periapical diagnosis. In the treatment of deep carious lesions and conflicting findings, caries removal may be necessary to assess restorability of the tooth and reach a pulpal diagnosis.
Challenges in Diagnosing the Pediatric Patient While behavior may be one challenge facing a clinician when treating children, another is reaching a proper diagnosis. Children are often unreliable reporters, and parents may be poor historians. This can make gathering subjective findings difficult for providers. A diagnosis may also be compounded by the use of over-the-counter analgesics or the improper prescription of an antibiotic by another provider (i.e. a prescription when no swelling was detected). 8 Sensibility testing, or pulp testing (Cold, EPT), in children also poses difficulties. The use of sensibility testing increases the reliability that a proper diagnosis is reached. Pediatric patients may not effectively communicate a positive or negative response to a test. This is compounded by the fact that the delta nerve fibers are one of the last tissues to grow into the tooth, and without these fibers, a false negative may occur. 9 With immature permanent teeth, studies show that cold tests are more reliable. 10 The author’s opinion is that in cases where conflicting results are reported, complete caries removal should be completed.
Indirect Pulp Therapy Indirect pulp therapy (incomplete caries removal) is the most common choice by pediatric dentists for deep carious lesions in the cases of reversible pulpitis. This choice is based on the principal that by removing the ability of bacteria to access substrate, the carious lesion will stop growing due to the lack of fuel for proliferation. Indirect pulp therapy can be performed with a high success rate if the proper diagnosis is reached. Studies have shown that this treatment can be highly successful. 11
Figure 2: Technique: 1. Local anesthetic 2. Rubber dam isolation (in case of accidental pulp exposure) 3. Incomplete caries removal, ensure a clean dentin enamel junction, avoid pulp exposure 4. Rinse and dry 5. Calcium silicate material placement (1.5—3 mm) 6. Glass ionomer base 7. Final restoration
INDIRECT PULP THERAPY A 7-year-old male presented with multiple carious lesions on primary and permanent teeth. Of note, two lesions presented on permanent mandibular first molars with immature apices. Due to patient cooperation and the extent of dental needs, the patient was treated under general anesthesia. Teeth #19 and #30 received indirect pulp caps and full coverage restorations. Upon 18-month recall apexogenesis is evident. While currently evidence does not favor one material over another, calcium silicates such as SmartMTA deserve attention in the coming years given the sealing potential.
# 19 & 30 Pre-op periapicals
# 19 & 30 18-month recall periapicals
INDIRECT PULP THERAPY (INCOMPLETE CARIES REMOVAL) IS THE MOST COMMON CHOICE BY PEDIATRIC DENTISTS FOR DEEP CARIOUS LESIONS IN CASES OF REVERSIBLE PULPITIS.
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A wide variety of bases and liners are available on today’s market. Practitioners should give some thought as to whether a certain base or liner makes an impact on clinical outcomes. Studies have evaluated the remaining number of bacteria present in stepwise caries excavation (two visit protocol) and indicate there is no statistical difference between IRM, GI, and RMGI in the number of bacterial CFUs upon re-entry. 12 This conclusion suggests there is no difference, from a bacterial standpoint, among these materials. Other literature has shown that a bioceramic will entomb bacteria in dentinal tubules. 13 While further research is needed to confirm clinical significance, it is a promising finding for practitioners utilizing these materials for indirect pulp therapy. In order to be candidates for indirect or direct pulp therapy, teeth should be free of signs of necrosis and irreversible pulpitis. They should be free of spontaneous pain (or history thereof ), respond to sensibility testing, be free of swelling or sinus tracts, and have normal radiographic findings. Abnormal radiographic findings include calcifications in the pulp space, apical pathosis, or a widened periodontal ligament 14 (see Figure 2).
Direct Pulp Therapy While most endodontists practice direct caries excavation (complete caries removal, which may or may not result in a pulp exposure), it has been shown that even those who make a conscious effort to avoid pulp exposures still experience them. 15 Practitioners who plan to complete an indirect pulp therapy should be well versed in the management of a pulp exposure, in case it should occur accidentally. Current evidence also suggests that there has been an improvement in direct pulp caps due to advances made in materials led by the use of calcium silicates. Current success rates for direct pulp caps have been shown to be 80.5 percent to 96 percent. 16, 17 Historically, direct pulp caps have been carried out using calcium hydroxide (CaOH). Calcium hydroxide has a high pH which is favorable for the formation of hard tissue and is unfavorable for the proliferation of bacteria.18 When placed in contact with the dental pulp, it forms a layer of coagulative necrosis and releases calcium ions into the pulp. Underneath the layer of necrosis, hard tissue forms. 19 The tissue that forms can be seen radiographically; however, studies show it is very porous (over 89 percent have tubular defects at two years) and that calcium hydroxide washes out over time. 20
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Over the past decade, more bioceramics have entered the market. These materials are composed of tricalcium, and dicalcium silicates and have many of the same advantageous properties that are associated with calcium hydroxide. They have a high pH, are bacteriostatic, and form dentin bridges when placed in contact with the pulp. 21 This author’s opinion is that calcium hydroxide should no longer be used for direct pulp caps or pulpotomies (see Figure 3).
Pulpotomy A pulpotomy can be performed in cases of reversible pulpitis or irreversible pulpitis. Pulpotomies are a common and familiar procedure for pediatric dentists to perform in primary teeth. The concept behind the pulpotomy is the removal of the inflamed and infected coronal pulp, while leaving healthy radicular tissue intact. This treatment is based soundly on the idea that if the pulp is free from bacteria, it can heal. Evidence is mounting that symptomatic permanent teeth (and those vital with signs of a widened periodontal ligament) can be treated successfully with bioceramics. A retrospective study published in the Journal of Endodontics showed that teeth with clinical signs of irreversible pulpitis that were treated with a pulpotomy had a success rate of 87 percent. In comparison, teeth that had periapical lesions had a reduced success rate of 76 percent. The average recall time was 36 months. The authors concluded that clinical signs of irreversible pulpitis and the presence of periapical radiolucency should not be considered contraindications for a pulpotomy. 24 Partial pulpotomies in permanent teeth have also been shown to be highly successful in cases of irreversible pulpitis. A randomized clinical trial showed 85 percent success rate for partial pulpotomies in mature teeth at two years. The authors concluded that calcium hydroxide was not a suitable pulpotomy material 25 (see Figure 4).
Pulpotomy treatment is based soundly on the idea that if the pulp is free from bacteria, it can heal.
Figure 3 : Technique: 1. Local anesthetic 2. Rubber dam isolation 3. Caries Removal (Caries detect as adjunct) 4. Exposures Controlled with 6% NaOCl cotton pellet (2—10 minutes), if hemostasis is not achieved consider irreversible pulpitis (pulpotomy, RCT, extraction) 5. Rinse and Dry 6. Calcium Silicate Material Placement (1.5—3 mm), cover the entire pulpal floor. 7. Glass Ionomer Base 8. Final restoration
DIRECT PULP THERAPY A 12-year-old male was referred for root canal therapy of all permanent first molars. After a clinical exam, sensibility testing, and radiographs, it was determined all four molars were vital. The patient was anesthetized and rubber dam isolation was obtained. Caries excavation on the maxillary molars resulted in pulp exposures. The pulp was disinfected with sodium hypochlorite, and SmartMTA (Sprig) was placed. The teeth were restored with Ionolux (Voco GmbH). Upon recall, the tooth was restored with a stainless steel crown (3M).
Pre-op periapical
Post-op periapical
Pre-op periapical
18-month recall
18-month recall
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Figure 4 : Technique: 1. Local anesthetic 2. Rubber dam isolation 3. Caries removal (caries detect as adjunct) 4. Amputation of coronal pulp 5. Hemostasis with 6% NaOCl cotton pellet (2—10 minutes), if hemostasis is not achieved consider irreversible pulpitis (pulpotomy, RCT, extraction) 6. Rinse and dry 7. Calcium silicate material placement (1.5—3 mm) 8. Glass ionomer base 9. Final restoration
PULPOTOMY A 9-year-old female presented for a comprehensive oral evaluation. The patient was asymptomatic at the time of evaluation and had no oral complaints. Upon evaluation, a stainless-steel crown was noted on tooth #30, and a periapical radiograph was ordered, taken, and interpreted. The radiograph showed an apparent open margin on the distal, with recurrent decay, and a widened periodontal ligament. The patient was anesthetized, and rubber dam isolation was placed. The crown was removed with a high-speed handpiece. After crown removal, the patient was symptomatic even though profound anesthesia was demonstrated. A temporary restorative material was placed, and the patient was rescheduled. At a subsequent visit, the patient obtained adequate anesthesia, and the tooth was found to be vital (asymptomatic irreversible pulpitis). A pulpotomy was performed with sodium hypochlorite and SmartMTA (Sprig) as hemostasis was obtained at the canal orifice. The tooth was restored with Ionolux (Voco GmbH). At a later recall, the tooth was subsequently restored with a stainless-steel crown (3M).
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Pre-op periapical:
Recall periapical:
Periapical radiolucency and prior treatment. Note the widened periodontal ligament of the mesial and distal root.
18-month recall showing resolution of the widened periodontal ligament.
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Conclusion When treating children with deep carious lesions in permanent teeth it is important to gather all the necessary information required to make an accurate diagnosis. Evidence suggests that many conservative options exist for treating these teeth successfully. As a practitioner who serves many patients with limited access to specialists such as endodontists, I truly believe my patients have benefited from using vital pulp therapy with calcium silicates. Perhaps we will discover that a simpler solution to these complex problems exist, if we will spend the time to make an accurate diagnosis and use the most effective materials available today.
REFERENCES: 1. Koopaeei M, Inglehart M, McDonald N, Fontana M. General dentists', pediatric dentists', and endodontists' diagnostic assessment and treatment strategies for deep carious lesions: A comparative analysis. J Am Dent Assoc. 2017;148(2):64–74. 2. Casamassimo P, Fields H, McTigue D, Nowak A. Pediatric Dentistry: Infancy through Adolescence. 5 ed. St Lous: Elsevier; 2013. 3. Kakehashi S, Stanley R, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surgery, Oral Medicine, Oral Pathology. 1963;20(3):340–349. 4. Mount G, Hume W. Preservation and Restoration of Tooth Structure. 2nd ed: Knowledge Books and Software; 2005. 5. Reeves R, Stanley H. The relationship of bacterial penetration and pulpal pathosis in carious teeth. Oral Surg Oral Path Oral Med. 1966:59–65. 6. De Rossi A, Bezerra Silva L, Gaton-Hernandez P, et al. Comparison of Pulpal Responses to Pulpotomy and Pulp Capping with Biodentine and Mineral Trioxide Aggregate in Dogs. J Endod. 2014;40:1362–1369. 7. American Association of Endodontics. AAE Consensus Conference Recommendation Diagnostic Terminology. J Endod. 2009;35:163– 164. 8. Read J, McClanahan S, Khan A, Lunos S, Bowles W. Effect of Ibuprofen on masking endodontic diagnosis. J Endod. 2014;40(8): 1058–62. 9. Johnsen D. Innervation of Teeth: Qualitative, Quantitative, and Developmental Assessment. J Dent Res. Apr 1985;64:555–63. 10. Levin LG. Pulp and Periradicular Testing. Pediatr Dent. 2013;32:125–128. 11. Maltz M, de Oliveira E, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int. 2002;33(2):151–159. 12. Duque C, Negrini T, Sanco N, Spolidorio D, Alberto de Souza Costa C, Hebling J. Clinical and microbiologic performance of resin-modified glass-ionomer liners after incomplete dentine caries removal. Clin Oral Invest. 2009;13:465–471. 13. Yoo J, Chang S, Oh S, et al. Bacterial entombment by intratubular mineralization following orthograde mineral trioxide aggregate obturation: a scanning electron microscopy study. Int Jour Oral Sci. 2014(6):227–32. 14. Orhan A, Oz F, Orhan K. Pulp Exposure Occurance and Outcomes after 1- or 2-visit Indirect Pulp Therapy Vs. Complete Caries Removal in Primary and Permanent Molars. Pediatr Dent. July/Aug 2010;32(4):347–355. 15. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol. 1996;12:192–196. 16. Miles J, Gluskin A, Chambers D, Peters O. Pulp capping with mineral trioxide aggregate (MTA): a retrospective analysis of
carious pulp exposures treated by undergraduate dental students. Oper Dent. 2010;35(1):20–28. 17. Bogen G, Kim J, Bakland L. Direct Pulp Capping with Mineral Trioxide Aggregate: an Observational Study. J Am Dent Assoc. 2008;139(3):305–315. 18. Stanley H. Pulp capping: Conserving the dental pulp—Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol. 1989;68:628– 639. 19. Cox C, Keall C, Keall H, Ostro E, Bergenholtz G. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosth Dent. 1987;57(1):1–8. 20. Cox C, Subay R, Ostro E, Suzuki S, Suzuki S. Tunnel defects in dentinal bridges: their formation following direct pulp-capping. Oper Dent. 1996;21:4–11. 21. Sakar N, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physiochemical Basis of the Biologic Properties of Mineral Trioxide Aggregate. J Endod. 2005;31(2):97–100. 22. Camilleri J. Staining Potential of Neo MTA Plus, MTA, Plus, and Biodentine Used for Pulpotomy Procedures. J Endod. 2015;41(7): 1139–45. 23. Bogen G. Protocol: Direct Pulp Capping Using MTA Two-Visit Technique. Nd. 24. Linsuwanont P, Wimonsutthikul K, Pothimoke U, Santiwong B. Treatment Outcomes of Mineral Trioxide Aggregate Pulpotomy in Vital Permanent Teeth with Carious Pulp Exposure: The Retrospective Study. J Endod. Feb 2017;43(2):225–30. 25. Taha N, Khazali M. Partial Pulpotomy in Mature Permanent Teeth with Clinical Signs Indicative of Irreversible Pulpitis: A Randomized Clinical Trial. J Endod. Sep 2017;43(9):1417–21. 26. Schwendicke F, Stolpe M. Direct Pulp Capping after a Carious Exposure Versus Root Canal Treatment: A Cost-effectiveness Analysis. J Endod. November 2014;40(11):1764–1770. 27. Cobourne M, Williams A, Harrison M. A Guideline for the Extraction of Permanent Molars in Children. London: Royal College of Surgeons; 2014. 28. Mente J, Hufnagel S, Leo M. Treatment Out Come of Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: Long-term Results. J Endod. 2014;40(11):1746–51.
I TRULY BELIEVE MY PATIENTS HAVE BENEFITED FROM USING VITAL PULP THERAPY WITH CALCIUM SILICATES.
JOURNEY OF THE SCRUBS
HOW SERVING OTHERS IN AFRICA HELPED ME GROW A PASSION FOR DENTISTRY by Mayanne Quion
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carefully packed my new teal and gray scrubs in my luggage. They were going with me to Kenya on a mission trip for two weeks. Our group was traveling half way around the world to Nairobi where we would catch a bus for a seven-hour bus ride to our destination in an underserved area of the country in which we would help build a school cafeteria and dining hall, as well as provide free medical and dental care to people in surrounding areas in need. I was looking forward to serving the people in Kenya—
an experience of a lifetime.
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W
hat motivated me the most and really got me excited was the thought of being part of a dental team. Ever since I was a young girl, I have always enjoyed going to the dentist for routine cleaning appointments. Now that I am older, I have become more interested in dentistry as a profession. Here was an opportunity to get some practical, hands-on experience in actually providing dental care.
In all honesty, I did not know what to expect. I had no idea what helping out in a dental clinic would be like and couldn’t help asking myself a number of questions. How will I react to the sight of blood? What will it feel like probing around in someone’s mouth? What if my hands shake due to my nervousness? The one thing I did expect was this. I planned to be the one bringing a blessing to the needy people in Kenya by providing free dental care. But I would soon realize that my assessment was distorted and needed adjustment. When I discovered I was definitely being assigned to the dental team, I was over the moon with excitement and anticipation. The night before clinic began, I made sure that my scrubs were laid out and ready to go. Early the next morning, I put on my scrubs, put my hair in a ponytail, and tucked my pen into one of my scrub’s many pockets. I was set. I looked the part. I felt the part, and I knew that the medical and dental work that we were going to provide people was going to be a blessing to them. I felt a bit nervous not knowing what I was actually going to be doing or what to expect when we arrived at the site where we would be working. After reaching the clinic site, I stepped out of the bus to see dozens of people eagerly waiting outside, hoping to see a doctor or dentist. I knew we would have a long day ahead if we were going to see every patient already waiting in line. Wanting to see as many people as we possibly could, we quickly started setting up our table and laid out the instruments, gauze, gloves, needles, and medicines. Simple plastic chairs available for the patients to sit in while they got their teeth examined lined the walls of the tent which would serve as our operatory. In a pensive moment surveying this situation, I realized right then and there that the planning required to make this clinic possible had taken months of preparation. Dedicated dentists had sacrificed time and donated supplies. Furthermore, they willingly volunteered to serve people to the best of their ability.
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TOP LEFT: Mayanne assisting Dr. Ham in a dental procedure. TOP RIGHT: Weimar Academy students surrounded by lots of new friends. TOP MIDDLE: A precious boy who attended the dedication of the newly-built cafeteria. BOTTOM RIGHT: Gira e looking back at us while on safari with Nairobi skyline in the back ground. BOTTOM LEFT: Weimar Academy students assisting Dr. Fisher.
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TOP LEFT: Maryanne’s first tooth extraction. BOTTOM LEFT: Waving to happy children along the road during our daily bus ride. BOTTOM RIGHT: Smiling kids from the Getare SDA School enjoying stickers. SIDE BOTTOM: The Head Mistress, teachers and students joyfully receive soccer balls and other gifts from our team. SIDE MIDDLE: Maranatha Volunteers International and Weimar Academy finish the new Getare SDA School cafeteria building in six days. SIDE TOP: Mayanne cleaning mortar joints of the cafeteria’s inside walls.
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One by one the patients filed into the tent. As I assisted the dentist, I heard patients describe the pain and problems they were feeling in their mouth. Listening to these people talk, I realized that many of them probably had never seen a dentist before, either because they did not have the money, or because a dentist was just not available locally. The vast majority of the patients that we saw had large amounts of tartar, decay, and dark spots covering their teeth. Some of them, through no fault of their own, may have even lacked the simple knowledge of basic dental hygiene and how to care for their teeth. Very few patients that we saw had bright pink gums and clean white teeth. Being interested in dentistry, I wanted to take advantage of every opportunity given to me. In time, I had the amazing opportunity to pull my first tooth. Initially, I was afraid that I wouldn’t be able to handle the sight of blood, but I was determined that if the dentist offered to allow me to extract a tooth, I would.
BEING INTERESTED IN DENTISTRY, I WANTED TO TAKE ADVANTAGE OF EVERY OPPORTUNITY GIVEN TO ME.
luxury of sitting in nice, comfortable dental chairs with padded head rests. Rather, they are sitting in plastic chairs while one of us supports their head, using our arms as a brace. It gradually dawned on me that even though these people may have walked barefoot to our clinic and may live in modest, humble homes, yet they still possessed an inner strength and dignity that caused them to break forth into beautiful smiles of gratitude. This was the beginning of a wakeup call I needed. Most of the time, I was so busy I didn’t have time to even stop or think of myself and how tired I felt. Yet, somehow serving these warm-hearted people energized me with each smile and encounter I experienced. My first fear vanished, and I loved the experience of serving the people—every minute of it. After this opportunity of working in a barebones, outdoor dental clinic, I realized that what was most memorable and worthwhile was not my being able to wear my new teal and gray scrubs nor the thrill of visiting an enthralling game park once our clinic concluded. Rather, it was about serving grateful people and expecting no material reward in return. What I received was something priceless and unforgettable—the return of a smile, the expression of a thankful heart, the clasp of a grateful handshake. That one moment I enjoyed spending with the appreciative, smiling patient whose tooth I had just pulled—knowing that we had relieved her pain—was the best possible reward. Money cannot buy a heart full of thankfulness or a smile of gratitude. I thought that I was the one traveling to Kenya to bless people there. But I was wrong. In fact, I was the one that received the blessings, blessings I will cherish for a lifetime.
The opportunity finally came. A patient came in experiencing pain caused by one specific tooth. The only option available was to extract it. The dentist asked me if I would like to pull the tooth. I was all in; I wanted to learn. I reached for the extracting forceps and started to carefully twist the tooth. Eventually it popped! I relished this experience, but the best part about the procedure was seeing the patient’s sweet smile, expressing relief that I had relieved her agony, and that she would go home and eat food without pain. This experience was, for me, the biggest reward. As time passed, I began musing to myself. Here I am in Kenya assisting people who need and want help to relieve their pain. Here I am in my clean scrubs while many of these patients are wearing tattered shoes and are forced to wash their clothes in muddy river water. Most of them do not have the opportunity to just stop by the dentist for a quick checkup. They don’t have the www. sp r i g u sa.co m / S p r i n g 2 01 9
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