Should You Remove All Stained Dentin?

Caries removal can be reproducible — this means consistent regardless of patient or practitioner. Caries detecting dye is essential to creating reproducible caries removal endpoints, but the techniques doctors pair with the dye are what prevent pulp exposure and maximize bond strength.

When Dr. David Alleman pioneered his methods for determining caries removal endpoints, he found that any doctor he trained could achieve the same predictable caries treatment that he saw in his own cases. How caries is treated is the first step in a restoration and determines whether that restoration succeeds or whether that restoration fails.

Article referenced in this episode:

• Anderson M, Charbeneau G. A comparison of digital and optical criteria for detecting carious dentin. J Prosth Dent. 1985;53(5): 643-646.

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• August 8-9
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Transcript

0:33

Well, welcome to episode four of season two. In the Six Lessons podcast. We've had a lot of great interaction with the Altman Center's Instagram, the reels that have been posted and the cases are being posted. One got you're not going to believe this 300,000 taps on it or exposure or whatever. I think he got 500 something likes, but the idea is that when something goes viral like that, it's because a lot of people are like, what's going on? What's going on? And it goes way back to 2010. I was, hired by Kuraray to lecture full time for a couple of years. Two and a half years. I was on the road two weeks every year at different study clubs and conventions and presenting the six lessons that I'd been, you know, doing since 1995, developing it. And then when I got hired in 2010, that's 15 years of research and development of beta testing. Basically, I'd been doing this for 15 years, and the development that got most dentists most freaked out when I'd give a lecture was, we're not going to do complete caries removal. Well, without caries detecting that you never do complete caries removal. So the first article is a very important article that was, published 1995. So this is Anderson, co-authors were Charbeneau,, professor, University of Michigan Maxwell Anderson eventually went to work for Delta Dental in Washington. Anyway, I've heard him speak, and this is an important article, but it tried to disprove the need for caries detecting die, and in reality it proved the need for caries detecting die. So this is how it worked. Caries detecting dye is introduced into the American market in the early 80s in England. They had terrible success with it because they did what Fusayama said you should do remove all stained tissue. So Fusayama was the master. He's the one who first had a successful bonding system to dentin, the father of adhesive dentistry. He's earned that title, for sure. But even fathers make mistakes. Don't ask my seven kids. But the idea is that Fusayama, when he said remove all stained tissue, he was mainly working on anterior teeth. Anterior teeth have a 10th of the occlusal forces put on them is posterior teeth. What does that mean? How does that relate to caries actually relates very significantly, because a crack in enamel will move about seven microns a tooth. that’s not cracked will expand about seven microns. So this expansion of an anterior tooth of seven microns, it can eventually, over decades, cause cracks in those cracks that move. Now you have about seven expansion and seven with the crack. They can start having some defect, but on the posterior teeth, the cracks don't move seven microns. They move 175 microns, because the forces are ten times that the measured forces. In the finite elemental analysis, the Tevan Oganesyan, and Pascal Magne, published in 2007, showed that these cracks, when they open around a restoration, have about 175 microns of opening, and that means you're going to have 175 bacteria living there colonizing. And that was confirmation of an earlier paper published in 2000, which was a confirmation of an earlier paper published in 1998 by Walker, that showed that a defect in the tooth is called the lamellae, which is a well known study defect in all natural teeth. It's a crack that goes not through enamel, but through the day and into the tooth. That's a naturally occurring defect. Walker in 98 published a paper that I actually referred to, a paper that was published in 1974. You guys weren't even born in 1974. So when, this paper by Walker is published in 98, inquiring minds like me wanted to know where was his inspiration. How did he figure this out? The references in the back of his article gave some hints, and some of them went back to 1952. Caries in enamel, published in the British Journal. Some of the references went back to early 1992, which is Edwin, a kid who was an expert in England on cherries. But for example, kid when she got the caries detecting dye and started to experiment with it, found that she was exposing pulps all the time. The clinical studies that were done in the 50s, 60s, 70s, and 80s on the difference between direct pulp caps and indirect pulp caps all showed that a direct pulp cap has three times the chance of killing the pulp. And, beautiful Paper was published in 2008 by Van Thompson. Documenting is the analysis of all these studies. So Van Thompson did a meta analysis on the difference between pulp caps, direct pulp caps, indirect pulp caps. And, he published this in the Journal of the American Dental Association. But all of a sudden, if you started to think about these lamellar that naturally occurred and cause caries in the tooth, then you say, because you're a microbiologist, as I was, that how many bacteria do you need to produce enough acid to start analyzing the inter-tubular hydroxy appetite and the peri-tubular hydroxyapatite. And it was obviously the this was important information. And then when Graeme Milicich use this article to write the article he wrote with Tim Raney on occlusal effect carries what they were saying is that occlusion causes these cracks. And in those gaps you have this development of a carious lesion that has nothing to do with brushing and flossing. When I read that article in 2000, it was like a jaw drop microphone drop moment because all of a sudden I understood what I had seen in my previous 22 years of dental practice. After graduation. For 22 years, I would see my wing x ray after bite wing x ray six months or a year after year, no decay, and the patient has good oral hygiene. And then, lo and behold, the next exam they would have a class two lesion. And you know, I'd almost say you need to floss better. And then I caught myself and like this patient has been coming here for three years. They brush and floss. They have regular cleanings. Why in the world are they having this class two lesion come out of nowhere and you know, I'm in a busy practice. I'm raising a large family. I'm not really thinking. I'm just keep doing as the lesion. You do a class two. And then in 1995 when I understood the caries detecting dye, was important. I started using it. But then as I investigated the literature and came upon this in a probably around the same year of 2000, I came across this study that was done at the University of Michigan, the Anderson and Charboneau study. And then I, was actually conversing with another faculty member at University of Michigan named Hamilton at an ADA convention. We had a little bit of an argument because he was convinced that visual, tactile use of an explorer and different color changes could tell you when all the caries were gone. And this guy's at Michigan. This was 15 years. I'm probably having this to this discussion in 1998. So about 13 years after this published study. And I said, well, what do you think about the study from Anderson and Charboneau? How do you interpret that? And Hamilton got a little defensive because he was probably about my age at that time, and he didn't want to be proven wrong. So he kind of just dismissed it as, well, there's defects in the DEJ. This is what it showed. It said 30%, 35% of the time you would leave caries stained caries. And so the interpretation is what does the stating mean? And so he had this in his mind for 15 years that this wasn't understood. So basically for 15 years he wasn't looking for an answer. If you put your head in the sand and don't look for an answer, you're not going to find it. But many studies investigated that phenomena of staining dredge areas, and what they found out is that those areas had irregular collagen formations. And the irregular collagen and formations that are part of this deck often can strip the the stain. The how deep are the deformations or the defects in the dredge? Well, they're like one tenth of a millimeter. Well, one tenth of a millimeter is 100 microns. That's how thick my hairs used to be. Maybe they're thinner now, but basically, if you pull one of your hairs out, even without a microscope, you should be able to see it. That's why you can see a even without magnification. But the idea is, if you have these defects that are smaller than a human hair, but they trap it. Once they dye stain at red, you can see them even better. And so this University of Michigan study that says, I said, the DEJ. and 30% of the time you got staining, then the people who didn't want to use caries detecting dye would say, well, it's never going to cause a problem. But in 1998, it showed that it did have a problem. And then doctors like me in 2000 started to look for the phenomena that was named by Rainey and Milicich. It's called occlusal effect carries meaning under causal forces. You have these cracks past the DEJ they get infected and they start a carious lesion. That wasn't well, I mean, you could have said, well, that's a theory. No, the theory comes before you actually observe something. And I've been teaching this since 2003. Every single doctor that I've taught has now seen occlusal effect caries. And they take photographs and the treatment is complete. Caries removal at the DEJ complete carries removal is the protocol. The pulp doesn't live there. You don't have to worry about it if you have a stain, DEJ., because it's not carious, but it's defective and traps dye. I'm okay with that. But still, the people who do not use caries detecting dye because they're afraid of pulp exposures. Well, how about the caries that's far away from the pulp by the DEJ.. Do you think that's a possibility that that causes a lesion that eventually could infect the pulp? That is the science. Those are the facts. But maybe my tone of voice is a little bit accusatory. I'm too judgmental. Whatever reason, people don't want to listen to it. You got to deal with it. But now we have the question. In my mind, I'm doing the research. Fusayama isn't very helpful because we have now Fusayama saying complete caries removal. And Edwina Kid and her, friend up in University of Toronto, Dorothy McCollum, say, yeah, that causes too many pulp exposures, Van Thompson and other researchers know that that will kill the pulp more times than not. But the Japanese for 40 years have studied this, and now we know there are six shades of red. And those six shades of red are three. We call pink and three we call red. The red cannot be re mineralized and it's highly infected. And so we want to remove that when we're not exposing a pulp, but in my private practice now I have the pulp vitality test of positive to cold Steve Buchanan my classmate has every year for 20 years, said, yeah, that's the best way to figure out how the bulb is responding to the infection. But this pulp that does not have periapical lesion and it is responding to cold, has deep carries on a radiograph. It looks like it's into the pulp. Well the infection is into the pulp even when the lesion is only one millimeter. past the DEJ. There are already bacteria being phagocytized in the pulp. That's what a microbiologist the cell biologist, the pulp biologist, would know about dental pulps and carious infections. And so I always had the question, okay. Last time it was a small lesion. I was able to remove all decay. I mean, all stain. Oh, okay. Everybody's happy with that. But then the next time it's a little deeper and I'm getting closer to the pulp. And as I'm getting close to the pulp, my question is where is the pulp? And that's when I had to do something that nobody else had ever done. There had been anatomical studies of teeth for 100 years, but nobody ever said, how far is it to the pulp from the occlusal surface versus the contact area of coronal Dentin versus the CEJ versus the route hadn't been done? I mean, you know, I'm above average intelligence. I just thought, well, let's measure. So I cut 50 teeth and half measured them. All of them were within a half millimeter of five millimeters. You won't get into the pulp if you measure down the long axis three millimeters, you will not get into the pulp. If you measure horizontally from the adjacent contact area. That was the sophistication. The nuance comes when it pulp tapers. Okay, so when a pulp tapers. And we go into the root. Then we expand our nuance into a one millimeter area all the way down to the apex of the tooth, that the pulp doesn't live there. So as I went deeper and deeper, both towards the pulp and down the root, then I evolved the technique, published partially in 2012, in the Alleman and Magne paper. And that's what I did. And then I started to teach it. But whenever I would go on the road to teach doctors not versed in caries detecting dye and not versed in dental anatomy, really in the detail that they needed to be, they were just blown away because my teachers taught us complete caries removal. I went to this dental school is the best dental school in the world and they said complete caries and then they might even, you know, have a favorite professor. Doctor Hamilton taught me complete caries removal. Well, I get this loyalty. You know, I get this, but it's like I'm never listening to a dentist who has spent three hours a day for a decade in trying to figure this out. I can understand how people get really, really loyal to doing something that they've been doing, especially if it means that it might show that they could have done better in the past, and they want to justify what they did is the best. You got to forgive yourself if you make mistakes in the past, just say, I did my best. That was my father's best phrase that he gave to me. My heritage was do your best. If you mess up, do a better next time. Whether I was cutting the lawn, you know, or trying to learn physics is like, well, if that's the best you can do, that's the best you can do. I mean, last night we had 20 doctors who had gone through the mastership give us their cases that they had been doing over the last two months, developing and integrating the six lessons. They were fantastic. Every one of them showed progress, but everybody had questions as they were trying to put this case, because everything's theoretical until it's right in front of you and all of a sudden it's your case, it's your tooth, it's your patient's tooth. The theories have to be at some point put into practical application. And that's where a mentor can help. Photographs helped tremendously. This one viral I think it's called a reel I'm not sure there's one viral really got 300,000 looks, 300,000 eyeballs and 500 likes or something like that. It showed a bicuspid that had ultra deep decay, no peripheral lesion. It tested positive to cold. Davey proceeded with complete caries removal in the peripheral zone. It was 3 or 4mm sub gingival after the decay in the root was removed, but he was able to isolate it with his band within the band. Copper band technique that he has perfected and taught hundreds of times, and posted on his Instagram hundreds of times. But they've completed the restoration using the six lessons approach. Three years later, pulp stil tested vital. And then, last month we had one that was even better. We had Brad Perrett posts an eight year follow up on a molar that every dentist that doesn't understand the science would have done a root canal and then a post, build up and a post, crown. It was on a 14 year old. This patient now is 22 years old as a molar restored. No leakage, no symptoms, no crown, no root canal, 22 years old. That Pope was young. It fought a good fight. Are there areas of scarring or necrosis that now was not vital in that pulp? The only way you could find out is to extract it and slice under a microscope. How good would that make the patient feel? You know, donate your tooth to see if we made the right decision. Of course we made the right decision. You've got eight years of success after eight years, even if the pulp died after eight years. That would be a good decision, because you'd have eight years of function and that eight years of function under hydration means that it's less likely to develop cracks and gaps underneath the restoration. I mean, these are all, in my mind, very much questions that have been answered decades ago. But for most dentists, they'll look at it and say, oh no, this is this is going to die. And, you know, the only problem is that they're wrong. So this is the way that science gets put into practice. But you have to have people who first are introduced to it. And then usually the people who deny it will eventually say, maybe I to look at it again, because Brad Perrett’s an honest guy, Davey Alleman’s, an honest guy, you know, they don't have any vested interests other than their stated Hippocratic oath of doing no harm in your in your medical dental treatment. Okay, so I think that wraps it up for episode four in season two. Till next time, stay bonded.