Dr. Ron Kaminer

	Silver Salts have a long history of intraoral use. “Ohaguro” is an ancient Japanese tradition in which silver salts were used to dye teeth black. 

	It was also discovered that these silver salts had anti-caries properties. In the early 1900s, Percy Howe, the director of Forsythe, used silver to arrest dental disease but the concept fell out of favor quickly because of the unwanted dark stain of the tooth associated with its use. 

	Over the years, there has been a tremendous amount of research associated using silver fluoride or silver diamine fluoride (SDF) in dentistry. Various studies have demonstrated the arrest of decay, inactivation of streptococcus mutans, histological changes of dentin and changes in the hardness of tooth structure. With the trend strengthening towards minimally invasive dentistry, the use of silver fluoride has gained popularity once again for caries arrest in day-to-day dentistry.

	As the uses for silver fluoride expand, more science has emerged in the journals. Studies over the past few years have emerged using silver fluoride to treat deep decay as a hope to prevent root canal (partial cares removal). Studies have also shown that placing silver fluoride in the base of a preparation followed by GIC capping layer, will not have a deleterious effect on bond strengths. That all being said the stain still exists and for many, the advantages of caries arrest, desensitization and minimally invasive procedures are outweighed by the dark silver stain associated with silver fluoride use.

	The Members of Catapult Education were asked to evaluate a new product from Southern Dental Industries, called Riva Star. Riva Star has a unique chemistry.

	After applying silver fluoride onto the tooth per the manufacturer’s instruction, one applies a second chemical, potassium iodide, directly onto the silver fluoride. The potassium iodide can decrease the incidence of teeth turning dark without having any negative effect on the final restoration. In the USA, Riva Star is approved as a desensitizing agent. In other countries, such as Canada, South Africa and Brazil, the same product received registration for anti-caries. 

	After the group reviewed Riva Star, they were asked if they would incorporate it into their practice. Keeping with the trend of minimally invasive dentistry, 100 percent of the reviewers said they would incorporate this product into day-to-day practice. Getting a 100 percent acceptance on any product from this well-respected and well-earned group is rare, so this in itself shows true promise for this new product.

	When asked what type of patients they thought would benefit from Riva Star, the answers vary but covered much of our regular patient population. Pediatric patients were an overwhelming response, but another group, the geriatric patient, was also a common response. The geriatric patient who develops root caries may benefit tremendously from the “off label” use of caries control using Riva Star.

	Interestingly, a few respondents from the group subscribed to the philosophy of using this product for deep caries either as an anti-sensitivity agent, or as an application over decay left in the preparation in very deep situations. The latter is an interesting concept, which has gained acceptance in Europe but has been much slower to be adopted here in the United States.

	While all the respondents felt the literature was strong concerning SDF, the need for more long-term studies for the off label use of caries control was mentioned.

	As expected, the hesitation by the evaluators in using SDF was purely due to the staining of product on tooth structure. The potential for non-staining was intriguing enough that the group overwhelmingly agreed they would incorporate this product as their SDF of choice in their practice.

	While there have been many “potshots” taken at this product, I can attest to the fact that very often there is little or no staining of the tooth structure and if it stains due to the reaction with extensive decay, by placing a restoration over the SDF, the color change is barely noticeable.

	A few of the evaluators did caution that with the high pH of this product as compared to others on the market, there could be some gingival irritation if too much got on the tissue for an extended period of time. The irritation is similar to the tissue irritation that sometimes occurs following in-office whitening and is very transient.

 show a before and after showing little-to-no tooth discoloration. Based on the groups’ clinical findings that this product worked as described, Catapult Education proudly gave SDI their Catapult Vote of Confidence for Riva Star. This is a product that should be in everyone’s arsenal and, when needed, will come in very handy for performing minimally invasive dentistry.   

	1. Aust Dent J. 2015 Mar;60(1):80-7. doi: 10.1111/adj.12276.
	Effect of silver diamine fluoride and potassium iodide on residual bacteria in dentinal tubules.
	Hamama HH1, Yiu CK, Burrow MF

	2. J Contemp Dent Pract. 2018 May 1;19(5):591-598.
	Antibacterial Effect of Silver Diamine Fluoride on Cariogenic Organisms
	Lou Y1, Darvell BW2, Botelho MG3.

 2016 Aug;51:15-20. doi: 10.1016/j.jdent.2016.05.005. Epub 2016 May 18.

	5. Randomized clinical trial on arresting dental root caries through silver diammine fluoride applications in community-dwelling elders.

Leave decay in my cavity? You must be kidding!

	6. Knight GM, McIntyre JM, Craig GG, Mulyani.

Articles

Catapult Review: Two steps to reduce stains and enhance bonding

	As dentistry continues to immerse itself in new technologies, Catapult Education members were asked to evaluate the new compact NLZ electric micromotor handpiece system from NSK Dental. Yes, electrics are in full growth mode in our operatories, so the question to our group was: does this raise the bar in electrics? The answer among our reviewers was absolutely.  

	To start, we all love the quieter electrics for sure, and the continued trend is even less noise. Ninety percent of the evaluators noted that the NSK handpiece was quieter than other handpieces and I found this to be a much quieter than any other system I’ve used. When I connected a different manufacturer’s handpiece (which the unit’s design accommodates), it was considerably louder than the NSK handpiece. Patients hate the sound of the drill and a less noisy handpiece should make “drilling” a far less negative experience. Considering that hearing loss among dentists has been found to be an ongoing problem, why bother with ear plugs when using air turbine handpieces?

	The next item we evaluated was the compact size of the NSK NLZ control unit and yes, it is that small!  The group loved the size and in dentistry, smaller is better. The majority of us mounted the unit beneath the bracket table and the installation was extremely easy as the control pad is separate from the main unit. The NLZ touchscreen control panel was easy and intuitive to use.

	Next, let’s talk about flexibility within the system. With NLZ, the system takes electrics to the next level because in this unit one has the ability to have a high-speed electric option for doing preparations, slow speed for all its uses, and then by just pressing a button, one can switch to a reciprocative movement for a wide range of endodontic procedures if desired. With so many endodontic systems moving to a reciprocative movement, we thought this was a wonderful feature. Ultimately it puts three of dentistry’s most used preparation technologies in one place - all run by one control pad.

The NLZ is a new micromotor system that makes this unique technology possible. This results in a more powerful rotation, which is necessary when working with today’s restorative materials such as e.max and zirconia. Rather than pushing an air-driven bur through such materials, electrics, with their high torque, cut through these materials meticulously with so much less effort. I found this system to have even more torque than other electrics. One great advantage of electrics is that they don’t work via turbines and as a result, these harder materials that take their toll on air-driven turbines are a nonissue with electrics. Add in the two-year bumper-to-bumper warranty and enough is said on this issue.

	I remember when I got my first fiber optic handpiece and though I was elated with the light, I wanted more illumination (don’t we all?). The fiber optic light is extremely bright - in fact, the brightest I have evaluated - and makes it easier when working in the posterior areas of the mouth.  You can never have enough light! I think that makes a huge difference in delivery of care.

	Lastly, a few added findings within this new electric handpiece. The NLZ has a “contra angle checking function” that eliminates the “hot handpiece.” It was developed to prevent burns via the head of the handpiece overheating. The operator is usually unaware that this occurring. This can be caused by deterioration of the gears and/or improper maintenance. If the NLZ handpiece is overheating during operation, the rotor automatically slows down or shuts off. I have seen this happen twice thus far and I find this function a wonderful safety feature. The handpiece is so “smart’ because it can recalibrate and correct the torque during its use.

	Every reviewer in this evaluation was an electric user and overwhelmingly the group loved this handpiece. One evaluator commented that the NLZ handpiece had become their go-to handpiece, and another said, “This is the best electric handpiece I have ever used!” All reviewers felt overwhelmingly confident in using the NLZ in their office and almost everyone stated they would continue to use it. For these reasons, the NLZ electric micromotor handpiece system receives the Catapult Vote of Confidence.

Catapult Education members evaluate this innovative ‘3-in-1’ handpiece system.

Taking electrics to the next level with the NLZ electric micromotor handpiece system

Check out these two clinical examples that illustrate how 

 can be used clinically to achieve outstanding results.

Since 1955, when Dr. Michael Buonocore challenged dentistry with his primitive yet innovative form of bonding, materials and techniques have evolved dramatically. Yet despite the improvement in materials and techniques, when surveying a recent group of dentists, I realized the group still uses a variety of techniques and materials to achieve a similar outcome. Some still use phosphoric acid and then an adhesive, some use self-etch primer and an adhesive, and some use a single bottle, self-etching primer and bond.  

One of the negative characteristics with self-etch primer and bond as compared to a phosphoric acid etch and bond system is adequate but decreased bond strengths. It is for this reason that many still like to use phosphoric acid prior to using a one bottle self-etch primer and bond (for improved bond strengths). This last statement is true for enamel but if you use 37% phosphoric acid on dentin prior to a self-etch primer and bond, you’re likely to encounter a decrease in bond strengths and potential sensitivity. This occurs by the phosphoric acid removing more dentin mineral that can be filled by self-adhesive monomers. 

A new generation of bonding materials called universal adhesives have been created so dentists have the option of total-etch or self-etch with no concern of decreased bond strengths when used in conjunction with phosphoric acid on dentin. One such product, Futurabond U from 

, offers simplicity of use with outstanding bond strengths. Futurabond U differs from its predecessor Futurabond DC in a number of characteristics.  Futurabond U has a lower PH than conventional self-etching systems like Futurabond DC. This lower PH will not allow for over etching of the already etched dentin in the total-etch technique. Futurabond U has a new surfactant that improves its wettability, leading to lower surface tension and improved bond strengths. Finally, the monomer chemistry is different than its predecessor thus enhancing the effect of the new acid.   

Futurabond U doesn’t differ from its predecessor in one of its most useful traits: the packaging. The innovative foil packaging of Futurabond U really separates it from all other adhesives on the market. The foil packaging consists of two compartments, each with its own unique chemistry. By pressing on a certain spot in the packaging, the material from one side shoots internally to the other side, allowing for an instantaneous fresh mix of the chemistry.

Step 1: In the self-etching technique, a microbrush is now used to penetrate the foil into the material and then consequently brush it onto the tooth. This eliminates any evaporation of material that can occur from a bottle being left open or material being dispensed onto a dappen dish (Fig. 1). In the total-etch technique, a 37% phosphoric acid is used on dentin and enamel for 10 seconds, rinsed off followed by the application of Futurabond U. The material is brushed on for 20 seconds, air dried for five seconds and light cured for 10 seconds. At this point the tooth is ready to accept the restoration.

Figure 1: A microbrush is used to penetrate the foil into the material and brush it onto the tooth

Because of its low film thickness, Futurabond U is ideal for indirect as well as direct restorations. Its chemistry allows it also to be used with any dual-cure or self-cure materials, eliminating any potential material incompatibility issues. Bond strengths in these instances still remain quite high, a feature not often seen with other systems. Futurabond U also bonds to zirconia, metals, aluminum oxide and silicate ceramics without the need for any other primers. It also is quite strong with bond strengths more than 30 MPa to enamel and dentin.

The following two clinical examples will illustrate how Futurabond U can be used clinically to achieve outstanding results.

As previously stated, Futurabond U can be used in the self-etch mode or with phosphoric acid in the selective-etch or total-etch mode.

Step 2: In this case, when bonding to an incisal edge, we elected to use phosphoric acid first to improve bond strengths of the composite. Our pre-op photo shows a chip on the incisal edge of tooth No. 9 (Fig.  2).

Figure 2: Pre-op photo shows a chip on the edge of tooth No. 9

), is used on the enamel for 10 seconds (Fig.  3). After thoroughly rinsing off the etchant, a mylar strip is placed between 8 and 9, and Futurabond U is brushed on the enamel for 20 seconds and air dried for five seconds. Futurabond U is then light cured for 10 seconds. One of the nice things about Futurabond U is that you can see it on the tooth after curing (Fig.  4). This reinforces the fact that you have adhesive in place before placing the direct restorative.

Figure 3: A 37% phosphoric acid is used on the enamel for 10 seconds.

Figure 4: Futurabond U can be seen on the tooth after curing.

Step 4: The final restoration is placed (GrandioSO Shade A1, VOCO), light cured, finished and polished (Fig. 5).

Figure 5: The final restoration is placed (GrandioSO Shade A1, VOCO), light cured, finished and polished.

Incipient decay can be treated conservatively with tunnel preparations to avoid removing unnecessary tooth structure. Radiographic examination in this case reveals early onset decay in and around the contact area between the bicuspid and the molar (Fig. 6).

Figure 6: Radiographic exam reveals early onset decay in and around the contact area between the bicuspid and the molar.

Step 5: Clinical exam reveals no occlusal break from decay (Fig. 7). A  tunnel preparation approach is chosen to access and remove the decay on both teeth (Fig.  8).

Figure 7: Exam reveals no occlusal break from decay.

Figure 8: A tunnel prep approach is chosen to access and remove the decay on both teeth.

Futurabond U is used here in the self-etch mode according to manufacturer’s instructions (Fig. 9).

Figure 9: Futurabond U used in the self-etch mode according to manufacturer's instructions.

Step 6: After light curing, GrandioSO Flow (VOCO), a highly filled esthetic flowable composite, is used to fill the preparation (Figs. 10-11). This material, while strong, is also very esthetic as evidenced by the natural appearance and blending of the restoration with the existing tooth structure.

Figures 10-11: After light curing, VOCO's GrandioSO Flow highly filled esthetic flowable composite was used to fill the preparation.

Universal adhesives such as Futurabond U are the newest advances in dentistry as it relates to the bonding process. They eliminate the need for multiple adhesive systems and allow you to bond restorations in any manner that you like. In other words, they allow you to “have it your way.”

Check out these two clinical examples that illustrate how Futurabond U can be used clinically to achieve outstanding results.

How to bond with optimal results in 6 easy steps

Minimally invasive dentistry has become a hot topic over the last few years. New technology and techniques have focused on earlier diagnosis and detection as well as early intervention of disease.

For  years the dental explorer has been the “staple” in most practices for diagnosing caries. The explorer’s use and interpretation of its findings is filled with inaccuracies. Studies have shown other modalities are more accurate than the explorer, our standard of caries diagnosis in dentistry.

 In this article I’ll review recent advances in caries diagnosis and treatment to offer a fresh perspective on minimally invasive operative dentistry.

Before we can seek improvement, we must first acknowledge that our traditional means of occlusal cavities diagnosis has faults. We all know it is far easier to stick an explorer into a tooth like we were shown years ago in school, than to seek another modality to diagnose dental disease. Studies show our explorer’s accuracy varies, with some studies reporting accuracy at 25%.

 Keeping that number in mind, and extrapolating that data a bit further, we can assume we are leaving areas of decay untreated.

As an adjunct to the explorer, many practitioners use caries detection dye. Caries detection dye comes in a variety of colors depending on the manufacturer. Caries detection dye works on the surface of teeth identifying areas of collagen and calcium displacement.

 Studies concur that if teeth are cleaned and free of debris, caries detection dye is accurate.

 Yet dye can be messy, interpretation can vary from practitioner to practitioner, and false positives are a major concern.

Laser fluorescence, as an adjunctive or stand alone tool, shows promise in the field of caries detection.

 KaVo Corp.’s DIAGNOdent (kavo.com) is a 655 nm caries detection laser that uses the diffraction of light to measure the extent of decay within the tooth. An audible sound alerts the practitioner to the presence of decay and a numerical value corresponds to the depth of the decay. While this device improved dramatically on traditional modalities, interpretation of results, especially in regard to early lesions, varied from practitioner to practitioner.

, seems to hold the most promise. It is highly accurate and solves many of the earlier problems with other techniques and modalities. SOPROLIFE uses blue LED light at a wavelength of 450 nm. This wavelength excites dentin and its reaction produces a light signal called fluorescence. This signal is very low intensity compared with the blue LED signal emitted by the 

When dentin is healthy, the spectrum (color) of the fluorescence is green. When the dentin is infected the spectrum is red. SOPROLIFE can be used in a diagnostic mode (pre-treatment) or in treatment mode throughout the entire excavation process.

The idea of dentists using SOPROLIFE is well thought out. Initially white light visualization (camera mode) allows for clear visualization of the dentition on a computer or television screen. Images in macro mode display in great detail and can be recorded and saved within a patient’s digital record. After pressing a button, the white light changes to the blue LED light, and detection mode is initiated. This allows dentists to perform a comprehensive laser-like caries exam and to record these images in a patient’s digital record. Once treatment is initiated, another button can be pressed, switching to treatment mode, and the practitioner can use SOPROLIFE to ensure a complete excavation of the lesion is achieved.

As evidenced here in clinical case 1, normal staining of the Class V composite is differentiated from decay with the SOPROLIFE (Figs.1 & 2). Caries detection dye may not be useful here and it’s possible this stained composite may only be polished as opposed to replaced. Once the composite is removed, the SOPROLIFE’s diagnosis mode kicks in and we can easily verify if decay is present (Fig. 3). (Note also slight decay on the lateral incisor.) Without SOPROLIFE, our options are caries detection dye or feeling if the dentin is soft with a sharp spoon excavator. Most practitioners use the latter and sometimes they can be fooled. It is apparent here that the dentin is still infected (slight red hue) and must still be excavated regardless if it feels soft or not.

Many patients have erosions on the buccal surfaces for a variety of reasons. These lesions, called abfractions, are sometimes restored or not, depending on if they are sensitive or if they have decay. Sometimes they are just stain and minimal treatment, if any, is done. The SOPROLIFE can quickly and accurately help the practitioner determine whether to perform a restoration. The initial exam of this canine clearly reveals the need to excavate the lesion (Fig. 4). Upon confirming with CDD, we see the dye is not as accurate. The SOPROLIFE image clearly shows an area of decay but the dye shows little penetration with mostly marginal staining (Fig. 5). Again, even after excavation is apparently complete, a slight red hue is present and we must remove more dentin (Fig. 6).

Routine hygiene examinations also are enhanced with the SOPROLIFE. Most hygienists use the dental explorer to determine if there is decay in a tooth. Here, (Fig. 7) we see some staining on the occlusal surface of the molar but the explorer does not stick at all. This stain potentially could be left or “watched,” but the SOPROLIFE clearly shows a problem that must be treated (Fig. 8).

For someone to invest in new technology, the piece of equipment should do a number of things. Most importantly it should be better than the current modality the practitioner is using. It also should be ergonomic and should either make treatment easier and/or allow dental professionals to be more productive in the office. SOPROLIFE not only meets some of these criteria, it meets all of them, therefore making it a must have in today’s progressive dental practice.

Dr. Ron Kaminer is a 1990 graduate of the State University of New York at Buffalo. He maintains two offices, one in Hewlett, N.Y. and one in Oceanside, N.Y. He lectures nationally and internationally on Minimally Invasive Dentistry and technology and is a clinical consultant for numerous dental companies. He can be reached for questions at 