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There were runes all about us, signs, and symbols - we did not understand them - Transitional Dentistry continued
Kevin Scally

"Ideas should freely spread from one to another over the globe, for the moral and mutual instruction of man, and the improvement of his condition".

Thomas Jefferson:

At the 1999 meeting of this association in its previous form: The New Zealand Hospital Dental Surgeons Association, I presented a paper titled: "The Whys of Dentistry: Zen and the Art of Oral Care: A medical management model of dental disease". 1

There I reviewed current dental practice as taught, practiced, and prescribed in Western World and asked some questions: Why we do do that voodoo that we do do so well? And is there a suite of conservative alternative treatments that could be prescribed until the oral diseases in at risk patients were under control? The treatments described in that paper could also be substituted for communities in difficult circumstances and in other defined hospital patient groups. These suggestions have evolved from some serious sole searching and a careful assessment of what we think we are doing with conventional dental treatments in some defined circumstances.

Dentistry’s focus has expanded over the last three or so decades and it now claims a wide field of interest about the oral cavity. You can call this the big picture. The scope of concern includes:

Craniofacial abnormalities

Oropharyngeal malignancy

Severe oral infections: NOMA, Aids related oral conditions

Craniomandibular disorders

Periodontal disease

Enamel and dentine loss:

Dental decay,

Tooth erosion

Tooth Abrasion

Other tooth-to-tooth contact tooth tissue loss

Internationally there is a crisis in conventional health care including oral health care delivery as presented in this list. Not the least is dental decay. Innovative and radically different approaches are needed to meet the burgeoning burden of oral disease debt.

At a recent pre WHO meeting of Commonwealth Health Ministers the need for Oral Health to be part of General Health and not separate from it was reinforced. One of the outcomes and recommendations of the conference was to encourage local dental associations to improve oral health and to increase their initiatives in finding ways to improve the oral health in deprived communities.

Initiatives are more likely to come from individual dentists up to their armpits in the problems rather than from a committee or an association. The exception might be the New Zealand Society of Hospital and Community Dentists.

This challenge of developing initiatives in the oral health care treatment has been my clinical life in Hospital Dentistry for a number of years. Recently I have been offering some radical solutions to delivery and I am suggesting a different way of looking at the problem. I have discovered that I am not alone in this and what I am presenting comes out of my Transitional Dentistry tool kit.* I believe the Transitional Dentistry approach is high quality, cost effective, and integrates a number of advances in oral health care. It suggests approaches to meet the management of dental decay for disadvantaged communities and individuals with high disease profiles.

I believe oral health care and treatment delivery is on the brink of a new era.

My development of Transitional Dentistry has been out of a frustration that what we have to offer as a profession does not seem to be socially just and ethical appropriate. Transitional Dentistry, as I understand it, and as I have developed it, integrates a number of advances in dentistry into a new model of oral heath care. While individual oral health care practitioners may be able to action alternatives, communities at need require the delivery of services through organizations. Committees run these organizations and more often than not the status quo prevails. Fortunately advances in treatments and current thinking in restorative dentistry are challenging some of the time honored surgical management model of caries. Slowly, the professions custodians are embracing these changes, (but there is still a feeling that what is on offer is second rate or temporary).

 

The emerging solutions to some of the problem:

 

  • Chemical removal for dental decay2.
  • Advance of biomimic materials.
  • Advances in imaging techniques, especially panoramic radiographs # 3
  • The promise of vaccines.
  • The use of Casein Phosphopeptides as remineralisation systems4.
  • And a profession that is examining the rationality of what is currently being prescribed and delivered, and doing something about it

To realise the promise of new materials, and methods of oral health care delivery several components of knowledge transfer need to be welded together.

The philosophy

The procedures

Understanding of the dental decay process,

Who does it?

The politics within the profession environment, both international and national.

Since last years presentation 5I had the opportunity to revisit and spend some time in Vietnam looking at the needs of a Third World country and how it was progressing appropriate oral care delivery. I also had an opportunity to introduce some of ideas to a Ministry of Health Task that was asked to review the role and training of the School Dental Therapist.

My musing also attracted the attention of Dr Per Åke Zillén of the World Dental Federation (FDI) after a meeting in Hanoi. These were presented through him to the FDI. As he noted:

I also raised the issue of "other categories" of dental personnel, as I assume that the FDI in due course (and probably reluctantly) will recognise that oral health in the world will not be solved by dentists only.

This was in response to my argument that a new class of Oral Health worker be considered. What I am calling an Oral Groomer 6.

Essentially what is at stake is appropriate and timely treatment, and a work force that can deliver it. I believe that what emerges will look very different to what we currently understand as dental practice. To realise this change in oral care delivery may take the will of a Government in a manner not to dissimilar to the initiatives the New Zealand Government took when it introduced the School Dental Service.

The evolution of ART demonstrates that you don’t need to be a dentist to do the treatment and you probably don’t need to be a Dental Therapist either. The team I envisage will use oral surgical assistants.

Also the model I have been promoting could be called a Social Model of care delivery and it is based on a personal and social grooming concept.

In essence, I am suggesting that oral health delivery needs to reinvent itself by developing an auxiliary that grooms mouths. A little like a hairdresser or beauty therapist. Focus would be on a personal grooming model, engaging an individual’s interest in oral health gains. Dentist, Dental

Therapists, and Dental Hygienists would treat the pathology but the primary focus would be on a feeling of a well mouth. This is what we experience in the medical area. Often the first port of call for a "dis-ease" is an alternative therapist, a massage therapist, for example. In that professional is well trained they refer on to a medical practitioner for further expertise, diagnosis, and treatment as a team.

The auxiliary would also be trained to undertake a variety of simple oral care duties including those of an oral surgical assistant. They would debribe and restore advanced decay lesions under the supervision of a Dental Therapist or Dentist. This approach is at the heart of ART and it is not new in other areas of surgery. In many dental practices dentist train their chairside assistants to scale and polish teeth. It is illegal but the assistant will often go on to formal training as a Dental hygienist or Dental Therapist. Such an auxiliary would also be able to progress through the oral health system with additional training. I believe this model would address the workforce short fall and deliver appropriate oral health care to the financially disadvantaged and disadvantaged communities. In addition the approach of oral grooming changes the experience of dentistry from negative to positive. The model I am proposing also addresses the problem of oral health care delivery for individuals who rely on care givers.

Now for some background to the symbols I am proposing to mark the state of the tooth at the time of treatment. The focus is on urgent treatment of advanced dental decay.

In the 1950s Massler revisited the philosophy that G V Black proposed7:

"The complete divorcement of dental practice from studies of pathology of dental caries, that existed in the past, is an anomaly in science that should not continue. It has the apparent tendency to make dentists mechanics only" G B Black 1908.

Massler showed that dental decay could be managed in a two step procedure he called Indirect Pulp Capping. A variation of this was to use Calcium Hydroxide underneath the Zinc Oxide Eugenol dressing as the preferred initial management of deep lesions. More recently Edwina Kidd has been promoting "stepwise excavation"8

In dentistry there is often confusion in diagnosis of dental decay: the radiographic picture is translated in the clinicians mind into a histological picture. In the best of clinical worlds what we see on a radiograph would translate into the true histological situation of the dentine’s demineralised and denatured collagen. The radiograph would also indicate the state of the dental pulp. At the moment we can’t do this and the diagnostic tools are rather crude. Yet as GV Black suggested and Massler demonstrated, and more recently Mount and Kidd have shown, there is significant remineralisation potential of demineralised dentine.9-12 Also, the dental pulp is a robust tissue with significant reparative potential. Clinically the aim is to protect the pulp from the ingress of the bacterial toxins and to create a situation whereby demineralised dentine can be remineralised via viable odontoblasts dental pulp.

To realise the tooth full potential the lesion at treatment needs to be handled on the basis of their radiographical and symptomatic grading. In the case of a R4 lesions the tooth needs to be managed with a restoration (GIC or reinforced IRM) and the dentine and dental pulp given an opportunity to heal. A favorable response should be confirmed radiographically before proceeding with a definitive restoration. (See Table 1 for a summary of the various classification currently in use to label the degree of tooth tissue destruction from dental decay.)

Some bright spark (I have yet to find out who) introduced red, green and white reinforced Zinc Oxide Eugenol to indicate to the next clinician (sometimes themselves) the state of the dentinal-pulpal complex at the time of treatment. However with the general acceptance of GIC as a "temporary" restoration this coding opportunity was lost. In its place I have used the lightest shade of GIC to indicate the restoration was placed as a "temporary" but there is no universal acceptance of this as a tagging system. This approach gives no information about the condition of the tooth, the clinical symptoms on presentation, or the differential diagnosis at the time of treatment.

In 1999, in an attempt to remedy this situation for myself I began using preset cylinders of Ketac silver. Out of this idea has developed a system of shapes. The system is simple, intuitive, and information rich.

It is part of an audit system to document what has been done to a tooth and the condition of the tooth at the time of treatment. The coding system I have developed enhances the value of using GIC as the preferred primary material in the management of dental decay.

So what I wanted in a tagging system

Easy to see

Acceptable to the patient

Biologically inert

An intuitive system of shape that gave core information

Coded or matched to and existing logic or systems within the profession

A system of shapes that lend themselves to providing more information

Variety of colours

Useful to the next oral health clinician

Useful in a Public Health environment

Consistent with the existing body of knowledge on symbols and coding

Universally accepted

Not dependent of high tech

Have sufficient built in redundancy to be developed

Over the last year I have talked and corresponded with a number of colleagues, both nationally and internationally, and the response to the idea of an auditing system has been overwhelmingly positive. The more sophisticated suggested putting a barcode in the tooth. While this approach may have merit in the First World the philosophy I have been working within is to develop clinical techniques that are suitable for all clinical environments, especially Third World situations and Third World situations in the First World (hospitals, and university and polytechnic students for example). The philosophy is also appropriate dental decay management within a minimal surgical management model.

I won’t go into the decision making process of surgical intervention, but once that decision has been made the approach is conservative intervention. Currently thought of as minimal intervention.

The approach I have been taking is to radiographically identify advanced dentine destruction: URGENT dental need, and treat the lesions with a biomimic material - Glass Ionomer Cement.

After the conference last year I returned to the drawing board and began looking at the evolution of human writing, symbols in different working environments. In that research I was directed to the work of Charles Bliss13. The symbology he invented is a universal written language. They include symbolic logic and semantics that include three basic concepts: a philosophy, a noun or object, and an action. It now has a wide following, especially in cognitive disorder rehabilitation. Unfortunately it is unsuitable for a tooth tagging system but its philosophy and the reasoning behind it hold.

The things we need to know in the management of tooth decay

The patient’s presenting symptom

Objective signs of the hard tissue’s condition

An imaged of the hard and soft tissues

A working management plan based on diagnosis

Documentation of the findings at treatment

Some indication of prognosis

What we don’t know

The prognosis for pulpal vitality

The histological condition of the dento-pulpal complex

If the tooth has been treated, what the last clinician saw

What the clinician wants to know when seeing a patient and when establishing urgent dental need

The grade of the lesion (1-4 and beyond)

The presence of pulpitis

Chronic reversible, or irreversible

Acute reversible or acute irreversible

What the next clinician would like to know

How the tooth was treated

The best gestimate of the pulpal state

The best guess at prognosis

And maybe:

The removal method of the effected dentine

The year of removal

Months or quartile of the year treated

 

Symbology – background and examples

 

In chat rooms smileys have evolved into a whole language of symbols developed from the computer keyboard that express emotion: J L (so universal is it that when I tried to type the colon bracket the keyboard automatically converted it into a smiling frowning symbol). They have evolved from keyboard symbols into a scripted emotive language emoticons. (See http://www.uscash.net/tips/chat.html for the emerging lexicon).

This process is a serious study in linguists and cognitive psychology. It also includes efforts to understand the meaning of dance languages in bees and scent languages in dogs. In the case of human communication attempts have been made to transcend oral language with the development of a symbolic sign language and written language.

It was the dream of Leibnitz over 300 years ago that someone someday would invent a universal pictorial symbol system that could be read in all languages.

The study of symbols has its own discipline "symbology" (See the most thorough recent account of symbols to date in Symbol Sourcebook-an authoritative guide to international graphic symbols)14.

The symbols I am proposing are based on this approach. They embody the philosophy of the treatment. This is First Order information.

The shape represents the state or differential diagnosis of dentino-pulpal complex at the time of treatment. This is Second Order information

Additional information can be coded into the symbol (Third Order information).

The constraints of the technology

During the last year I developed a system based on an organic shape consistent with a biological form but the laser could not cut the detail at small point sizes. This limitation of current laser cutting technology limits the size and complexity of the symbols. There are also the constrains of what the unaided human eye can see. This is an important consideration since these symbols will be read in many situations by oral health workers without the aid of magnification and without the aid of special equipment.

The basic shapes are intuitive and the side number (three and four) parallel existing grades of dental decay diagnosis:

For grade 3 lesion a triangle: three sides
For a grade 4 lesion a square: four sides
For a grade 5 lesion a pentagon: five sides
For a pulp expose - a circle
For a transitional root filling _
an oval.
A triangular divot to indicate that the lesion was mechanically prepared
When treated with HealOzone - a rounded divot within the symbol
More information can be added to the symbols by rounding the corners and divoting other faces with specific shapes.
The system is designed to be developed into an information rich audit trail: the philosophy of treatment, the condition of the tooth at time of treatment, and how it was managed


At the time of treatment a grade 4 lesion will often present with an acute pulpitis of unknown reversibility

If frank pulpal involvement was encountered and the treated tooth is considered capable of a pulpal healing I suggest this could logically be graded a Grade 5 lesion. For this condition I suggest a pentagon. 

For a treated pulpal exposure a circle. 

At the moment symbols of a pulpotomy and a transitional root filling are undecided but an oval would be a logical shape for a transitional root filling since this shape suggests the shape of the internal coronal anatomy and entrance into a root canal.

I have provisionally decided that the three additional bit of information would be relevant: the mode of caries removal (at this stage mechanical or chemical) and, with the advent of ozone treatment, a mark for sterilizing the demineralized dentine or root canal.

I have been used Carisolv® to treat a wide range Grade 3 and 4 lesions in-patients both in the hospital and private setting. I have been impressed with the ease with which it removes denatured and deminerilised dentine. In many cases a local anesthetic is not necessary. There is a confidence that the determination between what is irreversibly diseased and what is potentially remineralisable can be determined chemically. It has the potential to take the guesswork out of the treatment and a surgical assistant can undertake the removal of the diseased dentinal tissue. (However, Dr Graham Mount has suggested that this system might over remove potentially remineralisible dentine and has suggested caution in its over zealous use [Personal Communication]).

For a mark of this therapeutic approach I suggest rounding off the corner of the basic symbol. To indicate that the lesion was mechanically treated I suggest a "V". (See Table 1)

The process of modifying the basic symbol is not unlike Korean written script where the mark for the concept is modified by additions to it. Written scripts of many languages, the most obvious being Chinese, have evolved in this way.

A further advantage of nicks, bulges and rounding over the corners of the basic symbol is that there is the opportunity for additional information. (Fourth order information).

Additional information can be included by the orientation of the symbol. For example, if reminieralisation of the dentine is the goal, then knowing the year the transitional restoration was placed would be of value. Since the calcium and phosphate ions derive from the dentinal tubules relies on a vital pulp. Radiographic evidence of remineralisation at a future date would reassure the clinician the Transitional Restoration can be confidently used as a dentine substitute for subsequent "permanent" (amalgam or composite) restoration.

The glass component of GIC lends itself to a variety of colours and cermets currently provide two colour options, gray for silver GIC and Black for amalgam GIC.

Additional developments for further clinical and treatment subtitles include a hexagon, and octagon. I anticipate that as the need to mark further degrees of differential diagnosis and what was viewed at the time of treatment evolves the symbols for those subtitles will become clear. 

I am confident that the basic symbols, I have outlined, present an unambiguous and intuitive, system of leaving an audit trail in the transitional restoration and that information will be of significant help to oral health clinicians world wide.

 

 

Acknowledgments:

Honorable Annette King, Minister of Health, who gave my ideas on Oral Grooming an ear.

The patients who have unwittingly challenged me to find a more sensible way to manage their often over whelming dental disease debt present in their unmeet dental needs.

Dr Per Åke Zillén for airing my ideas within the FDI.

Dr John McIntyre for his enthusiasm for the ideas and in sharing his unpublished clinical observations.

Dr Graham Mount for the initial support and subsequent correspondence and dialogue. His pioneering use of GIC has set the foundation of my clinical practice in recent years and the foundation for Transitional Dentistry.

Dr Hien Ngo for his input and his arguments to change the name from Intermediate Dentistry to Transitional Dentistry.

Dr Peter Denninson for his support, encouragement and common sense during difficult times

Canterbury Hospital in its various name change metamorphoses.

And Stephan Haynes from GC Asia Dental

 

 

Table 1

Dental Decay classifications and associated symbols

The R, D, and WHO systems are based on a variety of clinical and radiographic appearances. What the radiograph does not give is an indication of the degree of denatured and irreversibly destroyed collagen associated with the radiographic appearance of mineral loss. This may be changing with digital radiography. However, the higher the classification indexes the more likely that the lesion has reached an advanced stage and will require some surgical intervention and prosthetic replacement of the missing tooth structure.

 

 

 

Code

Radiographic

WHO

Symbol

D1

R1

1

None needed

Smooth surfaces: white/opaque or brownish lesion in enamel only, including slight loss of enamel; the surface appears smooth, hard, and glossy; the lesion is most often separated from the gingival margin

Occlusal surfaces: dark fissures or pits which are hard on probing; the lesion appears to be confined to the entrance where there is extrinsic discoloration only, then recorded as sound

Approximal surfaces: clinically visible, whitish/brown lesions where no obvious cavity can be probed; where approximal surfaces are not in contact with the neighboring tooth, then the same criteria as for smooth surfaces are applied

 

D2

R2

2

None needed

Smooth surfaces: enamel lesion (white/opaque or brownish/dark in color) including slight loss of surface, but without suspected dentinal involvement; the surface is rough or softened and dull; often located along a swollen gingival margin Occlusal surfaces: fissures and pits with distinct sticking on probing indicative of ongoing caries activity without evidence of dentinal involvement Approximal surfaces: recording of darkened enamel lesions catching on probing, but no evidence of dentinal involvement

D3

R3

3

Coronal caries involving the dentin, but pulpal involvement is not suspected

D4

R4

4

Coronal caries with possible or definite pulpal involvement

 

Table based on An Epidemiological Approach to Dental Caries

F. Manj and O Fejerskov. Chapt 7 .Textbook of Cariology, Second edition, 1st printing 1986

1994 Munksgaard, Copenhagen. ISBN 87-16-10916-3

 

*The origin of a stigmata grew out of a desire to indicate that a tooth had been indirectly pulp capped with calcium hydroxide and that the tooth needed to be retreated. Instead of IRM as a temporary filling, I was using glass ionomer cement. I made cylinders of ‘Ketac’ silver and pushed into the setting GIC. I could identify what teeth needed to be revisited at the patient’s recall visit. I used colour coded IRM in Vietnam in the late 60"s and in private practice in the early 70’s. In discussions with Dr Graham Mount I wondered if fluorescent dyes could be added to GIC to give the same results. This had two disadvantages. The system would need a special UV light and the dyes would not effect the GIC you need to revisit the tooth by drilling back into it. Unfortunately the dyes were not compatible with the GIC. He also persuaded me that the same clinical results could be achieved by a one step procedure if you used carefully adapted GIC. The problem then arose: what teeth had a question mark hanging over them with respect to pulpal vitality.

! As well as being a logical system, the basic symbol sets needed to have redundancy. When the symbology becomes established there should be a set of guide lines as to how to modify them for universal meaning, for example rounding off the corners and how many and in what order.

# Advances in orthopantomatography, especially the advent of digital systems, now make this a preferred method of imaging Grade 3 and 4 lesions. In a service designed to meet the needs of a disadvantaged or disenfranchised patient group (university students for example) this screening service would give the best auditable system for grading urgent dental care with respect to untreated dental decay3,15.

References

 

1. Scally, K. B. The Whys of Dentistry: Zen and the Art of Oral Care: A medical management model of dental disease. 1999. Unpublished.

2. Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: a review of the techniques and latest developments. [Review] [26 refs]. British Dental Journal 2000; 188:427-430.

3. Thomas MF, Ricketts DN, Wilson RF. Occlusal caries diagnosis in molar teeth from bitewing and panoramic radiographs. Primary Dental Care 2001; 8:63-69.

4. Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. [Review] [61 refs]. Special Care in Dentistry 1998; 18:8-16.

5. Scally, K. B. Transitional DentistryTrailblazing into the new millennium. 2000. Unpublished

6. Scally, K. B. Oral Grooming: an evolutionary perspective. A New Model for Oral Health and Wellbeing. 2000. Unpublished. (Available on request.)

7. Black G. Operative Dentistry . Medico-Dental Publishing Company, 1908.

8. Kidd E. The Cartwright Prize. Caries removal and the pulpo-dentinal complex. Dental Update 2000; 27:476-482.

9. Massler M. Effects of filling materials on the pulp. Journal of the Tennessee Dental Association 1955; 35:353-374.

10. Mount GJ. Glass ionomers: a review of their current status. [Review] [43 refs]. Operative Dentistry 1999; 24:115-124.

11. Banerjee A, Watson TF, Kidd EA. Dentine caries excavation: a review of current clinical techniques. [see comments]. [Review] [62 refs]. British Dental Journal 2000; 188:476-482.

12. Banerjee A, Watson TF, Kidd EA. Dentine caries: take it or leave it?. [Review] [33 refs]. Dental Update 2000; 27:272-276.

13. Bliss CK. Semantography: One Writing for One World. In Dreyfuss . Symbol Sourcebook: An Authoritative Guide to International Graphic Symbols. John Wiley & Sons, 1984.

14. Dreyfuss H. Symbol Sourcebook: An Authoritative Guide to International Graphic Symbols. John Wiley & Sons, 1984.

15. Langlais R, Langland, Nortje. Radiology of the Jaws. Baltimore: Williams & Wilkins, 1994.


Kevin Scally


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