Last year I presented “The Whys of Dentistry” and in that paper, I challenged the idea that we should be exclusively using the surgical management model of management of dental caries. Since then the list has grown and the thinking that went into the paper has metamorphosed into what I began calling Intermediate Dentistry, but I am now calling Transitional Dentistry.

Shortly after the conference where I presented the challenge I went to Adelaide and meet with Dr John McIntyre. His enthusiasm for the ideas encouraged me to pursue the development of an integrated model of transitional dental care.

As I have outlined previously, the focus on dental decay as an infection and the advent of a bio mimic material offers an alternative for dentists in the management of caries. The advantage of a material that has the potential to re-mineralize de-mineralized dentine is a major breakthrough. That this material chemically bonds to enamel and dentine gives dentists the opportunity to reconstitute a tooth and the opportunity to manage the disease while a definitive treatment plan is evolving.

The process of developing my thinking on transitional restorations stimulated the idea of leaving an audit trail behind in transitional restorations and to overcome the clinical ambiguity where they are placed as a temporary filling material. These materials are so easy to use they have become a substitute for reinforced zinc oxide and eugenol materials (IRM especially) and in other cases where they have been deliberately placed for their re mineralising potential.

In addition, in response to my experience of the shortcomings of the publicly funded oral health care system, I set up a private practice service called SOCAS (Specialist Oral Care and Anesthesiology Services) where dentists could refer patients for integrated oral care management. One of main need is caries and periodontal management.

In the constraints of time, I set out to debride all the carious lesions, extract the unsalvageable teeth, treat the periodontal disease and “temporise” the pulpally involved teeth those with periapical pathology. This is the medical management model and it is feasible to completely debribe and manage a grossly carious mouth in two or three hours.

After this course of treatment, the patient is given intensive preventive support in subsequent months and the disease processes are evaluate. The post-operative problem was how to document what had been done in a simple way to complement the written record.

I have used colour coding in the past on the treatment record but this is often difficult to convey or the records are not available. As a backup and as part of a reporting system in a referral situation I felt leaving a blaze mark on the restoration or having different coloured restorations would be a valuable adjunct to the written record. This would make it easy for subsequent clinicians to know what was done and what was the condition of the tooth.

I initially used a lighter shade of GIC as a colour contrast. I approached the GC Company through Stephen Haynes and Graham Mount to look at dyes of various sorts but it was found that they alter the materials properties. In the meantime, it occurred to me that we already have coloured GIC: “Ketac Silver”. I made thin diameter rods by injecting the material into polycarbonate sleeves off IV needles. I could then break them up into lengths and insert these into the restoration. This gave a good round cross section marker. I began using these to “tattoo” the surface of the restoration.

The more I thought about it the more I felt there was the opportunity to increase the information content within the symbol by making a range of shapes that would give additional information:

The year, the quartile when it was placed.

The status of the pulp at the time of placement.

If the pulp was capped or removed and a transitional root filling was placed.

What it had been capped with.

Was the restoration being used to allow for pulpal healing and re mineralisation of the effected dentin?

Another use of Ketac Silver is to use rods in the pulp chamber to act as guides to the canals diagram

The other advantage is its ease of placement and the short time it takes to restore a tooth with transitional systems.

While I have not finalised the symbol or symbol range I think I have a number to offer for critical comment. If there was a universal understanding of what the symbols meant this would make it easy for subsequent clinicians to know what was done and what was the condition of the tooth. There are also a number of research and public health benefits in using the system.

The challenge has been to get the dies small enough and cleanly cut so the symbols are easy to read. So far, I have used oblongs, squares, rounds, stars, triangles, and diamonds. I would prefer to use a “C” and a tick as the basic symbol with additions to add information (year and quartile). With the advent of other colours then there is an opportunity to extend information content.

The next challenge is to develop a symbology that will be right from the start. I would like input from you.

Now that the GIC system is working, I have extended the philosophy of Transitional Dentistry to other areas of dentistry.

The product line:

Transitional restorations

Transitional Crowns

Transitional Partial Dentures

Transitional Implants

Transitional Dentitions

To date I have extended the philosophy to plastic partial dentures (basically the Every Plastic partial denture system www.hospital-dentistry.org.nz ) Transitional crowns, and Transitional root fillings. This uses calcium hydroxide as a transitional root filling but there is clearly an opportunity for safe alternative materials that are either therapeutically neutral or have a therapeutic effect*. The advantage of this approach is the pulp chamber can be quickly debrided and dressed and sliver Ketac rods can be placed in the opening of the root canals. The compromised tooth can then be restored with tooth coloured GIC and the rods act as a trail-blaze and a track way back into the pulp chamber with a minimum of disruption to the stabilising transitional restoration.

The idea of a suite of treatments based on the philosophy of transitional dentistry is growing and I will be adding detail to the list and more ideas to the list. In the meantime would like to thank those individuals who have been part of this adventure.

Acknowledgements

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 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

* Any suggestions anybody ?)

Kevin Scally

Hospital Dentistry Services

Canterbury Health

2000