Treating Geriatric Wear With Minimally Invasive Composite Restorations

Individuals in this population can have extensive medication lists as a result of undergoing procedures such as knee or hip replacements, heart valve replacements, organ transplants, and chemotherapy and/or radiation therapy, among other treatments. When treating these patients, it is necessary for the dentist and the dental team to pay meticulous attention to their medical histories during the comprehensive exam. Furthermore, the dentist/physician relationship has also changed over the years, and today, the norm is for the dentist to have a conversation with the primary physicians/specialists who are caring for these patients before any dental treatment is rendered.

Conditions that can impact the treatment of the geriatric population include poor oral hygiene, gingival recession, root decay, overall physical disability, and cognitive decline. Due to various patient-related factors, there are many times that the ideal treatment cannot be provided to these patients, so dental healthcare providers have to think outside the box. When planning treatment for these patients, their overall systemic health related to age should be a significant consideration.

With the life expectancy of patients increasing, dentists see many more older patients with worn dentition as a result of clenching, grinding, or the occurrence of erosion over the years. The clinical manifestations of wear or erosion can include decreased vertical dimension; flattening of the incisal edges; facial, cervical, incisal, and occlusal abfractions; chipping of the teeth; worn enamel resulting in exposed dentin; sensitivity; and more. For dentists, providing treatments to help preserve the natural dentition of geriatric patients can offer opportunities to increase production. One of these areas of opportunity involves the treatment of anterior abfractions and worn incisal edges with minimally invasive direct composite restorations.³ For example, mandibular incisors may exhibit chipping and breakdown of the lingual enamel and smooth buccal enamel and remnants of the pulp, which may have receded or calcified. Stains and decay are also common (Figure 1 and Figure 2). To best capitalize on this opportunity and maximize treatment acceptance, dentists should ensure that patients are informed of all of the advantages of these restorations, including:

• Slowing the breakdown of the teeth from wear;

• Strengthening the teeth when abfractions are restored;

• Reducing sensitivity;

• Improving esthetics;

• Experiencing the benefits of minimally invasive preparation and bioactive materials;

• And in a majority of cases, avoiding the need for anesthesia.

An 82-year-old female patient who presented to the practice with severely worn edges on her mandibular incisors and mandibular left canine agreed to treatment with minimally invasive composite restorations (Figure 3).

Preparation Technique

The approach to anesthesia-free minimal preparation can vary slightly depending on if decay or staining are present. For teeth with no decay or staining present, bevel the incisal edge and remove any irregular enamel chipping with a fine or extra fine finishing flame-shaped diamond bur with the handpiece at a reduced speed. Roughen the dentin with a small carbide bur, such as a 330 or 556 fissure bur. If decay is present, cautiously remove the decay with a brush technique. Lowering the speed of the handpiece while using the same burs will reduce the possibility of discomfort or pain in the patient. If there is staining but no decay, the clinician should determine on a case-by-case basis if the staining should be left, removed, or partially removed. Upon completion of the preparation, it is cleansed with a 2% chlorhexidine solution prior to the restorative steps.

Restorative Materials

The preferred material for these minimally invasive procedures is a flowable composite. In this case, a nanohybrid flowable composite with bioactive properties (Beautifil Flow Plus^® X, Shofu) was used. This material was selected because it adapts well to the preparation, is easy to place, maintains strength, is easy to polish, and incorporates Giomer Technology. Giomer Technology is a bioactive technology that releases and recharges six beneficial ions, including fluoride. Together, these ions have been clinically proven to inhibit plaque, neutralize acid, and eliminate secondary decay.^4,5 They reduce tooth mineral solubility, which encourages the remineralization of tooth enamel and decreases the acid production of cariogenic bacteria, providing both bioactive and therapeutic benefits.⁶ It's beneficial for all patients but particularly for geriatric patients with high caries risk like the one in this case.

After completing the preparation and achieving proper isolation, the enamel was selectively etched with 35% phosphoric acid for 15 seconds, rinsed, and then dried. Next, a one-component self-etch bonding agent (BeautiBond^®, Shofu) was applied to the preparations and left undisturbed for 10 seconds. It was then air dried with a gentle stream of air for about 3 seconds followed by stronger air until a thin and uniform bonding layer was obtained. The bonding agent was then light cured with an LED light curing unit for 5 seconds. After the bonding agent was cured, the nanohybrid flowable composite was placed (Figure 4). It is available in two viscosities (low flow and no flow), and for this case, the no flow viscosity was selected for its self-leveling properties and adaptability. The patient's occlusion was then checked, and the final restorations were finished with finishing and polishing discs (Super-Snap X-Treme^™, Shofu) and composite polishing paste (CompoSite, Shofu). The patient was very excited about the result and stated that she loved how the composite fill made her incisal edges smooth (Figure 5 and Figure 6).

As patients live longer and their dentition wears, the dental team is tasked with providing treatment to restore and maintain the strength of their teeth. When the benefits of the procedure described in this case report are explained to indicated patients, they are inclined to agree to treatment. By delivering an anesthesia-free procedure that reduces wear and improves and/or maintains the strength of the teeth with an esthetic result, the dentist and dental team become heroes to these patients. This procedure is an untapped production area for many offices, and it is usually covered by insurance. Due to the shorter treatment time and lack of anesthesia, the procedure has reduced overhead, which can result in more profit for the office.

A. "Tony" Tomaro, DDS
Private Practice
Chicago, Illinois