Monthly Archives: June 2019

Use of Bioactive Restorative Materials in Patients with High Caries Risk

By Stefano Daniele DDS, MSc

The focus on prevention has reduced the incidence of caries in many western countries; however, we continue to observe a high rate of dental disease and decay. This is largely due to intrinsic conditions, such as gastro-esophageal reflux and gastric regurgitation (bulimia), and extrinsic dietary causes, such as continuous snacking, high sugar products, and soft-drinks that contain high levels of sugar and acids, which are known to cause aggressive enamel demineralization.1

A 46-year-old male was referred to my office with serious decay and hypersensitivity to cold. His patient history indicated he had undergone stomach constriction surgery to treat obesity. It also revealed a propensity for frequent consumption of a famous carbonated beverage with high erosive potential.2

The patient comes from a middle class socio-economic and cultural background. He is aware of the serious condition of his teeth, but he has no idea of the reasons for his condition. He reported to me that he brushes every day and is careful to practice good oral hygiene, even if he did not schedule regular visits to the dentist. It was only when he experienced hypersensitivity that he took a close look in the mirror and observed the clearly visible damage to his teeth. His major concerns were how this condition affected his smile and the impact of hypersensitivity on his quality of life. He was embarrassed by his teeth, and he could no longer tolerate cold food or drinks.

An initial examination showed large areas of demineralized enamel and exposed dentin, especially in the cervical area (Fig. 1). The extensive caries process could easily be traced to gastric regurgitation as consequence of stomach reduction surgery,3 and the frequent consumption of soft drinks.

I explained these causes and established the treatment plan. The patient was instructed to immediately modify his dietary habits and eliminate soft drinks; he was referred to a gastro-intestinal specialist to address the acid reflux episodes; he was instructed to rinse with sodium bicarbonate solution after each gastric regurgitation episode and avoid tooth-brushing after these episodes to prevent loss of demineralized and fragile superficial enamel;4 and he was placed on a fluoride-based mouthwash regime.

I restored the teeth using a mild self-etch adhesive and a conventional composite resin. However, at a 6-month recall visit, I noticed secondary caries at the restoration margins. Although improvements had been made in the patient’s diet and gastro-esophageal disorder, these had not been fully corrected.

Information on research and advances in dental materials are now readily available through journals, educational programs, and online portals. Through these sources I learned about an esthetic, bioactive, restorative material with a durable resin matrix (ACTIVA, Pulpdent Corporation, Watertown MA, USA). The material releases calcium, phosphate and fluoride ions5 that offer protection to the restorative-tooth interface, which is where secondary caries develops.

I removed the conventional composite restorations on the teeth affected by secondary caries, selectively etched the enamel, applied a self-etch bonding agent, and restored the teeth with ACTIVA (not shown).

At this visit, I observed that a new active carious lesion had developed on the distal of the upper right lateral incisor (Fig. 2). This tooth had not been previously restored, and I treated this lesion with the bioactive material (Fig. 2-6).

The patient is still under my care, and the restorations placed with ACTIVA bioactive material did not show any staining or secondary caries at the one-year recall visit (Fig. 6).

The patient continues to show improvement. The gastro-esophageal regurgitation disorder has been reduced, and the patient follows the prescribed rinsing protocol after each episode. He has completely removed the erosive soft drink from his diet.

Patient history and patient education provide information to both the clinician and the patient that is essential for success. Lifestyle changes and medical interventions may be necessary to achieve desired outcomes. The restorative materials with bioactive properties could be a valid choice – and an alternative to the conventional procedures – in patients exposed to dental erosion, either of an intrinsic or extrinsic nature.

Fig 1. 46-year-old male presented with serious carious process due to gastro-esophageal reflux (intrinsic factor) and frequent use of carbonated soft drink (extrinsic factor).
Fig 2. At a later visit, a new active carious lesion had developed on the distal of the upper right lateral incisor.
Fig 3. Caries is removed.
Fig 4. Shows restoration with ACTIVA BioACTIVE-RESTORATIVE (Pulpdent, Watertown, MA, USA) and with matrix and wedge in place.
Fig 5. Shows completed restoration with ACTIVA.
Fig 6. Shows one-year recall of ACTIVA restoration.
Dr. Stefano Daniele DDS, MSC
Specialist in restorative dentistry and endodontics
University of Milan, Italy


1. Carvalho TS, Colon P, Ganss C, Huysmans MC, Lussi A, Schlueter N, Schmalz G, Shellis PR, Björg Tveit A, Wiegand A. Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear-diagnosis and management. Swiss Dental Journal 2016:126; 342 – 346.

2. Kitasako Y, Sasaki Y, Takagaki T, Sadr A, Tagami J. Multifactorial logistic regression analysis of factors associated with the incidence of erosive tooth wear among adults at different ages in Tokyo. Clin Oral Investig 2017 Feb 7. doi: 10.1007/s00784-017-2065-7. [Epub ahead of print]

3. Barron RP, Carmichael RP, Marcon MA, Sandor GK. Dental erosion in gastroesophageal reflux disease. J Can Dent Assoc 2003;69:84-89.

4. Yip KH, Smales RJ, Kaidonis JA. Case report: management of tooth tissue loss from intrinsic acid erosion. Eur J Prosthodont Restor Dent 2003;11:101-106.

5. 45. Evaluation of pH, fluoride and calcium release for dental materials. Morrow BR, Brown J, Stewart CW, Garcia-Godoy F. J Dent Res 96 (Spec Iss A) 1359, 2017 (

Sherri Lukes Discusses Fluoride Varnish in Free CE Webinar

Hygienist, educator and public health advocate Sherri Lukes will present Flavor Vs Function: A Look at Rationale for Fluoride Varnish Product of Choice, a Continuing Education (CE) webinar on June 18, 2019 at 7:00 PM ET / 4:00 PM PT.

Sign Up for Sherri Lukes’ Free CE Webinar

This CE webinar offers an overview of factors to consider when selecting a fluoride varnish product. Flavor aspects will be presented with a conversation about taste as the current primary determinant for product choice. The benefits of additional ingredients in fluoride varnish will be discussed as well as other characteristics for superior patient benefit. The entire dental team can profit from information concerning fluoride varnish choices for best patient care. This free CE Webinar will be available for On-Demand viewing after June 18, 2019 on

About Sherri M Lukes, RDH, MS, FAADH
Speaker, author and public health advocate, Sherri Lukes has been a hygienist for 37 years. Most of her career has been in academia, retiring in 2014 as associate professor from Southern Illinois University where she taught oral pathology, public health and multicultural dental hygiene. Research efforts were concentrated in migrant farmworker oral health, oral pathology, and issues of other underserved populations. Mission work is a passion that was shared with her students for years and she continues to offer the opportunity for students and faculty to participate in bi-annual trips.

As professor emerita, Sherri is fortunate to be able to now integrate years of experience into CE courses to empower dental professionals in the process of care.  She offers courses on oral pathology, cultural competence and older adult oral health. She can be reached at

Direct from the Operatory: Embrace Esthetic Opaquers

By Dr. Marty Zase

Embrace Esthetic Opaquers (Pulpdent) are the best opaquers I have ever used. They are a near perfect match to Vita shades, resulting in very consistent and predictable clinical outcomes.  The Embrace resin technology makes the opaquers much less likely to dissolve or come off the substructure when they are treated with bonding agents. A very thin layer is all that is required and light cures in 20 seconds.

Shows old metal post that requires an esthetic opaquer.

In this case, we are about to cover an old, long metal post that I did not dare to remove (Figure 1).  The goal was to complete a composite core build-up over the post so a porcelain crown could be placed as a final restoration without any sign of the metal post showing through.

Embrace Esthetic Opaquer is used to cover the metal post.

I find it easiest to use an explorer to place the opaquer on the substructure I want to cover.  In my experience, the pink opaquer covers metal exceptionally well. Another layer can be added in a shade if desired.  Total etch and bond can then be used to adhere a core material to the opaqued post and the tooth (Figure 2).  The result (Figure 3) completely hides the metal post so that a ceramic crown can be constructed with natural translucency, rather than using a very opaque crown which would look less natural.

A composite core build-up is placed over the opaqued post and the preparation is ready for an esthetic, translucent ceramic crown.

About Dr. Marty Zase
Dr. Marty Zase received a B.A. from Boston University and his D.M.D. from Tufts University School of Dental Medicine.  A former clinical instructor in restorative dentistry at Tufts, he is guest lecturer in cosmetic dentistry. He has published over sixty dental articles, has served on the editorial or review boards of The Journal of Cosmetic Dentistry, Contemporary Esthetics, and General Dentistry magazines, and lectures internationally on cosmetic dentistry. 

He is one of only about a dozen dentists in the world to have both a Mastership from the Academy of General Dentistry and an Accreditation in Cosmetics from the American Academy of Cosmetic Dentistry. He practices in the Colchester Dental Group and is the only dentist in the greater Hartford area Accredited by the AACD. 

Dr. Zase has developed numerous techniques and instruments that are currently used in modern cosmetic dentistry.  He has been strongly recognized for his contributions to dentistry and dental education.  Dr. Zase has been selected by Dentistry Today magazine as one of the Top Clinicians in Dental Continuing Education for the last eleven years in a row. 

Larry Clark and Dr. Salierno Discuss Biomimicry

Dr. Chris Salierno of Dental Economics stopped by the Pulpdent booth at the Chicago MidWinter Meeting to learn about biomimicry from Larry Clark, Director of Clinical Affairs at Pulpdent. The following video captures their conversation.