Air Abrasion Today:
An air abrasion dedicated newsletter: Web version

3rd Quarter, 1999                                Volume 1, Issue 5

FAQ’s
Q. "  I have used air abrasion for the past six months. I have noticed that my patients experience much more sensitivity lately, even at reduced pressures. What could be causing this?"

A.  It is puzzling for sensitivity to become an issue after a period of time of using equipment without patient complaint. One principal factor can contribute to this problem.

Typically, the source of the problem lies in a moisture contaminated air supply that is finally having a detrimental effect on the machine’s performance. Once moisture enters an air abrasion device, the powder begins to agglomerate 

and because of this, powder feeds through the equipment rather poorly. Consequently the mixture ratio of powder volume to air volume is distorted and taken away from optimum (made "lean" in powder). As a result, the dentist must dwell on the tooth for a proportionately longer period of time in order to remove the same amount of tooth structure. My hypothesis is that this prolonged exposure of the dentin to a progressively less efficient abrasive stream will tend to dry the dentinal tubules and progressively lower the temperature of the tooth. I believe this to be the reason why we occasionally find a dramatic increase in the incidence of patient discomfort in air abrasion clinical procedures.

To trouble shoot your system you will need to utilize an inline air moisture dryer/indicator. These are small air canisters which contain a color coded desiccant inside (available from Crystalmark). This desiccant will turn color progressively as it absorbs moisture. We have found that should one of these canisters completely change color in a period of four to six weeks or less, the level of moisture in the air supply is unsatisfactory for air abrasion use. This excess moisture will lead to a progressive degradation in the equipment’s performance over time. Solutions are varied and some are quite frankly expensive.

Crystalmark has found an elegant solution to the problem of air supply moisture contamination in the form of an inline unidirectional membrane air drying system. This system is built into the company’s Abradent  DV-1 air abrasion systems. At the present time the system is only available built into the DV-1. (Maybe we can convince the company to build systems for external, at-the-compressor use.) Other solutions are a properly maintained refrigerant air dryer (expensive), and canister air drying systems (needs to be maintained also). Ultimately, a compressed gas source, whether it be CO₂ or nitrogen, can be a solution and many doctors have opted for this way out. You do have to have the tanks filled periodically but the cost is very low. You are assured dryness !

If you find yourself with this unique and insidious problem, look to your air supply first. It is extremely doubtful that your clinical technique or your patient pool has suddenly changed. We will cover clinical technique to minimize discomfort in the next issue. Hope this has been of help. Take care and happy abrasion to you !

Editorial: Lets find the

Editorial: Lets find the answers together

We need a forum. Air abrasion will progressively grow in its penetration of the everyday clinician population. We are missing a common meeting place where viewpoints can be revealed and the experience of clinicians, freely interchanged.

The first (to my knowledge) professional air abrasion organization has been founded in June of this year by Dr. Christopher Clifford in England. The tentative name for the organization is the British Airbrasive Society and it has gotten off to a wonderful start. I was present at its inaugural meeting and I can relay to the reader the serious and professional attention being dedicated to air abrasion within that organization. Dr. Clifford has been involved with air abrasion for many years and is very dedicated to the formal adoption of the modality by the profession.

The society will function as a clearing house for information on air abrasion as well as a meeting ground for dentists and industry representatives. Equal in importance will be its function in promoting air abrasion to the public. The association will also help to establish the safety and treatment guidelines for the profession. Dr. Clifford is available at: Chris@ amerydental.freeserve.co.uk

Cheers Dr. Clifford !

Literature Review

As promised in last issue, I am including another article on the detection of carious dentin via staining with dye indicator. This paper is titled, A comparison of digital and optical criteria for detecting carious dentin, MH Anderson, GT Charbeneau; Journal of Prosthetic Dentistry:53;5(643-645) May,1985.  The article basically compared conventional optical and digital criteria for detection of carious dentin with a dye-enhanced method. The authors utilized the same dentin-staining dye formula as was utilized by Dr. Fusayama and Terachima (previously reviewed).

The cavity preparations (100) were prepared by third and fourth year dental students and were evaluated for remaining carious dentin using the fuchsin dye after they had been checked for carious dentin by a faculty member. The results are alarming. Of these teeth, 59% showed fuchsin staining at the DEJ in more than one location; 72% had fuchsin staining in any location (not just the DEJ) at the end of caries removal. The reader should remember that the DEJ was cleared of all discoloration that could be attributed to the carious process and was additionally judged by tactile discrimination with an explorer to be sound and caries free by faculty members !

When evaluating texture and hardness of dentin, the authors referred to Terashima et al (Hardness of dentin remaining after clinical excavation of soft dentin. Jpn J Conserv Dent 11:115, 1969 ) who found that experienced dentists excavated carious dentin with a spoon excavator to a Knoop hardness number (KHN) of 22.8.  With a round bur to an average of 28.4. Alarmingly, sound primary dentin has a hardness of 68 KHN. These results point to tremendous inaccuracy with the established systems of carious dentin detection.  Deep cavity preparations found a more pronounce caries staining percentage of 97%, which corroborates other research data dealing with cultivable bacterial presence deep in preparations. The investigators also pointed out that the most common area for fuchsin staining of dentin was at the DEJ. This staining occurred most often on the gingival wall under cusp and triangular ridges and less often on buccal and lingual proximal walls. Additionally, molar preparations stained significantly more than premolar preparations. These are all interesting points which I am sure you will find yourself re-evaluating mentally for some time to come. I ask myself, what had I been doing for the previous years before caries detecting?

I believe that this as well as other articles in the literature well demonstrate that caries disclosing dyes are an excellent method by which we can to some extent remove the subjective element from caries disclosing and its subsequent eradication. Until next time, enjoy and take care.

Clinical Tips

In this issue I can’t help but discuss one of those topics that for one reason or another (I leave that up for debate) is rarely spoken of in professional referenced literature. In the application of this new modality of air abrasion, clinical prowess and knowledge are obviously important. How does this translate into generating income?

Let’s talk about giving the patient excellent service AND about generating income with this modality as well. As far as I am aware of, we did not enter the profession hoping that by chance we would make a living. We did not swear an oath of poverty and simplicity. It is time that we recognize as a profession that there is no evil associated with talking about income. We have spent a great part of our life-resources in school; a very difficult schooling and we carry a huge responsibility into our operatories. Let’s recognize from the git go that we MERIT a handsome income, commensurate with our education and our level of responsibility to fellow human beings.

In order to PROFIT (yes, it is not a dirty word) from this modality, first know the how and why of its application. Beyond that, several issues need be addressed to maximize its income generating potential. 

First of all, institute an internal, in-office "awareness" program to inform your staff of this new tool the treatment team (think teamwork) now has at its disposal. Foremost, educate your staff about air abrasion. Explain to them its strong points and limitations. They must know and believe in its usefulness and benign, atraumatic nature. They will most likely be some of your first volunteer patients, once they observe you treating patients with it.

Secondly, inform your patients. This can be done by way of patient education tapes, brochures and staff discussions with your patients. It’s great to show them a tape while waiting for a prophy or for radiographs to develop at the initial exam appointment. Remember that fully informed patients will be your most fervent allies. Tell them everything, the benefits and the drawbacks. An exchange could go something like this: "It’s not for everyone, but most patients can have small to medium sized cavities prepared with this miniature sand blaster without the need for anesthesia." "You won’t feel vibration, heat or a sharp, sudden pain." "You might experience a slowly increasing ‘strange sensation’, as you would experience with cold ice cream." Furthermore explain to your patients that they can control the procedure by communicating with you via sequentially raising fingers, starting with their thumb and progressing towards their pinky. When they hold out all of their fingers, you will stop. "If you experience something you find uncomfortable, show me with your fingers and I will adjust the equipment such that it operates differently and allows us to get all of the decay out with minimal if any discomfort" "By way of using this new technology, when we are done, you’ll be able to leave the office without numbness and ready to eat....isn’t that great...?"

At this point, I must refer to my father, who demonstrated to me the power that suggestion had on patients. Not only was he well versed in formal hypnotic procedures but he could very subtlety suggest to patients that they would have an easy time with a procedure. I have seen this sublime suggestion disarm the most resistant opponent and although it certainly wasn’t 100 percent effective, it did manage to break down barriers in about 70 percent of patients. What I learned from him was that targeting the final outcome and explaining to them why they would be comfortable really had a relaxing effect on most patients. It is no different with air abrasion. Important to carry this off is the unmistaken belief in the procedure. If you doubt its true potential, this will be transmitted to your patients; they’ll know in a heart beat. Truly immerse yourself in the knowledge of what air abrasion can do and you will never look back.

The patient is informed, your staff is enthusiastic and the patients are expectant; now what? Understand that you can produce an awful lot of dentistry in a short period of time, particularly when dealing with incipient or moderate lesions. You can begin the procedure that is scheduled the moment the patient is seated and ready. When dealing with mandibular teeth in particular, the long period of time it sometimes takes waiting for anesthesia is no longer an issue. I have personally operatively treated ten units in one appointment of about an hour duration. I have seen this repeated many times by other clinicians. In one particular instance, a doctor in England saw two patients, prepared approximately a dozen carious lesions in about two hours, and this was his FIRST time using the equipment. True, I was there coaching him, but believe me, he didn’t need much help.

If this sounds too good to be true, then perhaps I have overstated the fact in my enthusiasm. It can be contagious. What I do want to get across to the reader is that with proper training and conviction, with the proper education of your staff and your patients, you will pay for the equipment in less than two months. All one needs to do is to carry out some simple calculations. In Southern California, single surface composite restorations range in fees from $80 to upwards of $140. By restoring two additional units per day, you will generate at the very least, $160 ($80 x 2). Additionally, you will diagnose incipient to moderate lesions at examination appointments. However, the key difference with air abrasion disclosing and diagnosis of these lesions is that you can address treatment on the very same day, saving that patient an additional appointment. There is more.

You will schedule patients for other procedures (fixed prosth, endo, etc.) and while waiting for anesthesia in these quadrants, operative air abrasion procedures can be performed. That means that the dead time associated with waiting for anesthesia can be dedicated towards additional operative treatment. This will save the patient additional appointments, and makes you more efficient with your time; in short, more productive. PRODUCTION: it is not a dirty word. It means financial security for you and your loved ones. It means the proper schooling for your children. It equates progress and a better standard of living. It means a reward for your hard, dedicated professional attitude. And the nice part is....the patient is getting excellent care.