By Dr. Dennis J. Wells

The notion of adding materials to teeth in order to change the way they look is nothing new to dentistry. Traditionally, teeth are prepared in some way or fashion in order to place and retain a restorative material — typically a filling, porcelain veneer or crown. Not only is tooth reduction generally necessary to restore lost or damaged natural enamel as a result of the ravages of tooth decay or trauma, but it is also necessary to create room to place an aesthetic and functional “restoration.”

The purpose of this article is to introduce and provide a clear understanding of an alternative cosmetic treatment option, the “no-prep” or “prepless veneer,” whereby no drilling is required to enhance a smile. It also endeavors to bring clarity and understanding to the numerous areas of confusion regarding this treatment modality. Most importantly, it examines the case selection process; when prepless dentistry will work and when it won’t. As with almost all dental and medical procedures, there are risks, benefits and alternatives. It is with the help of a dental professional experienced in these advanced techniques, together with your own goals and understanding, that you can make decisions that are right for you.

No-Drilling: Reality Or Ridiculous?

“Prepless veneers” is a concept that elicits various reactions and opinions among dentists, ranging from absolute disbelief that they can facilitate effective restorations, to appreciation for these conservative and advanced works of art! This range of opinion about a novel approach to cosmetic dentistry is vast and with good reason. The concept of “additive only” restorations intuitively causes the experienced clinician reason for concern as visions of bulky, over-contoured teeth quickly come to mind. Unfortunately, some prepless techniques and products circulated heavily in the media have shown thick, bulky looking restorations, causing skepticism among some dentists and consumers alike.

And yet, despite these concerns, an undeniable trend is emerging among many esteemed cosmetic dentists to incorporate not only minimal prep, but also “no-prep” restorations into their compendium of viable treatment options and alternatives. In recent years, new developments in techniques and materials have resulted in a fresh look at the aesthetic possibilities for the no-prep veneer option. Cases done by talented dentists and lab technicians have produced results which would meet the highest standards in cosmetic dentistry [Figures 1 and 2]. Part of the advanced level of training for prepless veneers includes the important aspect of proper case selection. Not every situation lends itself to a no-prep approach, but when it does, the results can be not only beautiful, but also stable and reversible!

Paradigms and Beliefs — A Shift

The promotion and endorsement of “prepless” veneers is predicated on the following paradigms and beliefs:

• It is not necessary to prepare a tooth to create a border (known in dental terms as a “margin”). Highly skilled dental technicians can design a custom-fit veneer that feathers into the tooth just short of the gumline.
• Aside from the other obvious benefits of prepless veneers, they are not placed under the gum tissue. This eliminates the risk of the restorations having a negative impact on the periodontal (gum tissue) health.
• In many cases it is possible to use an additive-only approach to create aesthetically pleasing and natural-looking restorations without reducing the underlying tooth structure.
• Consumers who are looking for a way to enhance their smiles are more likely to seek out and accept a no-prep approach with a highly-skilled dentist in situations in which they don’t need aggressive enamel removal.

Potential Cases for No-Prep Veneers

• There are a significant number of patients who have relatively small teeth for a variety of reasons:, e.g. external causes such as acid erosion; genetic factors resulting in naturally small teeth and in spacing between the teeth; discrepancies between jaw size and teeth size — to name a few. These instances all provide potential candidates for “prep-less” restorations [Figures 3 and 4].
• Orthodontic cases that involved the extraction of teeth to solve a crowding problem typically result in narrow arch forms with the teeth that sometimes tilt inwards.
• Short, worn teeth — creating a smile with more visible tooth length can sometimes “turn back the clock” for someone who has worn their teeth down by grinding.
• Narrow smiles — Many times, the teeth in the sides of the smile are positioned inward and do not show from a frontal view.
• Teeth that need to be more visually present, e.g. when big lips may overpower them, or the teeth are too small in relation to the overall smile.
• Teeth that are genetically misshapen; “Peg laterals” is a fairly common condition in which one or both of the teeth directly next to the two upper front teeth are very small and peg-shaped.

When No-Prep Veneers Won’t Work

While no-prep veneers can make many positive changes, there are some situations that no-prep veneers can’t correct. In cases that involve improper tooth position, large discrepancies in root position, poor bite relations or a poor facial profile, some form of orthodontic treatment will be required to mechanically move the teeth. If orthodontic treatment is declined, some amount of tooth preparation may be required to create the illusion of proper alignment. When veneers are used to “camouflage” improper tooth positions, it must be with an understanding of the degree of limitations and risks.

Not every smile can be enhanced with prepless veneers. Teeth that are already relatively large or positioned forward in the smile do not typically lend themselves to adding another layer of thickness. In these situations, careful decision-making in partnership with your dentist will be necessary to explore other options that might involve tooth preparation or orthodontics.

There is no substitute for an expert dentist’s talent and expertise in the various cosmetic techniques. These skills — combined with a clear understanding of an individual’s goals and determination of the clinical needs obtained by a thorough diagnostic evaluation — are critical to ensuring a successful and beautiful smile.

Test-Drive Your Smile: Another Benefit of Prepless Veneers

Committing to porcelain veneers can take a great deal of faith on the part of a patient because once the teeth are permanently reduced, there is no reversing the decision to have veneers designed. With no-prep veneers, the process is reversible (though removing them is not an easy task and best accomplished using a laser) and practically risk-free.

If a patient qualifies for prepless veneers, a highly-skilled dentist can artistically design hand-sculpted prototypes in order to allow both a preview and “test-drive” of a new smile. In this prototype phase, changes can easily be made to the tooth-colored materials and to capture them as a blueprint for the laboratory technician who fabricates the final veneers.

While this same approach can also be used for traditional veneers, the difference with no-prep veneers lies in the fact that the prototypes can be easily removed and the patient’s original smile is unaltered.

A Preview of Coming Attractions

After a discussion about the goals and anticipated outcomes of the smile enhancement, detailed diagnostic records are gathered prior to beginning any dental restorations.

A comprehensive smile analysis is completed in order to compile information about the function and health of all the dental structures including the surrounding lips and facial features. Sometimes, a simple “mock up” can be made as a rough sketch in an effort to determine the feasibility of a prepless approach. The prototypes allow evaluation of the results in temporary materials before even making the final veneers. This is where an understanding of natural tooth shapes and contours allows an experienced cosmetic dentist to create the changes necessary for creating a natural looking smile.

The prototype stage allows individuals the exciting prospect of being involved in their smile design process. They can interact with their dentists providing feedback on shapes, sizes, and even colors of the new teeth. The prototypes can be test driven for several weeks while they are duplicated in the final porcelain veneers.

Once the laboratory technician has fabricated the custom porcelain restorations, the prototypes are removed and the final veneers are bonded directly to the enamel on the front surface of the teeth. The porcelain is then carefully contoured and polished to exactly mimic the natural teeth.

Questions to ask your dentist

• Am I a candidate for prepless or drill-free veneers?
• Can you create prototype veneers for me to test drive what my new smile will look like?
• How much will the prepless or drill-free veneers cost?

Conclusion

Though additive-only techniques cannot be used in every case, prepless veneers should be considered for their benefits in cases where they may apply in whole or in part. A prepless approach requires specific skills and training together with a keen sensitivity to natural tooth contours. Those who want to explore this as an option should consult with a dentist whose credentials and experience demonstrate an understanding of this technique-sensitive option.

More and more, dentistry, like medicine, is finding ways to be as conservative as possible while providing the best possible results. No-prep or prepless veneers are one way to improve and enhance smiles without the downside of drilling away healthy tooth enamel.

Don’t wait for cavities to occur and then have them fixed — Stop them before they start

By Dr. V. Kim Kutsch and Dr. Douglas A. Young

Modern dentistry is moving towards an approach to tooth decay management that is evidence-based — meaning it is based on years of systematic, accumulated, and valid scientific research. In other words, using current science, your dental treatment is tailored to your actual risk rather than a “one size fits all” approach. The previous method of “drilling and filling” to treat decay does not change the conditions that lead to the disease in the first place, so that the risk for further infection still remains. What follows below are facts you should know to change the conditions that lead to decay!

A New Look At Dental Decay — A Dynamic Infectious Disease Process

To help you understand, think of the mouth as an ecosystem, where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of enamel, a highly mineralized and crystalline structure composed mainly of calcium and phosphate. The teeth are bathed in remarkable fluid— saliva. While it has many functions, one of the most important is its role in maintaining a neutral pH environment or balance between the acids and bases found in your mouth. Acidity is measured scientifically by the pH scale, which ranges from 1 – 14. A pH value of 1 is extremely acidic while a pH value of 14 is extremely basic. The pH of the mouth is generally 7 – neutral.

The oral environment is loaded with bacteria with some of them having the potential to cause decay. Specific acidogenic (acid producing) bacteria attach themselves to dental plaque, the whitish sticky biofilm that collects and forms on the teeth. When you eat sugars or carbohydrates, these acidogenic bacteria break down the sugars and produce acid as a by-product, which in turn drops the salivary pH. At about pH 5.5, the minerals just below the enamel surfaces of the teeth begin to dissolve in a process known as de-mineralization. During this process, more calcium and phosphate leave the surface of the teeth than enter it — the first step in the decay process leading toward cavity formation. And because a tooth’s roots are made of dentin, which is softer than enamel, they are more susceptible to decay. For example, the roots of an exposed tooth will de-mineralize quickly and easily with even weak acids at pH 6.0 – 6.7, which is much closer to neutral.

Why Me? How To Assess Your Risk

Given similar habits, you might wonder why some people get cavities and others don’t. Dr. John Featherstone, an imminent researcher studying the effects of all these different factors, introduced the concept of the Caries Balance in 2002, in which he demonstrated that both the disease, dental caries, and dental health are a delicate balance between pathologic (disease causing) and protective (health promoting) factors. This dilemma can be further explained by understanding that individuals have their own unique balance, similar to a playground’s seesaw that is constantly changing. The challenges are to identify what is out of balance and how to tip it towards health and protection.

It’s Sort Of Like…

A great analogy is likening caries risk assessment to how a physician assesses risk for cardiovascular (“cardio” – heart; “vascular” – blood vessel) disease. The physician reviews your health history, takes your blood pressure, monitors your heart, and provides a treatment plan that may include prescription medications to reduce or manage risk. If your blood pressure is high, it doesn’t indicate that you have had a heart attack or stroke or that you definitely will one day. However, it does mean that you are at higher risk for having a heart attack or stroke and that it would be wise for you to take preventive actions! Some of these include: changing your life-style in terms of diet, exercise, and perhaps medication for lowering your risk.

This same process is precisely what we are doing in dentistry today with the CAMBRA approach. We are providing individualized dental care so that we can minimize your caries risk. In fact, modern dentistry can now evaluate risk factors for dental caries disease and use them to make preventive recommendations with the goal of lowering the risk of tooth decay. And as a result, create more predictable, longer-lasting results for any cosmetic or restorative dental procedures.

New Tools Of The Trade

As we’ve already said, not everyone has the same risk level for developing dental caries. This is further complicated by the fact that risk is dynamic and changes daily, as well as over longer periods of time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Simply put, there are factors that tip the balance. Some of these include: Disease Indicators and Risk Factors that lead to imbalance, which underscores the risk of disease. Protective Factors shift the balance toward health. These entities are measurable and quantifiable; but importantly, they are modifiable thus leading to predictable preventive and treatment outcomes.

From Research to Practice

By profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life, today’s dental professionals are using a more proactive approach. We’ve summarized these points in the illustrations of the caries balance and imbalance to show you how to identify your own risks. Not only do these illustrations show you what is out of balance, but they also show you what is required to correct it. Mastering the skills necessary to determine risk accurately is greatly aided when your dental professional uses a caries risk assessment form to ask you specific, scientifically validated questions to help pinpoint imbalances. And once an imbalance is identified, corrective action should be taken.

Your dentist may use two types of forms to help assess and manage your risks. One is for children between the ages of 0 – 5 and the other is for everyone (including adults) over the age of 6. The simple form we’ve included shows how easy it is to access and record your Disease Indicators and Risk Factors.

Disease Indicators

Psychologists tell us that the best predictor of future behavior is past behavior. That’s sort of how Disease Indicators work; they are clear signs of what could happen based on what has happened. Identifying them includes the use of modern dentistry’s most sophisticated tools for early diagnosis of decay. This topic will be discussed at length in the next article in this series, “Minimally Invasive Dentistry.”

Here are a few highlights:

Visible cavitations: Decay that is visible in teeth ranging from very early (microscopic) detection using, for example, innovative laser technology, to cavities that are visible to the naked eye.

Radiographic lesions: Early decay that is visible by using today’s highly sensitive yet low dosage x-rays (pictures).

White spot lesions: The first sign of decay in the contacting surfaces of the tooth’s enamel that is often reversible with fluorides.

Cavity within the last 3 years: Any previous cavities add to your risk of further disease.

Risk Factors

A Risk Factor is a variable associated with an increased chance of disease or infection. Risk factors may be linked with a disease, but they do not necessarily cause the disease. For example, it is inaccurate to say, “being young causes tooth decay” just because young people are at a higher risk due to the fact that young enamel is less resistant to decay.

Visible plaque: Dental bacterial plaque, now known as biofilm, is the whitish film that collects on teeth in the absence of effective oral hygiene. When it is clearly visible, it means there is a very high quantity of it. And if the pH of the mouth is low (acidic), the biofilm are especially prone to contain decay producing (acidogenic) bacteria.

Inadequate saliva flow: As we stated earlier, your saliva is critical for protecting your teeth against decay. If you have poor salivary flow (dry mouth), or if its ability to neutralize acid is diminished, protection against decay is seriously compromised. This is considered an extreme caries risk.

Medications that cause dry mouth: Many medications can cause hypo-salivation (“hypo” – below or under; “salivation” – saliva production) leading to dry mouth, which significantly increases the risk of decay. This is also considered an extreme caries risk.

Frequent snacking: Eating sugars, refined carbohydrates, and acidic foods actually promote acid producing “BAD” bacteria, as discussed earlier. Eating a healthy diet will help, but so will reducing how often and how long you expose your teeth to them.

Appliances: Retainers, orthodontic appliances, and bite or night guards all tend to restrict saliva flow over the teeth causing stagnation and promotion of dental bacterial plaque.

Deep pits and fissures: The shapes of teeth vary from person to person thanks to your genetic make-up — another thing you can blame or give credit to your parents for! In other words, your genetics control how deep the tiny grooves (fissures) and pits are on your tooth surfaces. And the deeper they are, the more likely they are to harbor bacteria you just can’t reach or remove with a toothbrush.

Acidic beverages or foods: Not only do acidic beverages and foods increase your risk of tooth decay by promoting the growth of aciduric (acid loving) bacteria, but they also can also directly cause erosion of the whole enamel tooth surface in addition to the areas that usually decay.

Other: Conditions like bulimia and anorexia (psychological conditions in which individuals induce vomiting), and GERD (Gastro-Esophageal Reflux Disease) can create highly acidic conditions in the mouth causing severe erosive damage to teeth.

Testing

Why wait for disease to start with early white spots or cavities when today it is possible to test for the acid-producing bacteria by taking a sample of the biofilm and testing it for acid producing bacteria? For example, if an acid producing biofilm is detected early, you can avoid passing these germs to others as parents and caregivers do unintentionally to infants. Or why not try to eradicate these bacteria by changing the conditions (pH balance) of the mouth? Testing meters can now give estimates of acid producing bacteria in 15 seconds. A reading from 0 – 1500 correlates with low risk and a reading of 1501-9999 correlates with higher risk. This simple and inexpensive test can also be repeated after treatment and is a great motivational tool for both patient and dental professional alike as everyone likes to know if change is working!

Diagnosis and Prognosis

A diagnosis can now be made based on your individual risk from the facts collected on your caries risk assessment form. This is important for three basic reasons: firstly, it is based on identifiable evidence; secondly, the risk can be modified based on recommendations and actions; and thirdly, repeating the procedure can objectively measure change to reduce your risk and improve your health. This affects your prognosis or the ability to predict the probable course and positive outcome from taking action.

Prescribe

In addition to the traditional things you’ve always been told to do like brush, floss, pay attention to your diet, and see your dentist regularly, treatment and preventive strategies are now based on your individual risk rather than treating everybody with the same approach.

If your risk is high, your dental professional may prescribe a program to reduce it. Some of the newer and more specific agents include:

• Rinses containing a safe dilution of sodium hypochlorite solution that can kill bacteria and raise pH (lower acidity) in those individuals found to have high acid producing bacteria levels. Other products are available that are designed to balance an acidic mouth and keep the pH neutral and encourage more normal bacteria.
• Rinses containing chlorhexidine, an antibacterial agent that has been used for eons to reduce bacteria, to disrupt their influence, and to lower the counts of those causing disease.
• Fluoride containing rinses to strengthen enamel surfaces making them more resistant to decay while encouraging re-mineralization.
• Xylitol, a natural sugar alcohol used for years as a sweetener and alternative to sucrose (table sugar), is known to disrupt the ability of acid-producing bacteria to thrive and attach to teeth. Xylitol is available in a rinse, spray, chewing gum, as well a breath-mint.

Once your risk has been modified and reduced, the level of prevention and treatment can be matched to it. For example, you can move from a treatment strategy to more of a preventive one.

Partnership

Finally, it’s about partnership. Your relationship with your dental office team is based on both a scientific approach as well as caring health professionals who have your best interest at heart. Working together, they will ensure that dental decay is a disease of your past so that you can enjoy a lifetime of good oral and dental health.