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Diagnosis and Treatment of Oral Diseases-- Lectures #36 Histopathology of the
Dental Tissues as Relates to Caries II, Review Session Dr. Wolff

Can you hear me in the back of the room?
Any questions from the audience at this moment you want to know about tooth decay?
Yeah?
[Student question: How long does it take for the stains to appear with the chlorhexidine?]
So the question is, how long does it take the stains to occur with chlorhexidine? The bad
problem is, quick. The stain is actually bacteria in the plaque dying. And staining in the
plaque, dying. Its ugly. So the CPC that you also see in the Crest products is also implicated
in the staining. So if you actually get an effective killing of everything, you get some
staining at the surface. And the place that stains the worst is at the gingival margins. You
put a restoration, you get this black line and you cant get that clean, no matter what. And it
starts very quickly its dependent on what you eat and how. Ive seen chlorhexidine stain in
patients, we use chlorhexidine after we put implants in places in patients because they
cant brush in that area, its sore, and we actually have them clean with chlorhexidine to
keep the bacterial counts down. Its probably all voodoo but its what I was taught when I
was taught how to place implants. Those patients come in with stain on their teeth in two
weeks. You want to get them off of it as quickly as possible. It prophys off easily if you see
them rapidly but after a couple of months you cant blow the stuff off with a sandblaster.
Any other questions?
[Student question: what about on the tongue?]
The tongue? Placing chlorhexidine or brushing with chlorhexidine on the tongue?
[Student question: will it stain the tongue as well?]
It will stain everything the same way, the tongue has abrasion on it which you tend to want
to clean off the tongue a bit. I cant say you havent seen any staining on the tongue
because of chlorhexidine, have you Kenny?
[Dr. Allen: No, Ive only seen it on the teeth]
Yeah I have to tell you, I havent seen it on gingiva or the tongue. Even on my cancer
patients that dont have saliva, the tongue doesnt change. I actually use it when they start
to complain that their tongue is getting slimy and hurts. So there are times when you need
it.

Any other questions? Yes?
[Student question: If you have caries in the last three years do you have high risk caries rate,
or is it only in the past year?]
Ah ha!!!!
[Student: Because you said both!]
We had said both!!!!! And it actually fits properly. The research shows that youve had
active caries in the last three years, you are Id have to go back and look at it was
something to the you are a thousand times more likely to get caries in the next three years.
Id have to go back and look at it, it is a Featherstone paper. Its wonderful data. The
problem is it hasnt been well defined how long you have to be caries free before we can
drop you out of the high risk category. So what we have adopted, because there is very
significant expense associated with high risk maintenance, is a lower cost knock down after
one year. So your first year youre high risk. If you have another caries, youre high risk. If
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you come in after one year and everything is staying the same, well talk about dropping
down to a lower risk. And we dont make you low risk, we make you moderate risk. So the
difference between our risk assessment and the Cambra thats been published in the Dental
Journal, which I think we made available to them? No? Well, make sure that you get it
available. We were co-authors on it. They actually have advocated for four levels of risk. I
dont have enough room for this to divide this in such micro. So when you look at the
highest risk, I have everybody coming in on three month intervals for fluoride, I have
everyone coming in using a home fluoride supplement. I have them using a calcium
supplementation of one form or another. I dont mean tums type calcium supplement. I
mean calcium containing toothpaste in a effort.. what Im doing and Ill show you on the
slides in a minute, Im using methods that have weak evidence, but because your disease is
so likely to occur, Ill use everything in the kitchen sink. When I get to the person thats got
caries AND no saliva, Ill even throw my anti-microbial on top of it. But youre high risk. I
have difficulty saying high risk and super high risk. Honestly, my cancer patient, my
Sjogrens patient, those are my super high risk patients. After a year, Ill knock down that
high risk patient to the moderate risk category which still has them using some sort of
home fluoride. Maybe or maybe not using a calcium supplement. But we are willing to take
down some of the high expenses. Ill move them from four visits a year for fluoride varnish
down to two or three and watch them from there. And the reason why we need to measure
severity of disease is we need to know whether or not it is advancing. I need to know how
the decay is advancing.

There was another question?
[Student question: With the chlorhexidine rinse, versus the varnish, is the varnish more site
specific?]
The answer is the varnish is much more site specific. Varnish literally became available
this year in the United States. It was illegal in the US before. The answer is we are probably
going to change the concept of going at where the caries is and treat the caries, Id love to
try treating the caries with a stamp. That makes a lot more sense than smearing it all over.

[Student question I couldnt properly hear about changing a patients risk assessment from
high to moderate after one year.]
If it stays the same for a year, they were high risk. She had [asked about] someone who had
caries. If I had someone who had caries and I managed to control it and they are not
getting new, well knock them down after a year to moderate risk. It will take them three
years before we put them back at low risk. Kenny, is that different then about what you
taught?
[Dr. Allen: No]
[Student: No, what you taught was that if it is the same then it was high risk]
If it was the same
[Student: If it hadnt, if it still remained the same it was - ]
Oh so youre asking if you had people with early lesions that just developed?
[Student: no (sorry I cant hear the recording here due to some background noise near me)
No Im asking you how that person that had early lesions isnt up in the high risk. How did
that patient arrive in high risk if you diagnosed them as having new lesions? Theyre high
risk.
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[Student: So theyll remain at high risk?]
Im saying that if Ive been able to prevent them from getting worse, ok, Ive got these early
lesions, Ive monitored them for a year, Ive taken bitewings, the bitewings havent revealed
any advancement of it, the patient is using the fluoride, their hygiene is correct, we see a
decrease in activity by virtue of How do I measure activity??? Youre going to have to give
it to me, Ill guarantee its a test question! Oh, got your attention. I got bad news, I dont
write the test questions, I dont care.
[Student: ICS?]
No! Yes? Help me out? Looking at a radiograph and seeing whether its advanced in a
radiograph. How do you classify caries in a radiograph? Give me the classifications of
aproximal lesions! E0, E1, E2, D1, D2, D3. Or pulp. Ok, thats aproximally. How do we
describe activity in a different fashion? It could be arrested, but how do I know whether or
not its arrested? How do I know whether its active on the surface or not? Youre not
allowed to touch it so you dont know its leathery. Color is helpful but not necessarily.
[Student: blow air on it?]
AND?
[Student: water?]
No, no, no, you were in the right location. Youre drying it with air AND? See if it is frosty. Frosted
surface indicates that we have continuing demineralization and remineralization. That patient
stays at high risk. There hasnt been a change. They were at high risk, they stay at high risk. You
listening? Did you understand what I just said?
[Student with original question: Yeah Im listening, Im trying to find the thing that he posted for you]
You can find the thing. You know, if I didnt help write the book on it, Id be ok. Im telling you that a
contradiction in what is written somewhere, it is an error. You are never raised from middle to
high because an inactive lesion on the surface has not progressed, and its been there for five years.
Youre never raised. Its the active lesion. You examine a patient and see a new, active lesion,
demineralization. A fifty year old comes in with those lesions that are just touching the enamel, I
look at his radiographs from a year ago, hes got these lesions from just touching the enamel, low
risk, high risk, or medium risk? Why? They were there a year ago! If I look and they were there ten
years ago, is this person at risk? No! They could be low risk. I have to look for something that is
indicating that the demineralization is active. That goes to the discussion about charting activity
that we had a couple of weeks ago. In a quiescent lesion does not make its not purely looking at a
radiograph, its not purely looking at the surface of the tooth. A white spot doesnt make this an
active lesion. Its a white spot with activity. Youve got to wrap this together. Its not a single
youre taking a snap shot and making a decision, high risk, low risk. Yes?
[Student with original question: thats how we were taught]
Who taught you?
[Student with original question: So how would you place a patient into moderate risk? ICDAS, is that
how you would do it?]
I dont use ICDAS. Please review your lectures.
[Student with original question: Ok so what youre saying is that when the lesion is active, you put
them into high risk, yes?]
If there is an active lesion they are high risk.
[Student with original question: So how does a patient go into moderate risk?]
Its no longer active, it cant stay active. It has to go into inactive. If in one year, they have
not developed new lesions and its become inactive, they go into the lower risk category.
And we measure activity, we started out, she had frosting, he gave me radiographs getting
worse, theres another way, how do I tell interproximally, aproximally, whether the patient
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is keeping that area clean? Its on the slide? Gingiva thats right. What does the gingiva look
like if they are not keeping it clean? Red and inflamed. Disease activity. If they still have an
active lesion they are still high risk. If the lesion is gone the lesion can still be there but it
cant be active. You can knock them down. What is the caries risk on this patient? [Slide
59]. Whats that? Ok, it was like this three years ago. [Class says low risk]. Yeah Im not
sure Id make the bold statement of dropping them totally to low risk, because they have a
history of activity. All of these black lesions are arrested caries. Ive already told you, why
dont we see caries up here? Yes, thats right, its a denture. You dont get tooth decay on
dentures. All this schmutz you see up here is just stain, its not caries. But this stuff here,
this black, thats caries. The question is now, if I saw a light color to it, if I saw frosting on
the enamel next to it, thats activity. If I see gingivitis, I mean, look at the gingiva here.
Thats a pontic (?) by the way. This guy has no disease activity going on here. Hes keeping
it relatively clean, its hanging out, its old, its been here for a long time, do you want to go
in there and redo all this work? YES, because youve got a Mercedes payment, but NO
because of caries. You know, you have to make that decision. Patient came in to me and had
like all these black spots on here, I would treat this because it is an aesthetic concern for
the patient, falls into what Dr. Vogel refers to as being broken. The patient doesnt like it!
My teeth are ugly! Im taking care of someone next week who has exactly this scenario. It
didnt bother her until it was time for her son to get married. Now she doesnt like smiling
and having black on the teeth. Its an esthetic concern. Its not associated with active caries.
Today we treat this differently, we try to control the environment. Do we have other
questions? Do you want to read it to me, do you want to put it up on the stage? (referring to
the student with the questions on the previous page). Put it on the stage and I will explain it
to you. Youre not listening or put it up!
[Student: No, Ill ask you after.]
Do you think these people arent confused?
[Student: No, it seems that everyone else is frustrated. No! With me, not with you!]
[Class laughing]
Is anyone frustrated with him? Hands down because questions are appropriate!!!
[Student: If it doesnt pertain to other people then there is no point in me - ]
Does everyone else got it, or is there confusion? Because Id rather settle it. Thats the value
of being in a classroom. Id rather settle it and get you to understand it, than let you go
home. Lets settle it because I want to see what this is! Bring it on!!!! Bring what you got,
and Ill project it!!! This isnt an embarrassment! (Clapping as student heads up to the stage).
Are we looking at the caries risk assessment form? Its easy to explain. First, there are
multiple versions of the caries risk form that are out there. Some have not been updated.

Ok, Ill take another question in the meantime!
[Student question: You mentioned before, I think in the first lecture, that chlorhexidine isnt
the best because while it kills bacteria, it actually causes more harmful bacteria to -]
Well, no, no. So the answer is yes, I did say that, I still agree with that. You have to stay on it
and Dr. Featherstones protocol was staying on it for a month and then going to it once a
week every month. So essentially what he was doing was trying to wipe it out and then it
comes back again. Keep killing it down the idea behind the stamp is to go in there and
eradicate that particular bacteria and let healthy bacteria come in. Do monitoring of the
bacteria, and if you can actually get the flora to become non-Strep mutans it would stay
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permanently. The chlorhexidine is a general kill. It kills about 80% of what is in the mouth
right off the bat. The stuff that happens to stay, stays in nooks and crannies, it includes the
Strep mutans, the lactos, all the things that we hate, still stay there and grow back real
quickly. It has, by the way, been shown to be effective in anti-periodontal disease as a
perio med. I mean, I dont want you to get that it does nothing, it gets in there and it kills
some of the slower growing bacteria. The rapid regrowing bacteria are the most difficult
for us to deal with.
[Student: I dont understand the exact mechanism, but I assume from the class talks about
antibiotics that would cause resistance, and that might not be ideal - ]
So, resistance is whether or not, you do shift the flora. Its not necessarily a question of
resistance. So resistance is you give an antibiotic, it kills all but the bacteria that are not
susceptible to that antibiotic. And the ones that remain keep growing, they are not
susceptible. Its similar except this is a broad spectrum kill. And it is an ineffective kill. It
doesnt kill 100% of. And its not killing it because this one is resistant and this ones not. It
just didnt get to that bacteria at a high enough concentration, at a high enough availability,
stay there long enough. So that guy got lucky and got it, you were sitting on the surface, you
die. Ok, so its not the antibiotic mechanism that all the bacteria get exposed to it and only
those that are immune to that antibiotic survive, now the next generation grows up being
immune. So it doesnt necessarily but what it does do is favor the most rapidly regrowing
bacteria. By wiping everything out and taking the competitive inhibition away, it allows
the ones that are still left there to reproduce rapidly once you take away the chlorhexidine.
So Featherstones idea is just to keep coming back with chlorhexidine and beating it down
again. And in fact in my cancer patients, like I said, the ones that have had head and neck
radiation, we do just that. We do varnishes, we follow them up. We beat it up aggressively,
because they cant even tolerate slight, they have no remineralization capability because
they have no saliva. Any other question? Yes?

[Student question: Im still unclear about how fluoride works how you ingest it. I think its well
explained the purposes of fluoride because -]
I got stuck reading (looking at what the student who went up to the stage projected).
Because, Kenny if thats whats on the form..
[Dr. Allen: Thats an old one.]
Thats an old form?
[Dr. Allen: Whats the date on it? The one thats on, that I posted, is different than that.]
Yeah that shouldnt be there. That is a wrong form. That form has been removed.
[Student: So this bottom part, it doesnt exist?]
No, actually if they stay,
[Student: This is from Dr. Glotzer here]
Then he gave you an old form. And thats why I said, you have to bring up the question. We
have lots of forms, he may not have realized this is an old form.
[Student: So this is wrong then?]
This is currently wrong. Two years ago, this was considered correct.
[Student: So how does one become moderate risk in the first place? You cant be diagnosed as
moderate risk first]
Correct. Well, no, no, no. Thats not true. Scroll down. Right over here, this is what gets you
in right off the bat. Patient comes in, theyve got xerostomia in their mouth.
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[Student: Other than salivary..]
No, other than severe salivary reduction. Xerostomia, Im taking a bunch of drugs, my
mouth is dryer. They wind up with moderate risk. How do we treat moderate risk? It could
be prevident 5000, I told you there is another alternative to it, thats the OTC mouth rinse.
Either of them will work ok. Thats the type of treatment that we give them. So we get them
on a supplemental fluoride. In that patient. What happens if they get caries? High risk. Ok.
Over here, whats the recall rate on this? Six months. If this person comes back at three
months, getting fluoride varnish, three months they are getting an in office fluoride, the MI
paste, they could be a meth addict, thats one of those real disasters. See how important it is
to ask the question? Because all of these people would have been confused forever because
there are multiple forms out!! We changed the form multiple times over the last, we had a
form out before John Featherstone in San Francisco had a form out. And it has changed and
been modified based upon the evidence that is available.
[Student: So do they move down the risk?]
What we did is we allow them to move down, it takes them three years to get down here (to
low). Youre going to have to show me three years of not getting caries. And I have to tell
you, from a personal story, somebody in my family, who is high risk because she had all of
these lesions and Im remineralizing all of them, she dropped down to low risk abra
cadabra, one of the lesions advanced over time. So you can go back, you have to take those
radiographs at a reasonable interval, and keep checking the patients. So the keys for me
here actually turn out to be these items. The bitewings, the number of visits, the patients
have to undergo, the recall interval. When Im doing fluoride, and what Im doing in here,
you manage the patient. So as you look at this, I keep working on the patients that are
moderate risk and recall them every six months, fluoride varnish every six months,
working on patients with tooth decay, Im giving them fluoride varnish every visit they
come in, they are scheduled for three months, they get a fluoride home that they have to be
using and there I do head to the prevident 5000plus. I give these patients, generally when
Im here, Ill go to xylitol before Ill use chlorhexidine and thats really pure whatever fits
me inside feeling better. Theres no specific reason. Everybody gets dietary advice, that
does nothing. Theres been no evidence if I could tell you, cut down on sweets to prevent
tooth decay, there would be nobody overweight in this world. Think about it, you can step
on a scale tomorrow and know that you ate less calories. Youre going to have to go for 1, 2,
3, years eating less sweets. Not less sweets, really, very few sweets to reduce tooth decay.
Whats a chance a human being has that mindset, Im gonna prevent decay, Im never going
to touch any sugar again. Not happening! And thats why dietary advice sounds like a great
thing! But the truth is it doesnt particularly work. But topical fluoride as it says every visit,
calcium supplement, sugarless gum to stimulate saliva xylitol is better than non-xylitol in
that case. Hygiene, flossing and brushing, I told you, you dont need much. Flossing,
brushing with a fluoride toothpaste two, three times a day is a great idea. And thats how
we go manage that. Any questions on caries risk?
[Student question: (Couldnt hear exact question, but she was asking if the most updated form
is what we will have access too in clinic)]
Yes. It should be. You know the problem with the clinics upstairs is the version will be the
one on the computer, and that is because I am the one putting it on the computer. The
problem with forms is these things hang out in the ethos for very long periods of time. And
instructors can make a mistake and hand out the wrong one, they can even teach the wrong
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one! The current one that is out, this is pretty much the uh, I dont think that the risk factors
have changed on this.
[Dr. Allen: I think thats incorrect there, the radiograph. We now use an interval at where
appropriate, not just four bitewings]
Yes, yes it should say when appropriate. So I have a question, somebody tell me why pit
and fissure protocol is all the way over there. And do pit and fissures put you in the high
risk? This is a tricky one folks. Pit and fissure caries, even if it is on an anterior tooth. Does
that put you at high risk? Youre at high risk well, lets ask a different question. Does
fluoride, cutting down on sweets, xylitol, fluoride varnish, calcium, reduce tooth decay in
the occlusal surface? Just slightly. Real, tiny increment. I would be a liar if I said it didnt
have an effect, it does, but just slightly. What has an effect? See if you put a sealant on it, a
patient that had active caries and would be called high risk until they had the sealant put in,
is at high risk. Once you put the sealants on, you go from being high risk to whatever
everything else is in the risk categories. If you are having smooth surface demineralization,
the bad news is you were born with deep grooves that werent coalesced, you get caries.
Not your fault. As much as youd like to blame them for not - for getting decay, its not their
fault. You instantly get out of the high risk category the moment you put the sealants in
place. So Im not recommending someone who gets occlusal caries get MI paste, fluoride
varnish, 4 times a year, bitewings, thats not what made you high caries risk. Your anatomy
did. So we actually did this differently than every other school in the country. We are right,
they are wrong. Well actually, a number of the caries scientists have started hearing the
wisdom and changing their thoughts on it. I just had obnoxious long enough for them to
finally think about it. Caries, if all you have is in the occlusal surface, may not be the
patients fault. Its the fault of the anatomy, and we have a way of correcting that. Once we
correct it is the patient at high risk? If everything else is good, if they have no redness of the
gingiva, they have no active lesions, they are keeping everything clean, they control their
sugars, they are fine, they are low risk. There is no reason to bump them up. They are high
risk until you put the sealant on.

So this is actually a wonderful publication that has just recently come out, I was honored to
be a part of this process. But this actually, if you use this as your guide to patients, youve
got it nailed. Youll understand in everything that you do, how to make your decision. Now
I have to tell you my faculty dont all have it yet. Many of them understand it, live it and do
it, but after 30 years of private practice and having learned GV Black, some of them just
cant kick the habit. Its tough. Yeah?

[Student: You never answered my question.]
Oh, I dont remember your question!
[Student: Well, my question was, in class it was well explained how the topical effects of
fluoride work, but you talked about ingesting fluoride tablets. How is the fluoride getting to
the tooth?]
So it gets into the blood stream. So the question was, how does systemic fluoride effect the
tooth. So when we drink fluoridated water, we get a very low concentration of fluoride
through the mouth. You may get some fluoride in the plaque and we believe there may be
some minor fluoride effect there. Were really not sure. If I put 1ppm coating on your teeth,
they havent been able to show caries reduction in young children. In older children they
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have, in young children they werent able to. On the flip side, when we ingest up to 1ppm, it
goes into the blood stream, it gets incorporated into the because fluoride has a high
affinity for calcium, gets incorporated into all calcifying tissues at that time. Bone, and
tooth. And that calcification, actually, thats probably where you get a true hydroxyapatite
crystal. We know it forms hydroxyapatite. If you put fluoride into it, you see fluorapatite in
tooth. We dont see fluorapatite at the surface of teeth as easily when you brush fluoride on
the surface. And what that did, and thats the original studies that showed how fluoride
worked, it lowered the critical pH. So tooth started to dissolve at 5.5, natural tooth. Natural
dentin, 6.2. If you fluoridate it, it drops as much as a full pH, 1.0, which is a lot. Its a big
value. But it drops somewhere between 5.5nand 4.5 before it starts to dissolve. Its pretty
remarkable. And that is if you incorporate it into the crystal. If you get it on the surface,
that also prevents that dissolution, but not by the same mechanism, there are probably a
couple of mechanisms. Yeah?

[Student question: (cant hear it at all)]
Theres actually some work being done looking at Tums. Do something, use something that
creates bicarbonate, with calcium in it at the same time. I didnt say that this was the only
way to do it. Were just talking about whats currently available. There is a good discussion
about chewing Tums after eating. It just hasnt been done. You want to do it with me, Ill
make you patent holder. You and I can become multibajillionaires. Dont make a joke. I
mentor is getting about 8 million a year off the patent I did as a graduate student. Oh you
dont want to do any of the work?? Well we wont know the outcome until you go look at it.
There are people that are currently recommending Tums, but I cant give any advice on it, I
havent seen anything on it.

[Student question about using triclosan, couldnt hear the full thing]
Well theres no scientific evident thats actually had a health outcome associated with it.
[Student: Dean Marrus is very adamant against it.]
He may be adamant about it but theres still no science. The current discussion you can
be adamant about something. Im sorry about it, I get tons of Colgate demo tubes. If you
want some feel free, Id be happy to give you some. You get Colgate toothpaste here. The
problem is, theres been no scientific evidence that there had negative health outcomes
associated with the concentration in toothpaste. There have been in other items. Im
conflicted in what I can say with association I have legal conflicts with what I can say on
the Colgate stand on it. I can tell you, they are very comfortable with the literature. They
are very comfortable with the literature.
[Student: So is its the concentration that is the issue?]
Yeah, its the amount of triclosan that you take. Theres some discussion about whether all
the triclosan that we are using is the big issue was triclosan in hand soaps. High
concentrations in hand soaps, killing bacteria, getting bacterial shifts and change in flora,
but the latest concern has been over the carcinogenicity of it. They are concerned about all
triclosan and where it is showing up.

[Student question: Since all of your favorite students are here and you are offline, I think we
are all dying to know what kind of things to focus on for the exam]
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I can certainly tell you that you are going to need to know that caries risk assessment form
that we went over quite extensively. The recall rates, the radiograph rates, the fluoride
regimen rates. Youll need to talk about the use of fluoride in patients, and where and
when. Youre going to need to talk about adjuncts and when youre going to be able to
bring in an adjunct, you go ahead and do it. Oh you want to know the answers? A, write this
down, C, F, Im sorry I cant help it. The obnoxiousness is my mothers fault. My father, a
nice, mellow guy. Mom, she has all of that sarcasm in her and all of that. So I blame it on my
genetics. You have to have something to talk to your psychiatrist about. Any other
questions? Dr. Allen, anything else you recommend, because I dont write questions
[Dr. Allen: Thats a very good starting point.]
Youre in the ballpark if you follow where I was. It follows that trend, what does saliva
bring to the situation and how, is Strep mutans the only bug you need to worry about at
night, what about circadian rhythms. Or we can go on microphone and give them some
things to study that I would read the paper by Adi. I can be so nasty. I told you who was
the cause of that? Mom, I told you.

[Student question: You said that for(hard to hear, I wrote what I thought he said) once you
put sealant on the prep they become low risk. Do you still recall them every three months or
do you lower the recall?]
I dont do any change to the patients recall rate. And it goes to the principle of, once youve
cured that site, if you believe if that that site became which, by the way, you need to know
we dont use ICDAS anymore as our classification. You need to be able to understand how
ICDAS fits with our current classification with early, moderate, and severe. ICDAS is more
extensive than we are currently using. I would remember that. You need to understand
why an ICDAS 2, 3, 4, even an ICDAS 5 that requires me to do surgery a moderate or severe,
cavitated to the dentin, I do the surgery on it, I look at the rest of the teeth, I say they are at
high risk, once Ive sealed them, that occlusal risk disappears. What happens if you seal in
caries? Nothing. Youre better off. So this slide actually, go through the slide thats there.
This stuff here, its all in the stuff I gave you. You got the pearl for being here, it was worth
the ten minutes not to, what else would you have been doing, sleeping or something? Are
you taking pictures? Im ready, take the picture! Are you videoing me???? If this winds up
on YouTube, Im telling you, Im coming after you! I will unleash the full power of NYU. No
even worse, Ill make you miserable and keep you here for extra years! More tuition and
YEARS here, youll pay for it!! I promise you!
[Student: Well, we still use ICDAS in Dr. Glotzers course to classify caries]
He taught you the ICDAS method. Im telling you what you are going to use in clinic. Whats
that, so ICDAS was the basis if you attended my lectures! ICDAS was the basis of the
classification that you are going to use in the clinic. So you will understand that an ICDAS 3,
4, is a moderate lesion, and an ICDAS 5, 6, is an extensive lesion. An ICDAS 1, 2, 3, are initial
lesions, early lesions. So learning the ICDAS doesnt mean that the classification system we
are going to use in clinic doesnt fit.

[Student question: you had a slide where the lesion (couldnt hear anything after that)]
Actually, if you look at that surface, it was one break in the surface. And the caveat thats
changed from ICDAS is that you need to look at bitewing radiographs to see whether or not
there is any evidence of decay below the dentin. And if there is, you have real problems
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because caries under the dentin is a fairly extensive caries under the occlusal surfaces of
the dentin is a fairly extensive amount of disease. Let me just make sure theres nothing
here I wanted to make sure you got. You gotta know this. Im tired of somebody saying,
lets put a restoration in here! Theres a life expectancy of that restoration. Watching is
malpractice. Its not treatment. If you think theres an early lesion, if you think its active,
put them under treatment! We need to treat this now in case the patient doesnt come back
again. Faculty will tell you that. Look them in the eye and say, I dont think Dr. Wolff is
going to agree with you. Should I give him a call? No, dont do that, that is obnoxious, you
will probably fail the rest of dental school. But I would have an intelligent discussion with
that faculty member at that time about why you believe this is not an active lesion. About
why you believe this should not be aggressively treated. Or, that you want to treat it in a
different fashion. You want to treat it with remineralizing agents. These are the important
things that you need to work on. Drilling and filling doesnt cure it, prevention does not
yield immediate results, prevention may lead to more permanent improvements, and it is
evidence based. All of these things do come as evidence based. This is the key. All of these
things were surgical in this school 9 years ago. Every one of these lesions would get cut
open. Today, were starting to talk about whether we should use a non-surgical technique
here. We arent there yet. Im telling you, five years from now, I think well be teaching the
children that sit in these seats, remember they are children to you now. Theyll be grown
up by then. Were teaching them to do something different for this. I dont think we are
going to keep drilling these holes. There will be more aggressive treatment. And they YOU
will be one of the faculty members at the school who look at the students and say well,
lets drill this before it gets worse. Where do you think those faculty came from?! They
were you 20 years ago! They listened to a me on the stage 20 years ago and I looked at that
and said, you have to restore that while its conservative. But the rules have changed! The
rules on caries risk assessment have changed in a matter of years.
[Student: Can we graft teeth yet?]
Can we graft teeth yet? Well we actually call that a composite. Dr. Allen, did you learn how
to use composite in dental school?
[Dr. Allen: Yes, adapt it]
Were you able to, so the reason I asked Dr. Allen, Dr. Allen and I were probably separated
by about five years in school. Did you use a polymerization light in school?
[Dr. Allen: No]
Ok. I went to dental school, I put composites in with ultraviolet light. That was latest thing.
It had to be put in under 1mm increments because it wouldnt set under the UV. But I was
now able to control the set. He was able to do it with putty putty mix and stick it in the
hole, I did it with UV, today we do it with yes, do I believe that there will be a method of
grafting, probably not. Growing, manufacturing, doing, you bet. This remineralization is
the earliest form of that type of repair.
[Student: Why? Why do you need to replace the whole tooth when -]
I dont need to replace the whole tooth
[Student explains further, couldnt hear]
The answer is, it is coming! That methods of growing crystals on teeth, of growing crystals
in the caries and, so if Dr Kim (?) was lecturing here, she would tell you take that occlusal
surface, open it up and clean it out and let saliva get in.

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[Do we need to know dates and percentages of the studies?]
I cant speak for all faculty that are involved in writing questions.
[Student: for you?]
Do they need to worry about dates for questions for me? I dont think so.
[Dr. Allen: Not for you but there may be some from somebody else with low attendance]
You should be able to put things in sequence. You know, the 1940s, the 1980s, 2000, and
understand what constraints GV Black had about fluoride.