Integration of Oral Systemic Health & Biomimetics via Ozone Treatments
In conjunction with the AMIBD mission statement, one of the objectives is to utilize an evidence based, multidisciplinary approach to treating oral hard and soft tissue disease through early, accurate diagnosis and intervention. Though oral systemic health is not typically considered biomimetic in nature, it is an important element of preventive dental care which can have a profound effect on healthcare in general including reduction of periodontal disease (including gingival recession) and the long term success of biomimetic restorations.
"New scientific research has shown that when long-term inflammation (such as peridontal disease) persists in the body, poor health is the result. Low-grade infections and inflammation are now recognized to be at the root of heart disease, diabetes, strokes, pregnancy complications, kidney disease, certain cancers, as well as many other diseases and medical conditions. Inflammation is now recognized as being a new risk factor for many of the medical diseases and conditions which plague our society.
As it relates to oral health, inflammation from oral sources is particularly worrisome because of its widespread prevalence and the stealthy manner in which it operates. The American Academy of Periodontology states that three out of four Americans suffer from some form of gum disease – ranging from mild gingivitis to the more severe form known as periodontitis. They state that despite this prevalence, only about 3% seek treatment for their gum disease. This obviously touches many lives and makes gum disease one of the more important sources of inflammation anywhere in the body.
Gum disease is more appropriately termed "periodontal disease". Perio is Latin for "around" and dont is Latin for ‘tooth’. Periodontal is thus dealing with the anatomical tissues and structures which surround the tooth. This includes the soft gum tissues as well as the underlying jawbone which serves as the foundation for the teeth. Type 2 diabetics have an increase in death rate from 3.7% to 28.4% (a 768% increase) when comparing diabetics with no gum disease and diabetics with severe gum disease, respectively. Periodontal disease is a strong predictor of death from heart and kidney disease. Diabetic Care 28:27-32, 2005.” (Ostler, 2011)
Ozone treatments can be utilized in conjunction with early diagnosis and intervention to kill bacteria and other pathogens, thus reducing or preventing periodontal disease in conjunction with biomimetic restorations. The common factor among all pathogenic organisms is the weak antioxidant/enzyme systems in the cell membranes of those organisms. Ozone treatments allow for penetrating the cell membranes, thus killing pathogenic organisms. After penetration and subsequent death of the organism, the contents of the organism are exposed to the biological environment of the host. This allows the immunologic system of the host to start its physiological cascade. According to recent biochemical and physiological studies conducted at Scripps Institute, this process mimics biological processes, e.g. it is a form of biomimetics. Biomimetics includes human-made processes, substances, devices, or systems that imitate nature. Biomimetics is the art and science of designing and building biomimetic apparatuses, and it is of special interest to researchers in the nanotechnology and medical industries. An example is the artificial synthesis of antibiotics. The Scripps Institute study reveals how antibodies actually produce ozone to kill microorganisms (Babior et al, 2003). Now antibodies, in addition to identification of pathogens, are used to kill pathogens with ozone.
"The chemical properties of ozone are the foundation of what makes it work so well in dentistry. Ozone is a powerful oxidizer — it effectively kills bacteria, fungi, viruses, and parasites at a dramatically lower concentration than chlorine, with none of the toxic side effects. One molecule of ozone is equal to between 3,000 to 10,000 molecules of chlorine and it kills pathogenic organisms 3,500 times faster! In a medical/dental ozone generator, the medical grade O² is converted to O³ in special tubes via a corona discharge reaction (similar to lightning). This type of generator is able to control the concentration of ozone critical to delivering the correct dose in micrograms/milliliters (mcg/ml). Concentration is determined by exposure and contact time of the medical-grade oxygen to the 5 to 13 millivolts [Bocci] sealed-corona discharge tubes.
Because of ozone’s physical properties in the dental model, the ratio of ozone to oxygen is extremely low. The typical average concentration of ozone used in treatments is 25 micrograms of ozone per milliliter of oxygen/ozone gas mixture. That translates into 0.25 parts of ozone to 99.75 parts of oxygen. Evidence-based research has shown at this concentration, ozone effectively kills bacteria, fungi, viruses, and parasites." (Mollica & Harris, 2011)
In addition to killing pathogen populated biofilms (plaque), ozone denatures the toxic waste of those microbial populations. Pathogenic biofilms thrive in acidic environments, quickly outnumbering beneficial bacteria and producing an abundance of organic acids (such as pyruvic acid) that support growth of pathogenic biofilms. These acidic wastes also facilitate the increased loss of minerals in teeth above the gumline, subsequently leading to decay. The presence of acidic waste from the pathogens below the gumline in the loose area between the gums and teeth serves as an incubator for accelerating growth of pathogens. Organic acids emitted by bacteria also aid in the growth of subgingival plaques which grow on the tissue side of the subgingival wall of the gum pocket, in the sulcular fluid of the gum pocket, and accumulate on the roots of teeth below the gums. This encourages the formation of harmful calculus. (Rainey, 2011; Vander Stoep, 2011)
Utilizing the proper ozone generator and technique, ozone gas is often used to kill pathogens in the periodontal pockets; to kill decay causing bacteria on root surfaces, smooth surfaces, and the pit, fissure, and groove system of the enamel of teeth; or directly into the root canal of teeth to simultaneously kill pathogens and mitigate organic acids produced by microbial populations. Ozone gas, when sufficiently applied to reach the base of even a cavitated tooth lesion can dramatically shift the disease environment. It denatures the protective protein coat that protects germs from pharmaceutical products, then oxidizes the germs and their wastes. The oral environment in general changes as friendly bacteria begin to predominate. Even in the worst cases, it takes months for germ populations to revert to an unfriendly balance. In the meantime, tooth banks are prepared to accept mineral deposits rather than lose them. Demineralization stops and remineralization begins. If demineralization or frank decay is present, ozone gas, carefully applied, can penetrate up to 5mm into the lesion. When microbes and their wastes are neutralized to its base, the biological environment within the tooth shifts immediately to a less acidic state. That less acidic environment begins to favor mineral gain over mineral loss for about four months." (Baysan 2000; 2001; 2004; Vander Stoep, 2011)
Ozone treatments (often referred to as ozone therapy when treatments are performed in succession) are utilized for prevention of peridontal disease, in pediadontics, treating caries, in conducting root canals when necessary, and for treating oral osteonecrosis, herpetic and apthous ulcers, and treating after surgery. Ozone treatments stimulate the immune system in many ways. (Vander Stoep, 2011)
Dental Physiology & Biomaterials
The physiological performance of intact teeth is the result of intimate and balanced relationships between biological, mechanical, functional and esthetic parameters. Natural teeth, through the optimal combination of enamel and dentin, constitute the perfect and unmatched compromise between rigidity, strength and resilience. (Magne, 2002)
Traditional restorative procedures and alterations can easily disturb this subtle balance. Maintaining this balance is further complicated by the age-related changes of dentition resulting from aging populations and the subsequent preservation of natural teeth which lose their protective enamel shell over time due to normal wear and tear on teeth. This reduces the natural crown flexibility of teeth in general and affects an ever increasing segment of our society as the average age at mortality increases.
The above chart represents changes in flexibility relative to the base line for incisors after removing coronal tissue (blue bars). An approximate of the original stress distribution of the natural tooth (red bars) is graphed as a reference. The amount of facial enamel thickness removed is represented by the fractions (e.g. 1/3, 2/3 & 3/3) listed below the column categories.
Factors stemming from aging and traditional restorations compromise tooth structure, impair biomechanical function, and have a negative effect on esthetics. Since teeth are not fully capable of repairing or reproducing the loss of enamel and dentin hard tissues, dental technologies have been developed in an attempt to remedy this problem and maintain tooth structure through tooth restoration processes.
Unfortunately, the detrimental effects of traditional restorative procedures and aging can have the opposite effect, resulting in deformations of the natural crown of the tooth. Additional loss of enamel and dentin resulting from conventional diagnosis and inadequate treatment using invasive procedures (drilling and amputation) which remove healthy enamel and dentin hard tissues further weakens the tooth.
This compromises tooth structure, reduces biomechanical function, and makes the tooth susceptible to bacterial infections. However, the tooth can be strengthened by increasing resistance to crown deformations through minimally invasive procedures, providing accurate diagnosis and state-of-the-art treatment of caries, and successful adhesive bonding technologies. These biomimetic procedures conserve the tooth and protect it against bacterial invasion. This is accomplished in conjunction with conserving as much of the tooth as possible and utilizing innovative biomaterials that restore tooth structure, biomechanical function and esthetics.
Utilizing biomimetics allows for optimizing biomechanics by using composite resins as pliable “dentin-like” biomaterials and porcelain as a more rigid “enamel-like” biomaterial (Magne, 2006). Multiple thin layers/coats of these biomaterials, such as ceramic/porcelain veneers, can be utilized to restore teeth in conjunction with specific adhesive bonding techniques to accurately mimic the natural structure, biomechanical function and esthetics of teeth. This is not possible to achieve with either metals (including amalgam and gold) or porcelain-fused-to metal substances that are typically used for fillings and crowns in traditional restorations (Walls et al. 1988; Allsopp et al, 1996). On average, amalgam restorations are replaced every 7.8 years (Anusavice, 1989). In an article published on 5 Apr 2011, the US government has announced that it supports a “phase down, with the goal of eventual phase out by all parties, of dental mercury amalgam." (Bolen, 2011 )
Feldspathic ceramics, pressed ceramics and high modulus hybrid composites all provide the desired results in terms of structure, durability, biomechanical function, and esthetics when
utilized for specific biomimetic applications. Ceramics are also referred to as porcelain products (such as feldspathic porcelain). Porcelain is merely a ceramic material made by heating raw
materials. The primary difference between these biomaterials is the manufacturing process utilized and the associated cost of fabrication. Skilled technicians utilize layered and pressed
applications of ceramics and composites for different purposes. (Magne, 2011; Alleman, 2011; Rainey, 2011)
Tremendous progress has been made to increase the strength and reliability of adhesive bonding through the use of innovative biomaterials and techniques. “Today, adhesive technology has proved its efficiency in simultaneously reestablishing the rigidity of tooth crowns while allowing for maximum preservation of the remaining hard tissue (intracoronal strengthening) (Morin et al, 1984; McCullock & Smith, 1986; MacPherson & Smith, 1995). These studies demonstrate that bonded composite restorations permit the recovery of tooth stiffness and rigidity that is not possible with amalgam fillings.” (Magne, 2002)
Crown rigidity can be restored to 100% when feldspathic porcelain (elastic modulus approximately 70 GPa) is used as an enamel substitute, as with porcelain veneer restorations (Magne & Douglass, 1999). Teeth restored with dentin-bonded porcelain veneers have also demonstrated that those substances provide absolute biomimetic behavior when subjected to cumulative restorative procedures (Magne & Douglass, 2000) and catastrophic testing. (Magne, 2002)
“Bonding and adhesive ceramic restorative procedures have the potential to reverse the esthetic manifestations of aging. Thus, restitution of enamel thickness using biomimetic procedures has a combined esthetic and biomechanical effect.” (Magne, 2002) The original profile of tangenital stress for a simulated model of an incisor tooth (refer to chart listed above) reveals that a feldspathic porcelain veneer can completely restore teeth to their original structure, function, and esthetics (Magne, 2002).
“The goal of adhesive restorative techniques is the maximum preservation of sound tooth structure and the maintenance of the vitality of the teeth that are being restored. From a biomimetic standpoint, moderate alterations of teeth should be treated with composite resins. Bonded porcelain restorations are recommended to treat the most detrimental situations (worn-down, non-vital or crown-fractured teeth) thus avoiding the use of intraradicular posts or full coverage crowns. This biomimetic approach results in considerable improvements, comprising both the medical-biological aspect and the socio-economical context (i.e. decrease of costs when compared to traditional and more invasive prosthetic treatments)." (Magne, 2006)
The Biomimetic Principle & Restorative Dentistry
The intact tooth in its ideal hues and shades, and perhaps more importantly in its intracoronal anatomy, mechanics and location in the arch, is the guide to reconstruction that determines success. The biomimetic approach using adhesive bonding and biomaterials is basically conservative and biologically sound. This is in sharp contrast to the porcelain-fused-to metal technique, in which the metal casting with its high elastic modulus makes the underlying dentin hypofunctional. The goal of biomimetics in restorative dentistry is to return all of the prepared dental tissues to full function by the creation of a hard tissue bond that allows functional stresses to pass through the tooth, drawing the entire crown into the final functional biologic and esthetic result. (Magne, 2006)
Producing hard tissue bonds is the key to adhesive dentistry which can “be expressed as a simple relationship between bonds and stress. If the bonds can withstand the stress, the restorative technique will be successful.” (Unterbrink & Liebenberg, 1999; Deliperi & Alleman, 2009) The following is an introduction to a systemic approach for early diagnosis, intervention, and successful adhesive dentistry as developed by David S. Alleman, DDS and J. Tim Rainey, DDS. Alleman and Rainey are successful dentists, leading research scientists, and pioneers of minimally invasive biomimetic dentistry.
Diagnosis & Treatment of Caries
The most common pathology that dentists treat is caries with its’ resulting decay. The treatment of this disease is divided into the diagnosis and management of the patient’s biofilm and the re-mineralization or restoration of damaged tooth structure. Treating decay without treating the cause of decay is a problem that the CAMBRA (Caries Management by Risk Assessment) movement is seeking to resolve. Small lesions can often be treated non-surgically according to the revised International Caries Detection and Assessment System (ICDAS II). After the systemic disease is treated and incipient lesions are re-mineralized or infiltrated, dentists are left with the question: ‘how much of the caries/decay should be removed before restoration’?
Evidence based protocols for the diagnosis and treatment of deep carious lesions in vital teeth are available. These proprietary protocols combine the caries detecting dye and DIAGNOdent laser fluorescence technologies with anatomical and histological knowledge to arrive at ideal caries removal end-points for adhesive restorations. These end-points generate a peripheral seal zone which can support long term biomimetic restorations.
Combining anatomic, pathologic and histologic knowledge with caries detecting dye and DIAGNOdent technologies produce ideal caries removal endpoints for adhesive dentistry without exposing vital pulps. This increases preservation of vital pulps and conserves dental hard tissue while creating a highly bondable peripheral seal that mimics the natural tooth when restored with low stress adhesive techniques. (Alleman & Magne, 2011)
Small & Shallow Lesions
For small and shallow lesions, limited to enamel and the superficial dentin closest to the dentino-enamel junction, the complete removal of caries by traditional visual and tactile techniques has been very successful. Minimally invasive dental treatments for these smaller sized lesions using air abrasion (Accelerated Particle Ablation/APA), glass-ionomer cements and resin composites eliminate the need for traditional preparations (utilizing invasive procedures such as drilling and amputation) that destroy important anatomical structures (Alleman & Magne, 2011; Malterud, 2010; Alleman, 2011; Magne, 2002, 2006; Rainey, 2011).
The use of high speed drills is incompatible with the porcelain like hydroxylapetite of tooth structure. Thus, high speed drills initiate fractures that radiate from the drill, through dentin, and the outer structure of enamel. One of the tenets of early intervention (and one of the advantages over conventional dentition processes) is that the initial micro-fracturing associated with high speed instrumentation, which are exacerbated by non-tooth compatible restorative materials (metals), are avoided with air abrasion technology. In conjunction with air abrasion, the treatment of children’s teeth using proprietary sealing processes in conjunction with state-of-the-art dental materials provide long term protection that prevents over 80% of future dental work (Rainey, 2011). This is in contrast to conventional materials (including plastics) used as dental sealants via inadequate sealing procedures to protect teeth, 50% of which fail within five years (Simonsen, 1999; Rainey, 2011; Christensen, 2011; Bravo et al., 1996).
Medium to Large Lesions
For adults whose teeth have lesions of medium and larger depths, more sophisticated techniques are required for determining caries removal end-points. Deep carious lesions have many visual and tactile complexities that can be systematically approached with caries removal endpoints and peripheral seal zone protocols. Early diagnosis and intervention using these proprietary procedures and techniques can avoid up to 90% of crowns resulting from utilizing traditional dental procedures (drilling and amputation) and subsequent use of non-bonding materials, all of which compromise the structure of teeth (Alleman & Magne, 2011).
Utilizing non-bonding materials in fillings and crowns, particularly in conjunction with high speed drills, results in cracks and fractures. Those cracks and fractures ultimately lead to bacterial infections, root canals, bridges and implants. These problems are avoided with conservative biomimetic procedures. The result of a systematic approach to caries removal endpoints determination are the maintenance of pulp vitality after restoration by adhesive methods, the elimination of dentinal infections by removing, deactivating or avoiding sealing in bacteria, and finally the conservation of intact tooth structure for long term biomimetic function. Specifically, a peripheral seal zone is created and pulpal exposures are eliminated while generating a highly bonded restoration with an excellent long-term prognosis.
Proprietary advances in the use of adhesive bonding, resin composites, and ceramics for both anterior and posterior teeth using minimally invasive procedures provide the foundation for biomimetic dentistry, a tooth conserving process using ceramic onlays which actually mimic the natural structure and function of the tooth, allowing for flexibility and movement not provided by amalgam fillings and porcelain crowns. A combination of direct, semi-direct and indirect procedures using CAD/CAM technologies can be performed by the dentist with or without the aid of a lab (Alleman & Magne, 2011).
In conjunction with increasing flexibility and movement to avoid cracking, leaking, and fracturing of tooth restorations, using the adhesive bonding techniques in the instruction modules dentists are able to virtually eliminate shrinkage (resulting from polymerization) and seal out bacteria (Alleman & Magne, 2011). This superior sealing/adhesive bonding technique provides patients with strong, durable white teeth and healthy gums. Patients enjoy beautiful smiles that can last a lifetime in conjunction with proper oral hygiene, balanced diets, healthy lifestyles and routine visits to their dentist.
State-of-the-Art Adhesive Bonding Techniques
After proper preparation of the tooth (air abrasion or acid-etching and drying), superior adhesive-composite bonds to dentin equal in strength to the enamel portion of the tooth can be achieved by controlling polymerization shrinkage. The following steps have been developed by Dr. Dave Alleman to reduce shrinkage:
(reduces total shrinkage to 0.10%)
In addition, precaulking dentin in the raised box (invented by Dr. David Alleman) with a Heliomar Flow layer absorbs stress resulting from the remaining 0.10% shrinkage due to
polymerization.
The safety zone provided by the Heliomar Flow is a fail-safe precaution for a dentin bond equal in strength to an enamel bond (Alleman, 2011).
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Adhesive Bonding & Biomimetics Enhances Preventive Dentistry
By using advanced adhesive bonding techniques and properly fashioned onlays, dentists insure that dental work will fail in a repairable way before teeth suffer any biological failures. By sealing the tooth against bacterial infections through superior bonding technologies, biomimetic dentistry prevents situations in which problems created by conventional dental procedures weaken and damage teeth, causing them to eventually become un-repairable due to permanent damage.
Biomimetic restorations are easily repaired upon failure and are designed and constructed so that the tooth is protected from permanent damage. Most biomimetic procedures require little or no anesthetic for restoration processes. The minor cost associated with biomimetic restoration is similar to the cost of a filling rather than the much higher costs of a conventional crown, root canal, bridge or implant.
Hierarchy of Successful Adhesion Dentistry & Online Instruction
The hierarchy of successful adhesion dentistry is comprised of six primary subject areas and associated procedures. The protocols for these procedures reduce the need for anesthetics and eliminate post-operative sensitivity for patients.
- Diagnosis & Treatment of Decay
- Diagnosis & Treatment of Structural Compromises
- Immediate Dentin Bonding
- Lowering C-Factor Stresses
- Semi-Direct Onlay Design & Fabrication
- Adjusting Occlusal Stresses
- Eliminating Post-Op Sensitivity
The specific protocols and procedures for these sequential steps, along with scientific documentation comprising over 400 PowerPoint slides compiled by Dr. David Alleman, are taught by the academy. Over 1,400 journal articles have been condensed into the above lessons for the purpose of teaching successful adhesion dentistry. Twenty seven journal articles form the core of the instruction modules. The ideal conditions for utilizing three different successful adhesive bonding techniques for posterior teeth (direct, semi-direct and indirect) are demonstrated in the instruction modules with emphasis on semi-direct onlay design and fabrication.
Chief Research Scientists David S. Alleman, J. Tim Rainey, Simone Deliperi and Pascal Magne continually conduct R&D including reviewing articles contained in the following scientific and technique journals:
- Journal of Adhesive Dentistry
- Journal of Prosthodontics
- Journal of Dental Research
- Quintessence International
- Journal of Operative Dentistry
- Journal of Dental Materials
- Journal of American Dentistry
Instruction modules for the Academy are continually updated with new information and state-of-the-art techniques. A detailed database and on-line library including a comprehensive bibliography is maintained and accessible to all graduates. An introduction to the online courses and additional research topics not included in the core curriculum are included in instruction materials presented at annual symposiums and conferences that are sponsored by the Academy. Individuals who are interested in attending conferences or enrolling in courses in biomimetics can complete the online registration forms and subscribe to the Academy newsletter via email.
Obtaining Hands-On Experience & Continuing Education Credits
Upon completion of the instruction of Dr. J. Tim Rainey's online instruction modules, dentists and their assistants are provided with an opportunity to obtain hands-on experience. This is accomplished over a week long mission and vacation excursion to a third world country and popular tourist destination such as Belize. Dentists will arrive at a four star hotel/resort on Friday or Saturday night. On Sunday they will attend orientation, followed by four days of working with the underprivileged under the supervision of an experienced mentor.
Emphasis will be placed on providing early diagnosis and intervention (preventive care) for children using the air abrasion technology followed by applying glass-ionomer cements or resin composites. In addition to providing hands-on experience, participation in the clinic allows dentists to complete their Accreditation under the supervision of a mentor trained by Dr. J. Tim Rainey. Each team will be comprised of a dental practitioner, dental assistant, and two support personnel. Each mentor can supervise 5-6 practitioner stations. On Thursday afternoon, dentists, their spouses and assistants are free to begin sightseeing, sport-fishing, scuba diving prior to returning home. The mission trips are tax deductible.
All AMIBD courses provide Continuing Education credits via Accreditation by the Academy of General Dentistry. Dr. Davis S. Alleman's online courses, and courses offered by other instructors, will require hands-on instruction in a traditional venue setting prior to Accreditation.
Successful Business Model for AMIBD Graduates
In addition to teaching biomimetic procedures which focus on minimally invasive dentistry, a successful business model for dentists will be presented. The business model will include utilizing an attractive and functional dental practice website, Internet marketing and state-of-the-art networking, all of which are provided for graduates of the Academy of Minimally Invasive Biomimetic Dentistry who become part of the AMIBD Network. A $20/month website fee is utilized to cover costs of hosting, provision of email accounts, continually optimizing content for search engines, and for conducting national marketing campaigns for biomimetic dentists who become Accredited. Refer to the website for the Alleman Center for Biomimetic Dentistry for a template that is utilized to develop websites for graduates of the Academy.
This business model will provide each dentist with support from an IT professional as a function of the Academy to continually promote biomimetic dentistry and refer patients to local dentists within the network. The business model will demonstrate how biomimetic dentists can gross up to $65,000/month in rural blue collar communities, even during poor economic conditions depending on demographics (primarily the number of biomimetic dentists in the community – refer to the AMIBD Network. This will allow dentists to potentially earn up to $500,000 in annual net income (top 10% of dentists) while focusing on doing what is best for their patients (Rainey, 2011).
Opportunities for learning how to effectively cross-train assistants and obtaining state-of-the-art dental materials and equipment (e.g., air abrasion unit developed by Dr. Tim Rainey; CAD/CAM equipment, ozone treatment equipment, etc.) at discounted prices from corporate sponsors of the academy are available to graduates (all net proceeds go towards conducting further R&D by the academy).
References:
Alleman DS, Magne P. A systematic approach to deep caries removal end-points:
the peripheral seal concept in adhesive dentistry. Academy of Minimally Invasive Biomimetic Dentistry, 2011.
Alleman DS. Personal communications, 2011.
Allsopp JF, Matthews JB, Marquis PM & Frame JW. Failure of amalgam restorations and their replacement in general practice.
(Abstract No. 35) J Dent Res 75(3):871-878,1996.
Anusavice K ed. Quality evaluation of dental restorations. Chicago: Quintessence 61-8:1989.
Babior BM, Takeuchi C, Ruedit J, Gutierrez A & Wentworth, P Jr. Investigating antibody-catalyzed ozone generation by human neutrophils. PNAS March 18, 2003, vol. 100, no. 6, 3031–3034.
Baysan A, Lynch E, Grootveld M. The use of ozone for the management of primary root carious lesions. Tissue Preservation and Caries Treatment. Quintessence Book 2001, Chapter 3, 49-67.
Baysan A, Whiley R, Lynch E. Anti-microbial effects of a novel ozone generating device on microorganisms associated with primary root carious lesions in vitro. Caries Res 2000; 34: 498-501.
Baysan A, Lynch E Effect of ozone on the oral microbiota and clinical severity of primary root caries Am J Dent, 2004, Accepted for publication
Bolen C. Guest Article by Charles G. Brown, National Counsel Consumers for Dental Choice. Tuesday, April 5th, 2011. Retrieved on 1 May 2011 from http://www.bolenreport.com/feature_articles/Guest/CharlieBrown/phaseout.htm
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Christensen, G. Personal communications with J. Tim Rainey, 2011.
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Magne P. Esthetic and Biomimetic Restorative Dentistry: Manual for Posterior Esthetic Restorations. Los Angeles: USC School of Dentistry, 2006.
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Magne P, Douglass WH. Porcelain veneers: Dentin bonding optimization and biomimetic recovery of the crown. Int J Prosthodont 1999;12:111-121.
Magne P, Douglass WH. Cumulative effect of successive restorative procedures on anterior crown flexure: Intact versus veneered incisors. Quintessence Int 2000;31:5-18.
Malterud MI. Air Abrasion: The New Rennaissance with an H2O Twist. www.dentistrytoday.com Oct 2010.
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Mollica P, Harris R. Integrating oxygen/ozone therapy into your practice. Retrieved on 6 May 2011 from http://www.toxinfreesmile.com/images/Ozone-Integrating%20Oxygen%20Ozone%20Thearpy%20into%20Your%20Practice.pdf
Morin D, Delong R, Douglas WH. Cusp reinforcement by the acid-etch technique. J Den Res 1984;63:1075-1078.
Ostler, L. Are You Gumming Up Your Heart? New Science Warns About New Threat to Your Heart. Retrieved on 5 May 2010 from http://aaosh.org/public_resources/health_library/gum-heart-connection/index.php
Ostler, L. The Perio/Heart Connection Report. Retrieved on 5 May 2010 from http://www.aaosh.org/public_resources/health_library/gum-heart-connection/gum-heart-connection-special-report.php
Rainey JT. Personal communications, 2011.
Ruefenacht C. Personal communications, 2011.
Simonsen RJ. Retention and effectiveness of dental sealant after 15 years. JADA 122(11):34-42, 1991.
Unterbrink GL and Liebenberg WH. Flowable resin composites as “filled adhesives”” Literature review and clinical recommendations. Quintessence International, Vol 30, No 4, 1999.
Vander Stoep C. Personal communications, 2011.
Walls AWG, Murray JJ et al. The Management of occlusal caries in permanent molars. A clinical trial comparing a minimal composite restoration with an occlusal amalgam restoration. Br Dent J 164(9):288-292, 1988.
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