Dear Dr. DiTolla,

I just received my issue of Chairside^®, Volume 4, Issue 2. In the article “Elective Cosmetic Dental Treatment: One Dentist’s Philosophy Concerning ‘When to Treat,'” Fig. 8 and Fig. 14 and the commentary by Dr. Lowe on his rationale for treatment of the gingival tissues is, in my opinion, not consistent with other articles in the same Chairside issue. Dr. Strupp’s and Drs. Pulliam and Melker’s articles and cases go the great lengths to manage periodontal and gingival tissue properly.

Under Fig. 14, Dr. Lowe mentions: “The marginal tissues are still immature and the sulcular environment is such that bonding restorations could be difficult.” I agree with his observation based on the photo in Fig. 14, yet he proceeds to bond the restoration using chemical means to dry up the sulcular fluids. This is inconsistent with the statement by Drs. Pulliam and Melker in the caption on page 50: “Currently, the gingival complex is a vital aspect of any restorative treatment plan.”

Dr. Lowe shows the final three-day post delivery slides in Figs. 19–23 (page 21), which show an “immediate result.” Again, in my opinion, the management of the tissues in this case is the issue — not the lab prosthetics. In my experience, the gingival tissue will not remain healthy in this case because there is and will be consequences from the manner in which the tissues were handled, as well as how the contours and margins were prepared. I would like to see a six-month pre-prophylaxis photo of this case.

– George V. Duello, DDS, MS, FACD
St. Louis, MO

Dear Dr. Duello,

I appreciate your comments regarding the case I presented in the recent issue of Chairside. I am familiar with Dr. Strupp and his protocols. Personally, I follow the protocols of Drs. John Kois, Frank Spear and Dennis Tarnow in regard to perio prosthetic management of the gingival tissues during restorative therapy. On anterior teeth, I place the restorative margins, as recommended by Dr. Kois, 3 mm from the bony crest on the facial aspect and 4 mm from the bony crest on the interproximal aspect. The bony crest position is determined by sounding from the free gingival margin to the bony crest prior to tooth preparation. I am sure that you assume there was no regard for biologic width when viewing the laser sculpting on Fig. 8. This sculpting was performed to allow the laboratory to correct the emergence angle of the restoration from the margin and avoid creating a ledge of porcelain to close the diastema. I assure you that the preparation margins were placed 4 mm from the bony crest in the interproximal area. Normally, I would perform the gingival sculpting, place provisional restorations to nurture the healing and contour of the proximal gingiva, and then make master impressions after healing.

The other aspect of this case that you are not aware of is that the patient was a long distance “fly-in” patient that I saw for a preparation visit and delivery visit only. I did not have the ability to have multiple visits with this patient. I will tell you that I have several years of experience using lasers and following Dr. Kois’ perio by the numbers protocol. I have taken master impressions prior to surgery in the same visit and have several years of follow-up on many cases to show what Drs. Kois and Tarnow say is true: if the restorative margin is placed in the appropriate position relative to the bony crest, biologic width and gingival health will be reestablished. This particular patient has been under the care of her local dentist for several years since the case was delivered. I do not have pictures to show follow-up, unfortunately, since I have not seen her personally, but her dentist has reported to me that the case has remained stable both gingivally and prosthetically.

Again, I appreciate your concern for the tissue management in this case, but I assure you that it is important to me as well. For years, I had followed a protocol of six months in provisional restorations after surgery. But now, in select patients (and this was not a surgical perio case), these cases can be managed, in my opinion, by careful margin placement with respect to the bony crest and allowing the tissues to mature around precisely fit and polished porcelain restorations, rather than ill-fitted plastic temporaries that after several months don’t fit as well and harbor bacteria. Remember, as well, that there is more than one way to gain a successful result when doing what we do. No one doctor has the corner on the “best protocol” to follow. It is the end result that matters, not so much how you get there. I assure you that the gingival health around this patient’s restorations, from all reports from her dentist, is excellent. Thanks again for your letter.

– Dr. Robert Lowe

Dear Dr. DiTolla,

I am a general dentist in Wisconsin considering the use of a compounded topical anesthetic. I have read several articles you have written on Cyclone and Profound (Steven’s Pharmacy; Costa Mesa, Calif.). Can you tell me if there is a specific technique that should be used when trying to get pulpal anesthesia from the topical to avoid an injection (such as with pedo)? Would the topical be syringed into the sulcus as opposed to the soft tissue over the injection site? Also, are there patients or situations where these compounds are contraindicated? Are there certain teeth/areas where pulpal anesthesia seems to be more effective from your experience? Thank you for any suggestions.

– Paul S. Petroll, DMD
Pulaski, WI

Dear Paul,

When I use PFG gel (formerly known as Profound) for pedo teeth (like when extracting my kids’ primary teeth), I place it with a cotton tip applicator on the facial and palatal tissue from the free gingival margin to the apical extent of where I thought the tooth was. If using it for pulpal anesthesia, I place it in the vestibule in the area I would expect the apex to be.

The only time I place it in the sulcus is prior to a PDL injection, which I like to do with the STA™ System (Milestone Scientific; Livingston, N.J.). With the combination of PFG gel and the STA System, I can finally give painless injections almost anywhere in the mouth — so I am actually less hesitant to give injections to nervous patients, especially since this combination allows me not to give lower blocks anymore.

PFG gel is contraindicated in any patient who has had a reaction to any of the ingredients — any of the “caines.” I haven’t seen one yet; most of what I hear from patients is related to epinephrine in a local anesthetic. With my PFG/STA System technique, I use only one-half to two-thirds of a carpule of Septocaine^® (Septodont; Lancaster, Pa.), which has half the epi of typical 2 percent lidocaine with 1:200,000 epi.

PFG gel seems to work best for teeth where the alveolar bone is thinnest. In areas where it is thick or the teeth are multi-rooted, an injection will be necessary if the procedure requires pulpal anesthesia. PFG gel is available through Steven’s Pharmacy (stevensrx.com) and the STA System can be purchased through Milestone Scientific (stais4u.com). To see this technique, go to glidewelldental.com and watch the Rapid Anesthesia video. I hope that helps!

– Dr. DiTolla

Dear Dr. DiTolla,

I just purchased a STA System. I noticed on one of your educational videos on Single Tooth Anesthesia that you used a PDL injection into buccal furcation on lower molars. Can this be used with the STA System rather than the two lingual injections, and can you bend the needle at 45 degrees to give the injection? Thanks.

– Douglas C. Stoker, DDS
Henderson, NV

Dear Doug,

That is exactly how I use the STA System: in the buccal furcation, with the needle bent at a 45-degree angle. I bought my STA System the week after that DVD was finished, so it doesn’t show up there, but it is used in the most recent DVDs. The folks at Milestone Scientific like the lingual injections better, but I start with the buccal and move to the MB or ML if I don’t get the pressure I am looking for in the furcation. That said, the people at Milestone are pretty smart and have some good reasons for preferring the lingual. But I don’t have any problems on the buccal and, therefore, I have no reason to change! Let me know how it goes.

– Dr. DiTolla