4. Dental patients with periodontaldisease always have more boneloss than is evident on full mouthradiographs.a) True b) False

s. Filmless (digital) radiography canreduce patient radiation exposureby 30%.a) True b) False

Speed filmb) accurate representations of

bony defects detected by clinical

periodontal chartingc) often underestimated by 40-60

% due to thick cortical walls of

boned) easier to detect with digital

technology but require more radi-

ation exposure for the patient

6. Cross-sectional radiographic im-ages, ideal for dental implanttreatment planning, can beachieved with low patient radia-tion with:a) the intraoral periapical filmb) the panographic filmc) CAT Scan seriesd) complex-m9tion tomography

ORIGINAL ARTICLE

By Izchak Barzilay, D.D.S., CERT. PROSTHO., M.S.

One of the most commonly usedproducts in the general dental prac-tice is articulation paper. The accu-racy of any indicator is important tothe creation of occlusal and dentalharmony. The uses of articulationpaper include:. assessment and adjustment of ex-isting occlusal contacts,

. occlusal adjustment and stabiliza-tion prior to fabrication and insertionof fixed partial dentures, crowns,and removable prostheses,. adjustment of occlusal and inter-proximal contacts during the fabrica-tion and insertion of fixed and re-movable prostheses,. adjustment of direct restorations

(composite resin and amalgamrestorations) immediately postplacement, ,

. recall evaluation of occlusion,

. evaluation of post endodontic oc-clusal contacts.. evaluation of occlusion on labora-tory casts during the fabrication ofdental prostheses.

Occlusal marking devices take upseveral different forms (Figure 1).Most often they resemble carbonpaper in that they are pressure sen-sitive and transfer ink to objectswith which they come into contact.The ideal marking device has thefollowing characteristics:1. colour transfer and easy to handleunder both wet and dry conditions,2. durable and reusable over multi-ple applications, and3. produce accurate and intensemarkings that are easily identifiable.

Occlusal marking devices may beclassified as:1. articulating paper,2. articulating ribbon,3. plastic tape marking devices,4. occlusal wax, and5. direct ink application.FIGURE 1. Select occlusal indicators include: Plastic (Mylar) Tape (Accufilm II (Parkell,

Farmingdale NY), Remarq (Dental Ventures of America Inc., Anaheim Hills, CA),articulation papers (Mynol - Thin and XX Thin (Block Drug Corp., Jersey City, NJ), DoubleCheck (Swedish Dental Supplies AB, AKarp, Sweden), Full arch paper (Swissdent,Glendale CA)) and articulation ribbon (Ardent, Broomall PA).

ARTICULADON PAPERArticulation papers are manufac-

SUMMER 1996 DENTISTS GUIDEjCDE 23

cates positive contact. Direct marksare not however left on the toothstructure and adjustment must bemade by relating the perforations totheir tooth locations.

TABLE.. THICKNESSES OF SELECT ARTICULATION PAPERS

BRAND

Myna!

Myna!

Myna!

Myna!

Myna.!

Bausch

Bausch

THICKNESS (MICRONS)

25

63

100

350

100

60

40

TYPE

XX Thin

X Thin

Thin

Thick

Premium

Articulation paperArticulation paper - Extra-thin

PAINT LACQUERAlthough not used commonly, apaint lacquer may be applied to theteeth under a dry field prior to tap-ping the teeth together,l.2 Thismethod is time consuming and maybe messy.3

Considering the fact that this is avery commonly used product thatensures the final occlusal fit of aprosthesis and therefore determinesits function and effectiveness, it issurprising that little has been pub-lished in the scientific literature onthe accuracy of these materials.Millstein 4 evaluated six occlusal

marking indicators using scientificmeans and found a wide range ofvariability between different indica-tors used for the same purpose. Lit-tle else has been published on eval-uation of these materials.

tween smudges and positive contactis easy in that a positive contact hasa dark periphery and pale center be-cause the dye of the ribbon issqueezed to the periphery by thetooth contact. Articulation ribbonsare usually saturated with ink sothey may be used several times onthe same patient before they needto be replaced.

PLAsnc TAPE MARKING DEVICESEarly varieties of these marking de-vices, introduced in the mid 1970s,were coated with ink on one side.The currently used var.ieties areavailable with ink coatings on bothsides and thicknesses in the 20 - 22micron range are available. Whilethese products may be accurate,they may be more difficult to han-dle since they possess static elec-tricity and may be difficult to sepa-rate from each other. The product isavailable in rolls (Pro-Mark Articu-lation Film, Pascal Co. Inc., Belle-vue, WA, Artifol, Bausch, Koln, Ger-many), precut strips (Accufilm II,Parkell, Farmingdale, NY) as well asadhesive sided to make laboratoryprocedures easier (Remarq Adhe-sive Backed Articulation Tape,Dental Ventures of America Inc.,Anaheim Hills, CA).

Mynol - Block Drug Corp., Jersey City, N.J.B,;..1'.' 8" ;,I'£iJ.;iCii'/ Gt'" "aUSC"f~ auscu,voJ.o~e, c ermany.

tured in different thicknessescolours and configurations. Thick-nesses may range from 25 - 350 mi-crons (Table 1). Use of thin articula-tion paper shou'ld result in a moreaccurate marking (marking of asmaller discrepancy). Thicker paperhas the potential to mark not onlycontacts but also produce falsemarks. This could result in adjust-ment of occlusal markings that arenot necessary.

Articulation paper is available in avariety of colours (blue, red, green,orange and black). Blue appears tobe the most common colour used.Red is useful on highly polished sur-faces gold or composite resin. Papersare available with different colouredsurfaces so that one arch is markedin red and the opposing arch ismarked in blue.

Articulation papers are manufac-tured in different configurations.The paper may be impregnatedwith ink through and through so itwill produce marks on teeth in botharches or may be inked on only oneside so as to produce marks in onlyone arch. The papers are available indifferent sizes (strips of differentlengths) as w(tll as full arch varieties.

ARnCULAnON RIBBONSArticulation ribbons have been usedfor many years and are either type-writer ribbons (Star Gemini RibbonNylon, Ko-REC- TYPE, Mississauga,ON) or are manufactured in silk (Ar-dent Madame Butterfly Silk Tape,Broomall, PA). These devices have ahigh degree of ink saturation and aretherefore reusable many times onthe same patient. Distinguishing be-

WAXOcclusal waxes are thin sheets ofwax (28g-32g) that are applied to theteeth and once occluded, the waxcan be evaluated either in themouth or removed from the mouthfor inspection. This method gives athree dimensional representation ofthe occlusion and perforation indi-

fiGURE 2. Silicone bite registration(Blue Mousse. Parkell. Farmingdale NY)of the right mandibular first molar tothe right mandibular cuspid indicatingocclusal contacts in the areas ofregistration perforation.

24 DENTIST'S ColIIDE/CDE ~IIMMI'R 1 OaF.

FIGURE 3. Occlusal marking using XX Thin Mynol (25 microns) showingaccurate marking of occlusal contact.

CLINICAL PROCEDUREWhen evaluating and adjusting oc-clusion in the centric relation jawposition the patient should be re-clining in the dental chair. Adjust-ments in the centric occlusion posi-tion should be done with the pa-tient in a more upright position.The articulation paper should besized to an adequate length to coverthe teeth that are to be marked.Strips should be mounted in articu-lating forceps and the teeth dried ifpossible to ensure accurate mark-ings. Markings should be madeusing different colours for centricpositions and excursive positions.Adjustments should be made asneeded being careful not to overad-just and affect vertical dimensionand jaw support. Articulation papershould be changed regularly to en-sure accurate contacts and ultimateocclusion verified with the use ofshimstock articulation film (ArdentShimstock Occlusion Foil - 8 mi-

crons, Broomall, PA).When using occlusal indicators,

difficulties may arise when markingwet or highly polished or glazed sur-faces. Care must be taken in read-ing marking from thick papers.Highly inked markers may producefalse readings and if overused, inkwill be exhausted and the indicatormust be changed often to ensure anaccurate marking.

fIGURE 4. Occlusal marking using Accufilm II (21 microns) showingaccurate marking of occlusal contact.CLINICAL COMPARISON

OF DIFFERENT INDICATORSIn an attempt to illustrate differentindicators in a clinical situation(based on Millstein4), a polyvinylsiloxane bite registration was madeof teeth in the mandibular right re-gion (Figure 2). This registrationshows definitive occlusal contacton the distal marginal ridge of thesecond premolar and two contactpoints on the buccal cusp of thefirst premolar. Contact is almostpresent on the buccal cusp of thesecond premolar. Different oc-clusal marking devices were usedto show their marking potential.XX Thin Mynol (25 microns)shows these occlusal points well -Figure 3) as does Accufilm II (Fig-ure 4). Thicker media s~art to pick

FIGURE 5. Centrimatic Articulation Paper (Swissdent. Glendale. CA) indicates a greaternumber of occlusal contacts than is present in the silicone registration.

SUMMER 1996 DENTIST'S GUIDE/CDE 25

4. Millstein PL. An evaluation of oc-clusal contact marking indicators:A descriptive, qualitative method.Quintessence Int 8(2);813-818,1983.

CONTINUING DENTAL EDUCATION

QUEST 0 N s

Mynol is a Mylar (plastic) basedarticulating paper.a) True b) False

2. Heavily saturated papers can beused "over and over."a) True b) False

FIGURE 6. Thick Myno! (350 microns) shows a large number of occlusal markings(false markings are evident).

up additional markiQgs (Figures 5and 6). Adjustment of these falsemarkings lead to needless reduc-tion of tooth structure.

correspondence to: 2300 Yonge St.,Suite 905, Box 2334, Toronto, ONM4P lE4, phone (416) 322-6862 fax:(416) 322-5282.

3. The thinnest marking devicesproduce the most accurate results.a) True b) False

4. Occlusal marking should be donein both reclined and upright posi-tions to cover CR and CO.a) True b) False

THE AUTHORIzchak Barzilay, D.D.S., CERT.PROSTHO., M.S., is Head of the Di-vision of Prosthodontics at MountSinai Hospital in Toronto; Associatein Dentistry, Faculty of Dentistry,University of Toronto, Toronto; andAssistant Professor, Eastman DentalCenter, Rochester, N.Y. He is also inprivate practice in Toronto. Address

5. Different coloured marking de-vices are only useful to differenti-ate between centric, lateral andprotrusive occlusal markings.a) True b) False

REfERENCES1. Troest T. Diagnosing minute de-

flective occlusal contacts. J Pros-thet Dent 14: 71,1964.

2. Chaiken RW. An occlusal indica-tor in continuous use and trial for15 years. Quintessence Int. 7(2)53-61, 1976.

3. Occlusion Ramfjord and Ash 1971W.B. Saunders Company Toronto.

By Louis P. Gangarosa, Sr., rhO, DOS;Alfred E. Ciarlone, DDS, rhO; and Arthur H. Jeske, rhO, OMO

method of killing microbes. Steriliza-tion is an absolute requirement forany instrument that will enterhuman tissu~s. The subject of steril-ization is not covered in detail in thisreview. These details can be foundin textbooks of microbiology and inhandbooks of operating procedures.

Although autoclaving is preferredit is not always possible, so there isstill a need for other methods ofcontrolling microbial growth. Chem-

ical antiseptics and disinfectants are,therefore, important, as are theproper use of asepsis, cleanliness,and hand cleaning. Here, we will re-view chemical antiseptics and disin-fectants and attempt to define theirusefulness in dental practice.

One of the most important require-ments of a dental practice is protec-tion of the patient and operatorsfrom spread of infection. This re-quires proper use of sterilizing pro-cedures (which kill all forms of life)as well as disinfection, asepsis, anti-sepsis, cleanliness and hygienic careof skin. Whenever possible, auto-claving is the preferred method,since steam heat under pressure athigh temperaturys is the best

A. DEfiNITIONSAntiseptic. A substance which,when used on living tissue, kills or

Continued on page 29

26 DENTIST'S GUIDE/CDE SUMMER 1996