Uncommon Common Sense: What YOU need to know NOW about Restorative Dentistry and Materials. Let s Rock! Things are not always as they APPEAR

Transcription

1 Uncommon Common Sense: What YOU need to know NOW about Restorative Dentistry and Materials Let s Rock! Daniel H Ward DDS May 5, 2017 Daniel H Ward DDS May 5, 2017 Things are not always as they APPEAR It may be your PERSPECTIVE 1

2 It may be your PERSPECTIVE Beautifil Flow 00 Unique glass ionomer filler particles Releases fluoride and other ions Neutralizes ph-antibacterial Good polishability Visibly blends in well S-PRG (Surface pre-treated Glass Ionomer) High Viscosity (Low Flow) Flowable Composite You may never have THOUGHT about it If we say it long enough we BELIEVE it Let s re examine some of our IDEAS we think we know Common sense is often UNCOMMON 2

3 Dentistry is Ever Changing How do you Choose? Minimally Invasive Dentistry Conservative Tooth Preparation 169L VF Lifetime of tooth often determined by first dentist intervention Fissurotomy bur How do you restore? G-aenial Universal Flo Homogeneous spherical particles Good wear resistance High flexural strength (167 MPa) Filled 50% by volume G-aenial U Flo Good polishability Low Viscosity Flowable Composite Blends in well High Viscosity Flowable Composite Conventional Nano-hybrid 3

4 CALSET Thermal Assisted Light Polymerization Completed Tooth Restorations Compule Tray Warmer W A R M E R Dispenser Gun Tray Low Viscosity Flowable Composite & Warmed Composite Minimally Invasive Dentistry Minimally Invasive Dentistry 15 Year Old 70% RED Proportion Multiple Step Layering Techniques Add dentin shade Aura Dentin 6 Miris Buildup dentin replacement Add Buildup translucent special remaining with effects form with shade opaque to incisal simulate hybrid similar darker or to desired hybrid imperfections microfill typically within final color with A3-A3.5 tooth structure hybrid (typically A1-A2) Add General Purpose Shade Aura MC 3 TPH Spectra 4

5 Finish and polish restoration Restore adjacent tooth Shape, finish and polish restorations Add Characterization Optrasculpt Add Facial Surface Aura Enamel Important-Junction G-aenial GT must be invisible Beautifil II Esthelite Sigma Quick Restore opposite teeth Pre-Operative Bonding Challenges Finished Restorations Post-Operative Sensitivity Hydrodynamic Theory Hydrodynamic Theory Hydrodynamic Theory Fluid flow within dentinal tubules causes PAIN Brannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12: Opened, unsealed dentinal tubules causes PAIN 5

6 Total Etch Technique Placement of Etchant Rinsing of Etchant Moist Dentin Placement of Resin Primer Overwet Phenomenon Placement of Resin Primer Moist Moist Apply multiple coats Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3): Overdrying Collapsed collagen fibrils Proper Moisture Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):

7 Moisture Variability Evaporating the solvent with dry air Air only syringe Warm air dryer Air/water syringe Air/water syringe Self-Etching Primer Self Etching Primer Acidifying Primer accompanies etch O O CH 2 CH 2 O O COOH COOH Methacrylate-group Hydrophobic end connects to polymer-network Spacer-chain link between functional groups Acid-groups Hydrophilic end etches tooth structure (self limiting) Acid reaction is self-limiting Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2): Self-Etch Technique Challenges Decreased bond strength to un-etched enamel Marginal gap formation with un-etched enamel Bond incompatibility to self-cure and dual-cure resins More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time 7

8 Effect of Enamel Etching-Marginal Gaps Solution: Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents. Self etching Primer Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37: Long Term Dentin Bond Stability MMP-Matrix Metalloproteases MMPs are naturally occurring proteases involved in dentin formation and trapped during odontogenesis Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers Low ph causes dentin to release these inherent MMPs which attack exposed collagen fibrils Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinasemediated collagen degradation. Eur J Oral Sci 2011;119: MMP-Matrix Metalloproteases In-vivo 12 m w/pbnt (Acetone) w/chx in 12 m Immediate (MPa) 14 mo (MPa) Control 29.3 (9.2) Control 19.0 (5.2) CHX 32.7 (7.6) CHX 32.2 (7.2) Carrilho et al., JDR 2007; 86; 529 Brackett et al.,operative Dentistry; 2009;34(4): Long Term Dentin Bond Stability Potential MMP Inhibitors Chlorhexidine (CHX) Benzalkonium Chloride MDPB ((12-methacryloxydodecalpyridinium bromide) GLUMA Epigallocatechin-3-gallate (green tea polyphenol) Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25: Long Term Dentin Bond Stability Disinfect to prevent MMPs Use Etchant containing 1% Benzalkonium Chloride OR TE-Apply SE-Apply 2% 2 Chlorhexidine coats 2% after Chlorhexidine acid etching prior for 30 to sec application of primer 8

9 Long Term Dentin Bond Stability Disinfect to prevent MMPs Selective Etch Technique Apply etch to enamel only for 15 seconds Wash thoroughly Place self-etching primer MDPB (12-methacryloxydodecalpyridinium bromide) Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7): Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10: Universal Bonding Agents Bond strength same to total vs self etch Dentin Bond Strength Total, Self or Selective Etch Universal Bonding Materials Self etch Selective etch Total etch Self-Etch Total Etch Moist Total Etch Wet Total, Self or Selective Etch Universal Bonding Materials Total-etch, self-etch or selective-etch technique Can be used for direct and indirect restorations Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate. Compatible with light-cured, self-cured and dual-cured composite and luting cements. Total, Self or Selective Etch All-Bond Universal Total-etch, self-etch or selective-etch Single bottle for direct and indirect restorations High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate. Compatible with light-cured, self-cured and dual-cured composite and luting cements since ph is 3.2 Becomes hydrophobic upon setting 9

10 Total, Self or Selective Etch MDP Universal Bonding Materials Cross-linking of polymer chains Hydrophobic upon setting Total, Self or Selective Etch Universal Bonding Materials Bulk Fill Composites Allow many posterior restorations to be built up in 1 segment Descriptions Stick the stuff in the hole and cure Evolutionary Monolithic Physical Advantages Deeper depth of cure Less Polymerization Shrinkage Less Polymerization Shrinkage Stress Reduced likelihood of air voids between layers Bulk Fill Composites Modes of Action Improved initiators Greater translucency allows better light transmission Delayed gel state formation Increased elasticity Materials Flowable Conventional Advantages Quicker, easier Less chance of enamel and cusp fractures Increased likelihood of adequate resin polymerization Bulk Fill Flowable Composites Low Shrinkage Stress Surefill SDR Voco Xtra Beautifill Bulk Flowable Venus Bulk Fill Surefill SDR Reduced polymerization shrinkage stress Bulk fill to 4mm Increased sensitivity to light Great placement with metal tips Self-leveling A1, A2, A3 Universal shades Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:

11 Polymerization Shrinkage Stress (MPa) Bulk Fill Posterior Composites Low Shrinkage Stress Voco Xtra Fill Beautifill Bulk Flow Aura Bulk Fill Tetric Evo-Ceram Bulk Fill Sonic Fill Sonic Energy Assisted Light Polymerization ADVANTAGES Sonic Energy Assisted Light Polymerization Improved flowability of composites Improved marginal adaptation 5mm depth of cure Increased sculptability and ease in shaping anatomy Sonic Fill Composite designed specifically for use Sonic Energy Assisted Light Polymerization Sonic Energy Assisted Light Polymerization Sonic Fill Sonic Fill Triodent or Palodent Plus 11

12 Oral Environment Challenges- Xerostomia Oral Environment Challenges- Xerostomia 40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect Multiple Medications Chalmers J. Personal Communication Oral Environment Challenges- Xerostomia Oral Environment Challenges- Carbohydrates Incidence increases with # of drugs taken 50% of patients taking 4 or more medications had Dry Mouth Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g Oral Environment Challenges- Bottled Water Oral Environment Challenges- Illegal Drugs Fluoride-less water Fluoridated water Meth mouth or chronic marijuana use 12

13 Need Therapeutic Restorations Composite Challenges Glass Ionomer Xerostomia patients High carbohydrate users Non-fluoridated water users Drug abusers Post-operative sensitivity Low post-op sensitivity Recurrent decay Fluoride Release Achieving proper moisture Moisture variability Polymerization shrinkage No shrinkage Increased time-layering Bulk placement Technique sensitivity Simple-more forgiving Glass Ionomer Base/Restorative Fuji IX Self Cure Glass Ionomer SDI Self Cure Glass Ionomer Glass Ionomer Characteristics More highly filled-reduced wear Self-curing in minutes No polymerization (setting) shrinkage stress Expansion/contraction similar to tooth High fluoride release Bioactive Glass Ionomer Uses Multiple cervical carious lesions Pediatric Patients Sealants Class V restorations Sandwich Technique Crown buildups Long term interim restorations Cements Glass Ionomer Restorations High caries rate individuals 13

14 Glass Ionomer Restorations Glass Ionomer Restorations Remove decay and place matrices Treat dentin with PAA Glass Ionomer Restorations Glass Ionomer Restorations Place, shape and wait 2:30 Shape with diamonds w/ water Glass Ionomer Restorations Glass Ionomer Restorations Dry and place Surface Sealant No phosphoric acid Pediatric Patients 14

15 Glass Ionomer Restorations Glass Ionomer Restorations Pediatric Patients Long term interim restoration Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration Glass Ionomer Restorations Long term interim restoration Dentist-Multiple Radiographic Caries 15

16 Posterior Glass Ionomer Stronger Glass Ionomer For use in posterior teeth Increased compressive strength (219 MPa) Increased flexural strength Greater wear resistance Increased acid resistance Equia Forte High fluoride release maintained Stronger surface sealant Better designed for Class II posterior restorations Posterior Glass Ionomer Posterior Glass Ionomer 47 year old female Been in the practice over 30 years Regular re-care appointments Significant changes in health history No restorations in 8 years Radiographs revealed multiple interproimal radiolucencies not present 12 months previous Required 16 restorations Need caries resistant restorations Sudden Onset Caries Preparations Posterior Glass Ionomer Posterior Glass Ionomer Preparations Posterior GI Restorations 16

17 How long do they last? 8-12 years- single surface 65% 10 yr 5-8 years- multiple surface 35% 10 yr The larger the restoration, the shorter its lifetime Long term interim restoration Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2): Resin-Modified Glass Ionomer Characteristics Acid/base and polymerization reactions Dual cured-faster Shortens time needed to control moisture More esthetic and translucent Fluoride release Higher tensile, bond strength and wear Resin-Modified Glass Ionomer Uses Liner or Base Class V Restorations Restoration Under Crown Temporary prior to crown Sandwich technique Cements Resin-Modified Glass Ionomer Base/Restorative Capsule Fuji II LC RIVA LC Resin-Modified Glass Ionomer Base/Restorative Paste-Paste Resin-Modified Glass Ionomer Ketac Nano Fuji Filling LC Gingival recession & root caries 1 st molar and bicuspid Remove decay place retention 17

18 Resin-Modified Glass Ionomer Resin-Modified Glass Ionomer Gingival recession & root caries 1 st molar and bicuspids Remove decay place retention Condition with PA Pre treat with dentin conditioner (Polyacrylic acid) Material Placed and Light Cured Place excess material Light Cure Resin-Modified Glass Ionomer Material Placed and Light Cured Place excess material Light Cure Final Restorations Shape restorations Hold back gingiva and shape with fine diamond Etch with phosphoric acid, wash and dry Place surface sealant and light cure Quick Temporary prior to Crown Temporary placed 6 years ago Sandwich Technique 18

19 Glass Ionomer Resin-Modified Glass Ionomer Exposed to occlusion Able to control moisture Not acid etching No shrinkage stress Highest fluoride release Out of occlusion Need quickness Need to acid etch Need to bond translucence/esthetic OH SH*T! Endodontic Root Canal Therapy? Perhaps not IF: Asymptomatic Single small exposure Able to achieve hemostasis Traditional Pulpal Protection Indirect Pulp Capping Best not to expose pulp Asymptomatic Sound 2mm around margins Stop when next scoop will expose pulp Place GI or Ca(OH) 2 Traditional Pulpal Protection Indirect/Direct Pulp Capping What are we trying to accomplish? Mechanical Sealing of the Pulp Stimulate hydroxyapatite formation Dentin bridge formation Traditional Pulpal Protection Indirect/Direct Pulp Capping How does this happen? Material sets hard and adheres to dentin Alkaline ph Release of Ca ++ ions Ca +2 H2O Ca +2 OH - OH - 19

20 Unproven Pulpal Protection Indirect/Direct Pulp Capping Resin Dentin Bonding? Dentin Bonding Agent-Composite Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy. Unproven Pulpal Protection Indirect/Direct Pulp Capping Glass Ionomer/RMGI? Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glassionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31: Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22: Improved Pulpal Protection Indirect/Direct Pulp Capping Ca(OH) 2 Paste Ultra-Blend Plus Ultradent Pulpal Protection Indirect/Direct Pulp Capping MTA (Mineral Trioxide Aggregate) ProRoot-Dentsply Biodentine-Septodont Thera-Cal LC-Bisco Tricalcium silicate (CaO) 3.SiO 2 Dicalcium silicate (CaO) 2.SiO 2 Tricalcium aluminate (CaO) 3.Al 2 O 3 Tetracalcium aluminoferrite (CaO) 4.Al 2 O 3.Fe 2 O 3 Gypsum CaSO 4 2 H 2 O Bismuth oxide Bi 2 O 3 20

21 Biodentine Theracal Resin Modified Calcium Silicate High concentration MTA (self setting) Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium Social Media Communication Cell Phone Text Messaging Appt Reminder/Late Cancel Custom Messaging Appt Reminder/Confirmation Custom Messaging Appt Reminder/Confirmation 21

22 Rescheduling/Reactivating Patients Increase Production Custom Newsletters Holiday Promotions $61, brought in from patients who did not pre-appoint in 2016 Custom Newsletters Regular Newsletters Custom Messaging Birthday Wishes Custom Patient Surveys Automated Post-Appointment Custom Patient Surveys Automated Post-Appointment 22

23 Custom Patient Surveys Automated Post-Appointment Online Patient Reviews Monitor Online Reviews Online Patient Portal Automated Post-Appointment Pay Bills Online Management Research-Maps Research Locale Demographics Mobile Devices New Mobile Apps Healthgrades Increase internet marketing March 1,

24 Healthgrades Increase internet marketing Limelight Online Patient Scheduling May 1, 2017 Weave Complete Phone Weave Complete Phone Syncs digital phone with your practice management system to instantly show caller information on computer screen Looks like a phone app Go down checklist Weave Complete Phone Weave Connects Phone to Practice Management Software Ability to text message Ask patients for recommendations* 1. When the phone rings, it tells your practice management software who s calling. 2. Prompt lets you know who s calling and gives you access to the patient s info with a click or by picking up the phone. 3. Patient s appointment info, todo list, insurance info, notes, balance and more are displayed. 24

25 Weave Other Features Weave Considerations Phone Service Connect your phones to your patient communication software. Reviews See positive reviews from patients and address negative reviews before they are posted for others to see. Conversational Text Messaging Appointment Reminders and Recalls Set automated, pre-made or personalized text reminders and recall messages. Mobile App Easier for patients to communicate with your office. Reports Advantages Ability to Maximize phone calls for scheduling and collections Messaging Capabilities Cost Savings Excellent Customer Service Challenges Learning Curve Internet Reliability Weave Growing Pains Texting works like a smart phone.. See stats on phone usage. Thank You! dward@columbus.rr.com 25