Dr. John Flucke is in private practice in Lee’s Summit, Mo. He also serves as technology editor for Dental Products Report magazine and keeps an active blog filled with thoughts and tidbits on the world of technology at blog.denticle.com.

Dr. John Flucke

I find it amazing to see and experience the continual expansion of our knowledge of the science behind our incredible profession. For those of you who don’t know, I am a huge fan of baseball, and one of my all-time favorite personalities of the game was a player for the Negro League’s Kansas City Monarchs named Buck O’Neil. He passed away in 2006 at age 94, and his positive attitude and indomitable spirit are still something of a legend in my hometown of Kansas City.

He had lived through segregation, racism, and other horrible parts of our history. However, he also met and played with some of the greatest players in the history of the game. He was once asked if he wished he would have been born during the current time when there is so much more focus on equality. Because of that focus, he would have played in the Major Leagues. His response was, “Waste no tears for me. I didn’t come along too early—I was right on time.”

That’s exactly how I feel in our current dental environment. The changes that we see today are incredible and are only getting better. There are extraordinary advancements made every day, no matter what aspect of our profession you mention. It is an amazing time to be in the health care profession. Another thing to consider is that just when you feel like things in a particular category cannot be advanced any further, along comes a product that completely knocks your socks off and changes things up once again.

That’s exactly what has happened in the realm of composites with a new product called VisCalor bulk from VOCO.

The name gives you an indication of one of the ways this composite changes things up. For years now, some of us have been warming our composite resins. Warming any composite resin creates inherent benefits, but VisCalor, as the name implies, is a material that is designed to be warmed. The smart minds at VOCO have come up with the term TVT (thermo-viscous technology) to describe the advantages of the product.

When warm, the material has incredibly low viscosity. In fact, when warm, it is practically a flowable. This means that it is incredibly easy to place and that it adapts amazingly well to the preparation. Many doctors choose to place a flowable composite on the floor of the preparation to ensure the dentin is properly covered. Total dentin coverage helps to decrease sensitivity.

Occasionally when placing a normal composite, as the placement instrument is taken off the material, a small amount of composite will stick to the instrument and pull up off the dentin. This creates a void on the pulpal floor. When the material is then loaded occlusally, it flexes and the void creates a pressure differential across the pulpal floor, leading to sensitivity.

Because VisCalor has such low viscosity when it is placed, it flows easily into all of the “nooks and crannies” of the preparation, meaning that a base layer of flowable is not needed. This saves steps, which is much more efficient, and makes the procedure go smoother.

So how does one go about warming this material? You have 2 choices.

The first is a compule warmer, a device that is AC powered, heats up, and holds the compules until you need them. It can also hold 2 hand instruments as well as a composite dispensing gun, which allows all of these items to be kept at the proper temperature for the material. The device takes approximately 20 minutes to heat up to the proper temperature, so it needs to be turned on before the first patient of the day and given adequate time to reach the optimum temperature.

The second choice is my personal preference—a gun-type dispenser that actually heats the compules as they sit in the barrel. The gun is powered by a rechargeable battery, and it heats the material using an array of near-infrared LEDs. The compule snaps into the barrel, and once it is in place, the LEDs (which are located directly over the compule) warm the material in 30 seconds.

Before I start to chemically treat the preparation, I place the compule in the gun and hit the “on” button. By the time we have gone through our bonding process and are ready to place the VisCalor bulk, the gun is done heating the material and is ready to go. After placement, the gun shuts off automatically 3 minutes after being turned on.

Sometimes a new idea comes along that is so simple that you think, “Why didn’t I think of that?” The compule for VisCalor bulk is one of those ideas. VOCO has redesigned the compule to allow for easier and better placement of the material. Because VisCalor bulk is so flowable when warmed, the compule has been created with a long, narrow diameter tip. The diameter allows the operator to place the tip all the way to the floor of the box in interproximal restorations and fill from the bottom up.

A standard composite compule has a rather large diameter lumen on the tip—simply because the material is so viscous that it could not be dispensed out of anything smaller, even when warmed. The problem with that design is that it is difficult to place those large tips into small interproximal boxes. Often, composite ends up being extruded over the matrix band, resulting in time-consuming cleanup. This rarely happens with VisCalor bulk.

The concept of TVT is pretty amazing. When properly warmed, VisCalor bulk is almost a flowable. But when it cools, it becomes very malleable. That means that initial placement is incredibly easy, and then the material can be shaped and sculpted.

The combination of low viscosity and the narrow tip of the compule mean that it is amazingly easy to place, adapts well, and can be placed without voids and bubbles.

One of the other terrific features of this material is, once again, in the name. It is VisCalor bulk, and that word 

 is a tremendous advantage. The depth of cure is up to 4 mm. Once again, that means that in a 4-mm preparation, you do not need to do a series of two 2-mm incremental placements. And that means patients spend less time in the dental chair.

This can greatly increase efficiency, especially if you are doing quadrant dentistry. As I’ve said many times in the past, no patient wants an appointment to take longer. Plus, the less time you and your assistant spend in the clinical posture, the better it is for long-term health and mobility. Dentistry is notoriously physically strenuous on practitioners, so the less time you spend in that clinical posture, the better it is for you.

Typically, bulk fill brings some disadvantages. The most common problem is esthetics. To get a bulk fill, the energy from the curing light must reach the bottom, or close to the bottom, of the material. Usually companies accomplish this by making the material more translucent. Although this helps with depth of cure, it sacrifices esthetics, often making the finished restorations look gray.

That was what I expected when I began working with VisCalor bulk. However, I could not have been more wrong. Simply stated, VisCalor bulk may well be the most esthetic material I have used in my career, and I have used quite a few. I am routinely amazed by the way this material blends in with the surrounding tooth structure. At times, it is practically invisible, and that is when I’m viewing it with my Orascoptic ×5 magnification.

The one thing I’ve learned over my years of practice is to expect the unexpected—whether with a treatment plan that suddenly goes sideways, which happens to all of us, or when I start to think there isn’t much further we can go with composites.

I have been using VisCalor bulk for about 6 months now because I was beta testing it in the fall, and I can tell you that it is an impressive restorative material that has taken composites to a new level.

VisCalor bulk was released in February, so you can order it now. I highly recommend you check it out. I think you’ll feel the same way about it that I do.

Articles

Just when I thought we couldn’t advance any further with composites, along came VisCalor bulk. 

Expect the Unexpected With VisCalor bulk

One of the things that fascinates me greatly about technology, and life in general, is the evolution of our products. I’ll use the microwave as an example. When it came on the market, it was a total home run, game-changing kind of product. Stores couldn’t keep them in stock.

But people began to notice that the device did not heat things evenly. Folks began to stop the microwave and rotate the plate 90° to 180° to allow for even heating. But before long, manufacturers created the rotating cooking plate that spun slowly as the food heated. In a matter of months, this upgrade became pretty much standard equipment with microwaves. Nowadays, I don’t think you can even buy a microwave without one. The industry created an evolution, noticed a small flaw, and adjusted it, and that evolution even became a part of the device.

Dentistry is no different. Manufacturers find areas that need enhancement and adjust them, and the adjustments become part of the product. And in no place in dentistry is this situation more apparent than in the world of chemistry.

Statistics from the American Dental Association estimate about 175 million filling procedures are accomplished per year in the United States. It is easy to see how improving that process can affect a serious number of patients. Even if there are 2 restorations on each patient, that is still over 85 million individuals directly affected by an improvement.

Those are just a few of the reasons that I have been impressed with my testing and the performance of 3M’s new Scotchbond™ Universal Plus Adhesive. The material has undergone several improvements this generation, making it a product that every office should consider.

Since bonding agents were invented, clinicians have struggled to tell the difference between composite interface versus recurrent decay. A radiolucent area along the gingival margin could very well be a bonding agent, or it could be caries and require intervention. How do we tell? Scotchbond Universal Plus Adhesive has a radiopacity similar to that of dentin in a bitewing radiograph. This removes the guesswork and saves the patient from potentially unnecessary replacement.

The material has the ability to bond and seal caries-affected dentin—this amazing property aids in practicing minimally invasive dentistry.It is no longer necessary to sacrifice tooth structure in order to compensate for a deficiency in the material. Doctors can restore with confidence knowing that their restorations are strong, stable, and durable.

Scotchbond Universal Plus Adhesive can be used in any clinical situation. Gone are the days of needing separate bonding agents or extra bottles. Whether the procedure is direct or indirect, metallic, glass, or resin, Scotchbond Universal Plus Adhesive bonds incredibly well to them all.

The days of bonding products that required a special additive to work properly in the dual-cure environment are behind us with Scotchbond Universal Plus Adhesive. It is truly a single-bottle solution!

Although 3M created a superior dual-cure resin cement called RelyX™ Universal Resin Cement that works hand in glove with Scotchbond Universal Plus Adhesive, the adhesive can also be used with confidence with any other dual-cure resin cement.

The material truly is a “universal adhesive” that optimizes bond strength to both etched and unetched enamel. No matter what bonding philosophy a dentist uses, this material works. I happen to use the total-etch technique, but whether you use total-etch, selective-etch, or self-etch, this material will interface with it.

Using Scotchbond Universal Plus Adhesive is as simple as:

placing in the prep and agitating for 20 seconds,

air drying and thinning the material for 5 seconds until the material is thin and does not visibly move anymore, and

In practical applications, it is imperative that the material is designed with ease of use in mind. To that end, the talented minds at 3M have done a great job of increasing efficiency and decreasing waste in the delivery system.

The dispensing system is designed to be easy on the environment as well. If you are familiar with the original Scotchbond Universal, you will notice that the rubber gasket in the cap is gone. The bottle is also manufactured utilizing less plastic than its predecessor.

The bottle is designed with smooth surfaces and edges that make it easier to clean and less retentive to bioburden, which is more important than ever. One of the other dispensing features I find advantageous is the elimination of the bottle. The material can be purchased in single-dose packs that help reduce the risk of cross-contamination.

Unidose systems are also beneficial because they ensure a totally fresh dose every time. Bonding agents contain a solvent that can evaporate over time, but opening a sealed unidose pack for every procedure removes that possibility.

3M is a key player in the adhesive dentistry market. It achieved this position by diligently researching and testing improvements in its products. It is a company dentists rely on to provide quality products that ensure long-term clinical results. 3M’s latest work, Scotchbond Universal Plus Adhesive, is something it should be proud of and should be on a short list of products dentists should explore if they are looking to improve their bonded restorations.

Opinions expressed in this article are Dr Flucke’s and do not necessarily represent the views and opinions of 3M.

This Product Test Drive explains why 3M™ Scotchbond™ Universal Plus Adhesive is another step ahead in dental bonding.

Advertorial: Increased Efficiency With Reduced Waste

When it comes to composites, the times they are a-changin’! It’s so exciting to be a restorative dentist right now. We are seeing lots of evolution in how we deal with our esthetic bonded restorations, and I couldn’t be more pleased with the way things are headed.

A couple of years ago, I was fortunate enough to have been chosen to help with the evaluation and testing of Tokuyama Dental’s then brand-new composite, OMNICHROMA. The material was a huge evolutionary step forward and continues to impress in today’s environment.

For younger practitioners reading this, I was unlucky enough to practice in a time before the invention of flowable composite. I still remember when I had lunch one day with a friend in dental sales. Flowable composite had been on the market about 2 years at that point, and I remember him saying, “Flowable is like the duct tape of dentistry!”

I laughed so hard I almost choked on my iced tea. Like any good piece of comedy, it was funny because there was a lot of truth to the statement.

For those of us who practiced before the age of flowables, many things were much more difficult to accomplish. Minimally invasive preparations practically were invented by the physics of flowable composites. They also allowed for easy margin repairs of existing composites, conservative Class III preparations, and the easiest way to complete Class V restorations.

When OMNICHROMA came along, it rocked the dental world, but doctors were still forced to go to traditional shade matching when they needed a “duct tape” solution. Basically, the market was begging for a “one composite, any shade” solution—and Tokuyama just delivered with OMNICHROMA Flow.

I love the tagline that Tokuyama created to go with the OMNICHROMA brand: “Every shade. One choice.” It gets the point across succinctly, and it’s true. Traditional shaded composites use dyes and pigments to change the color of the material. However, this means that shades can vary from manufacturer to manufacturer and within individual batches from the same manufacturer.

Instead of pigments and dyes, OMNICHROMA Flow relies on the same technology as regular OMNICHROMA. The shade matching is provided by an amazing supra-nano filler particle. This “tiny” particle does something truly amazing. Tokuyama has created a technology that allows them to produce these particles in a perfect spherical shape. This shape lets the ambient light that strikes the composite be uniformly spread out, which allows the light to pick up and transfer the shade of the surrounding tooth structure back into the OMNICHROMA Flow.

In the simplest (and zen) terms, OMNICHROMA Flow allows the tooth to provide its own shade. This is what allows the composite to basically “melt” into the preparation with practically invisible margins. Whether the tooth being restored is A-1 or D-4, the light-transferring physics of OMNICHROMA Flow allow the material to match and blend, yielding spectacular esthetic results.

Another great thing about spherical particles is evident in the polishing phase: Spheres are much easier to polish. All flowables use a mixture of resin and filler particles. In other flowables, these filler particles are randomly shaped and appear like microscopic pieces of gravel in scanning electron microscope images. Think of it as trying to polish a marble or a bowling ball versus trying to polish a randomly shaped piece of stone. The spherical fillers of OMNICHROMA products provide an incredible substrate to polish against, and frequently, polishing isn’t even necessary.

Inventory control in the office changes from “How much of each color do we have?’’ to “How much OMNICHROMA Flow do we have?” When you have one material that matches every clinical situation, your inventory control is greatly simplified. This makes it easy for the dentist and incredibly simple for whoever is in charge of the restorative inventory. Only needing 1 of something is always easier than needing lots of other things.

There is also the efficiency that comes with clinical usage of only 1 product. The duct tape analogy comes into play again here. The joy of having a terrific flowable composite in your armamentarium is the number of clinical uses the product provides. Reaching for only 1 flowable for every conceivable clinical situation makes procedures more efficient and less stressful. You also take away the need for shade matching and the potential extra time required to correct the esthetics in cases where a shaded composite doesn’t properly match—which is normally not discovered until after it is polymerized.

Another benefit of the “single shade for every tooth” concept is that you will never experience a case in which you ask your assistant for a specific shade of composite only to find that you used the last bit of that shade earlier in the day or that it’s back-ordered from your dealer. As we all know, Murphy’s Law is alive and well in a dental practice, so anything you can do to keep Mr Murphy at bay is well worth the effort.

For years now, the profession has worked hard to help make adhesive dentistry more predictable. Companies have improved their composites in many ways. We have overcome problems such as long curing times, polymerization shrinkage, polishability, stain resistance, and more.

Now, with the introduction of OMNICHROMA Flow, we have finally entered the realm of one composite for any clinical situation that requires a flowable composite. I salute Tokuyama Dental for their hard work and dedication in bringing this product to our profession. It is truly impressive.

This Product Test Drive showcases how OMNICHROMA Flow from Tokuyama Dental makes achieving esthetic success easier than ever.

Advertorial: A Flowable Fix That Works in Every Situation

I love history. However, I don’t love it in the way of memorizing names and dates. I love the lessons of history. I love the way that a problem presents itself and is then solved over time. Sometimes things are no-brainers, like seat belts, for instance. Other times, the lessons require convincing individuals of the reason behind the change, such as infection control.

In the 1800s, when the theory of infection by microscopic organisms came about, many scoffed at the idea of “invisible bugs that make people sick.”

Yet, lessons were still learned, and the world became a much better and safer place because of the hard work of those who believed and eventually had the science to back them up. Both seat belts and infection control have saved countless lives and greatly lowered the number of individuals who experience injuries or infections.

I truly feel that the practice of dentistry can be a lot like a pilot flying an aircraft. By that, I mean that pilots are always encouraged to keep learning and vigilantly study every flight they make. Pilots are told to evaluate every landing—even the great ones—to learn what was done right and what could have been done better. I love the expression “Any landing you walk away from is a successful one,” but post-evaluation is critical. A professional is always obligated to evaluate their successes and, more importantly, their failures to improve outcomes.

These lessons bring me to the point of my column this month. By the time you read these words, it will have been over a year since dentistry was shut down due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the coronavirus disease 2019 (COVID-19) infection it caused. I remember watching a press conference from the White House when Seema Verma, then administrator of the Centers for Medicare & Medicaid Services, announced that all elective dental procedures should stop. That date was March 18, 2020. My staff and I were watching the press conference live, and I turned to my staff and said, “We’re done.” They all nodded, and like the efficient team they are, began closing out our schedule and preparing the office for a shutdown of at least 14 to 21 days, which was the American Dental Association’s recommendation at the time.

My office was closed until May 18, 2020, and in the 60 days that passed, the infection control world turned on its head, figuratively. Hopefully, none of us will have to deal with a similar situation again in our practice lifetimes, but we can never know. All we can do is be prepared.

Having never seen anything like a global pandemic in our lifetimes, we were a bit flat-footed when it struck. Hopefully, we can be better aware and prepared for future problems.

Giving credit where it is due, our “early warning systems” of dangerous infectious agents are incredibly robust and accurate. The original SARS that showed up in China in the early 2000s could have potentially been worse for the United States than what we are currently experiencing. However, the Centers for Disease Control and Prevention and its equivalent in other countries spotted it quickly. Through vigorous quarantining and contact tracing, it shut the spread down in an incredibly efficient manner. SARS never truly got out of control. It certainly could have, but the safety net of our public health services held firm.

The outbreak of SARS-CoV-2 was a different story. From what I can discern, there was much less cooperation from the Chinese government this time around, and that allowed the virus to spread more or less unchecked for the first 1 to 2 months. However, the US government made no concentrated effort due to a lack of direction from the executive branch.

I feel the very first takeaway from this pandemic is the importance of a domestic supply chain or a frequently overturned emergency supply of critical equipment. Gloves have a limited shelf life, but the stocks could be rotated by selling gloves before they expire and begin to breakdown. This would allow a department such as the Federal Emergency Management Agency to always have masks, gowns, and gloves in a national stockpile that our health care system can access in times of mass infections with limited supply chain support.

We learned a hard lesson by allowing mask and glove manufacturing to be concentrated in foreign countries. The Department of Health and Human Services says 95% of surgical masks and 70% of N95 respirators are manufactured overseas. As the pandemic worsened, some factories abroad closed because of the virus, whereas some countries refused to export masks for fear of needing them within their own borders.

With supply issues and counterfeit masks, many frontline workers, including those in dentistry, worked in dangerous environments with subpar personal protection equipment (PPE) that did not meet the approved standards. Yet, there is no way of knowing.

There is the global nitrile glove market. It is estimated that 99% of nitrile gloves are manufactured in Malaysia, Thailand, Vietnam, and China. For similar reasons, the glove supply has dropped precipitously, and the price of gloves has risen 175% since last year.

The US needs to reverse its dependence on foreign suppliers of critical health care goods and equipment. Although supplies have been limited, critical supplies have remained available. Next time, we may not be so lucky.

I’ve said many times that dentistry was better prepared for a pandemic than many other health care specialties simply because we have been so cautious about infection control since the 1980s. And yet, there are new products that help us practice more safely.

Auxiliary air cleansing vacuum systems such as the Aegis Aerosol VacStation from CAO Group, Inc, have allowed doctors and teams to practice in safer environments as they literally suck up and purify aerosols as soon as they leave a patient’s mouth. We’ve also seen UV light systems that can kill viruses on surfaces and in the air.

Companies are now selling large air purification devices that use a variety of filtration methods, including ozone to eliminate virus particles as they circulate through the air.

We’ve also learned that devices that function as auxiliary suction systems play a vital role. The original idea behind devices such as Zyris’ Isolite, the DryShield, and the Mr. Thirsty Kit from Zirc not only provide better access to the field but also by connecting to the high-speed vacuum system, grab a high percentage of aerosols before they even leave the mouth.

I’ve been particularly impressed with an ozone system called “Air & SurfacePro+”. Dr. Deborah Birx, who headed the White House Coronal Virus Task Force in 2020 has endorsed the product. In Mid-March 2021 the company announced that Dr. Birx will join the parent company ActivePure Technologies as Chief Medical & Scientific Advisor. A person of her skill set is a powerful endorsement.

Forgetting all the other advantages of the systems we have in place, digital also provides greater infection control. There is no biohazard to a digital impression or to models or other dental devices created by a 3D printer. There is no potential for cross-contamination of a crown, bridge, or denture that comes out of Axsys’ Versamill 5X400. That device is cranking out restorations in my office as a regular part of our procedural day, and I have ZERO concerns regarding any potential of it spreading pathogens.

The fewer things that go in patients’ mouths or start in the mouth, the less chance of cross-contamination we have. Although a computer virus might ruin computer files, it certainly won’t spread COVID-19.

I’m not sure how it happened, but somehow this whole pandemic became politicized. Mask wearing became a hot-button issue of “control” instead of science. Somehow the concept of preventing infection became a subject for argument. The whole thing never made any sense to me, but then I’m a huge fan of science. Politics? Not so much. Yet, I will always be in favor of being kind to one another. Nobody ever went wrong loving their neighbor. Maybe that will also be a takeaway from the terrible events of the last year.

Our health care system functioned for almost a year under a “bend but don’t break” philosophy. We are still working our way out of this. Heck, I still cannot get my favorite brand of gloves from my preferred supplier because the factory has so many backorders.

Although no one will admit it, I believe the reason government experts did not encourage mask use by the general population was that there were not enough masks, and they needed as many as possible for hospital staff who were trying to save lives. We did not have a sufficient PPE supply to fight through COVID-19’s first wave.

Overall, I’m very proud of the individuals in this profession. In the short span of 1 to 2 months, each office devised an opening plan and put everything in place to accomplish this objective. My staff and I are still working in N95s every day, and we probably will continue to do so for the rest of my career. I feel it makes us safer. The really good news is that our profession is coming back strong.

Here are a few things to think about: almost 50% or more of our patients are anxious about what we do. They are often looking for a reason to avoid us, and yet, with the perfect excuse right in front of them, most offices are still busy. Why? I believe the reason is simple. Patients trust us. They know we have their best interests at heart. They understand we are doing everything we can to keep them safe and healthy. That is the strength that we have created together as a profession. We have every reason to be proud of that. Better times are on the horizon.

I’d also like to give a big shout-out to the incredible people in the dental supply industry. Those folks managed to get their hands on the necessary things that we needed to keep the profession running… and running safely. I was amazed at how hard those people worked. My job here at Dental Products Report allows me to see things from the non-doctor side of things and there was a tremendous effort made by lots of people to get us back to business as normal. Lots of people worked long hours and weekends to put a supply chain that was in tatters back together in a very short span of time. We owe them a great deal of thanks. Make sure your preferred suppliers understand how grateful you are. They deserve it.

The events of the past year have a lot to teach us, but only if we’re willing to learn.