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Avoid these key mistakes to improve patient outcomes.
Composite is a versatile and useful material for direct restorations. However, there are common mistakes you might be making with composites that could affect your patient outcomes. We spoke to our experts about some of these common mistakes and what you can do to fix them.
Mistake No. 1: Not using magnification during your work
Composite application is technique sensitive with multiple steps on a small scale. Justin Chi, DDS, CDT, director of clinical technologies for Glidewell Laboratories, believes doctors who don’t use magnification while working can’t see the detail they should.
“You have so many steps, so make sure you can have a great view of all the little things you’re doing,” Dr. Chi says. “I’ve done several cases where I might be waiting on a crown to cement, and I see a little fuzz fall on the tooth prep. I might not have seen that without adequate magnification.”
Dr. Chi says all dentists have their preferences, but he uses 4.5x magnification. Some dentists also use microscopes in their work.
“At least 2.5x is where to start, but anything that will allow clinicians to see what they are doing in a clearer way is important. You might not notice little things if you are not magnified enough,” he says.
Many doctors already use magnification, and most dental schools are requiring or recommending their use. However, Dr. Chi advises doctors just starting with loupes to take it slow.
“It can be frustrating to make that transition because everything's different. Your field of view is different from what you're used to seeing and it will take some time to adjust your movements and hand coordination,” Dr. Chi says.
Despite these challenges, Dr. Chi says it’s essential to make the change. Not taking advantage of the technology could result in suboptimal patient care.
“You can’t do great work if you can’t see,” Dr. Chi says.
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Mistake No. 2: Allowing moisture to contaminate your prep
In the days of amalgam restorations, small amounts of saliva didn’t have a significant impact on outcomes. The same isn’t true for composite resins, Dr. Kalmanovich explains.
Saliva and blood contamination decrease the efficacy of interaction between the composite resin and the tooth. These contaminants inhibit composite resin infiltration into the tooth structure and decrease bond strength between the resin and tooth. Dr. Kalmanovich says avoiding contamination with saliva and blood is critical after the etching phase, which aims to get rid of the smear layer, creating a porous surface to which the composite bonds.
In other words, isolation is vital when working with composites. It’s also a significant area of opportunity.
“You need direct contact between the tooth and the adhesive primer and etch,” says Alex Kalmanovich, DDS, a private practice dentist in Laguna Beach, California. “If you have something that contaminates the area, you will lose the bond, and you are going to have failures.”
“Isolation is super critical,” Dr. Chi adds. “When you are bonding, you want to make sure the field is as pristine as possible.”
Dr. Chi says the ideal isolation is rubber dams. However, rubber dams are time-consuming, and few doctors use them once they leave dental school.
Dr. Chi doesn’t always use rubber dams these days either, which he says makes isolation much tougher. He advises doctors to focus on retracting the tongue during bonding, watching the fluids in the area (under magnification) and controlling any bleeding to manage the bonding process.
Dr. Kalmanovich doesn’t use dental dams, either. Instead, he recommends training your assistant to set them up for you if it is allowed in your state. If you can’t use a rubber dam, then alternatives include dry shield or cotton rolls, among other options, to ensure that you have a dry field for where you’re working on the composite restoration.
If there’s much bleeding in the area, Dr. Chi recommends using a hemostatic agent. He uses either ViscoStat® (Ultradent Products) for mild to medium cases or Astringedent® X (Ultradent Products) if there’s heavy bleeding. Some doctors use soft tissue lasers to cauterize the tissue.
Dr. Chi also says to watch out during Class II restorations so that the bands and wedges used to create a seal for the restoration don’t irritate the gums. If they do, fluids can get back into the area.
“Contaminating the preparation would compromise the final restoration,” Dr. Chi says.
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Mistake No. 3 Rushing your curing technique and neglecting your equipment
As materials improve, Tim Bizga, DDS, FAGD, a private practice dentist just outside of Cleveland and a lecturer, says some of the technical sensitivity has decreased. However, the basics still apply. Ensuring you maintain and test your curing light regularly is crucial.
“You need to know how much light energy is getting delivered to these materials and whether you are getting the full physical property out of it,” Dr. Bizga says.
When Dr. Bizga lectures on the topic and mentions curing, he says that everyone in the audience nods his or her head or chuckles. Many doctors recognize that in the flow of the procedure, they’re focused on moving ahead to the next increment, and curing often gets overlooked.
“You’re not always paying attention if the assistant is curing the area where you just placed composite or just sort of nearby,” Dr. Bizga says. “Just ‘okay’ is not okay. If it were you in the chair, you would want to make sure it was done perfectly.”
The same goes with the curing light. Many times, if the light still shines and it’s blue, doctors go on using it without knowing if its output is sufficient for curing. In Norway, a study published in the Journal of Dentistry revealed the vast majority of doctors in the public dental service (78 percent) didn’t know the irradiance value of their lights when they bought them. Furthermore, a significant number of them didn’t check them or have them sent in for routine maintenance (17 percent and 14.5 percent, respectively).1
Dr. Bizga says that once you know what you don’t know, you realize how the details make a significant difference in the outcomes.
“You’ve got to know this stuff. It has a drastic effect on longevity, performance, outcomes and the results of your treatment. Materials have forgiveness to a degree, but not if you don’t cure it properly,” Dr. Bizga says.
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Mistake No. 4: Lacking an understanding of the handling and properties of the materials
A dentist may have any number of composites on the shelf. Different categories exist, each with its intended use and areas of performance. Also, different manufacturers have their unique formulations and techniques for achieving the best bond.
Dr. Chi believes that a common mistake isn’t appreciating the nuances of the different materials. He advises doctors to know the handling and properties of the composites they use.
For example, dentists can over-etch the tooth, which can cause post-operative sensitivity, or not etch enough with some systems, which interferes with the strength of the bond. Also, some systems require scrubbing in the bonding agent, and if you swipe an area with saliva or blood with the micro brush and get contaminate on the tooth, it can lead to a weaker or compromised result. Another problem could be the solvent in the bonding agent didn’t have enough time to evaporate, which affects how the resin monomers fill the micropores in the dentin.
Dr. Chi says that doctors must not only have excellent operator skills in general but also understand the necessary technique to achieve the best possible bond for their chosen materials. For example, dentists should know the balance between over-drying the tooth, so it’s moist enough to prevent postoperative sensitivity, but prevent the prep from being so wet that it interferes with the bond of their product.
“Bottom line is it is super important to make sure you follow the directions, understand the correct usage of everything and how it all comes together,” Dr. Chi says.
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Mistake No. 5: Rushing the composite process
Dr. Kalmanovich says you should take your time and be diligent about completing all the steps listed in the given materials.
Part of the problem is the pressure to be productive and complete multiple restorations in one visit. However, consequences will arise if the clinician rushes through the timeframe indicated in the manufacturer’s instructions.
Dr. Kalmanovich found that slowing down and focusing on the composites more has helped him to reduce failure rates. Whether it’s a three-step adhesive (an etch, prime and bond) or a one-step, seventh-generation set etch system, he says it’s crucial to follow the instructions.
He also advises doctors to take their time with checking occlusion. Checking the bite is important to prevent patients from returning with sensitivity.
“While the patient is lying down, we check occlusion by having the patient tap down gently, then we move on to checking the lateral inferences,” Dr. Kalmanovich explains. “We also double check the bite with the patient sitting upright to confirm the occlusion is correct in case there is a discrepancy in the bite due to postural changes.”
Composite materials have improved in recent years. Current nanofilled composite materials have particle sizes that allow them to be more fracture- and wear-resistant, allowing composites to be a good choice for the treatment of worn dentition.
Dentists are doing more with composites as a result. Dr. Kalmanovich believes that composites’ versatility allows dentists to give patients more treatment options, particularly in place of a full-mouth reconstruction.
“In today’s age, it’s important for dentists to become experts in composites,” Dr. Kalmanovich says. “As the economy fluctuates and patients are eager for phased treatment plan for larger cases, it’s important for the dentist to be able to offer alternative treatment plans. Being skilled in composite restorations allows doctors to begin bigger cases without having to complete all indirect restoration at one time.”
Kopperud S.E., Rukke, H.V., et al. “Light curing procedures - performance, knowledge level and safety awareness among dentists.” Journal of Dentistry. (2017) Vol. 58:67-73. From Web: sciencedirect.com. < https://www.sciencedirect.com/science/article/pii/S0300571217300301>.