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Break out of your restorative rut

Dental Products ReportDental Products Report May 2019
Volume 53
Issue 5

New materials are changing everything from inventory to esthetics.

It’s easy to do. Familiarity with a particular restorative material can cause complacency in the most diligent clinician.

Why explore new materials when you already have this one that works well enough? Sure, the restorative you use might have its problems or limitations, but you’ve adapted to them, and you’re, well, comfortable.

However, you’re also in a restorative rut.

“When clinicians fall into a restorative rut, they’re most likely acting out of habit, which may not be profitable or efficient. They have become comfortable with their techniques after years and years of always doing it a certain way,” says Nikki Sparacino, MBA, global manager of restorative procedure solutions from Dentsply Sirona.

“It’s easy to get into that restorative rut because you get in your comfort zone and you’re used to the way things work,” says Carla Cohn, DMD, a private practice general dentist limited to children in Winnipeg, Manitoba, Canada.

Improved properties, enhanced outcomes        

Restorative materials enjoy continuous development from manufacturers seeking to enhance their offerings while improving patient outcomes and benefiting a practice’s bottom line. From better mechanical properties to more natural-looking esthetics to simpler processes than the previous class of restoratives, new materials are changing dentistry at an unprecedented pace.

However, for dentists who have tuned out all the press releases, marketing pushes and direct sales force presentations, restorative materials are performing (or not performing) like they always have.

 “They may not be getting the quality from the cases that they do,” says Justin Chi, DDS, CDT, director of clinical technologies for Glidewell Laboratories.“They may be having problems and aren’t aware of it or accept it as normal for using that type of material. They may not be getting the longevity or the esthetics some of the newer materials can provide.”

Dr. Cohn questions the logic of using materials a dentist isn’t 100 percent satisfied with-or maybe even unsatisfied with-when there’s such a large amount of new technology and advancements in dentistry today.

“Why do we need to leave ourselves and our patients wanting more when all we need to be willing to do is try something new?” Dr. Cohn says.

We spoke to several clinicians and experts in dental materials to uncover the challenges for clinicians who might have fallen in a restorative rut, what benefits are possible with new materials and which restoratives they’re excited about these days. Here’s what they had to say about breaking out of your restorative rut.

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The challenge of a restorative rut

A significant drawback to staying in a restorative rut is missing out on the improvements to materials. Material improvement brings a practice new opportunities to deliver a higher level of patient care and esthetics. However, Sparacino thinks staying in the rut could affect the practice’s bottom line as well.

“Materials continue to progress and with them come new techniques. By not adopting those techniques dentists are not realizing the efficiencies that come with them and potentially missing out on opportunities to make their practice more profitable,” Sparacino says.

Jean Madden, science affairs manager for 3M™, understands why clinicians would be cautious about switching their composite. They want to be assured of excellent clinical outcomes both for their patients and their practice with no unnecessary risks.

“We also understand that there are so many choices and so many different acronyms and marketing claims for direct composites that it can be intimidating and confusing to clinicians when researching new options,” Madden says.

“Dentists may hesitate to try new procedures outside of their comfort zone or embrace the latest innovations in new materials and restorative practices,” adds Beth Collington, director, digital materials and laboratory equipment for Zahn Dental.

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Indirect advances

Jeff Lineberry, DDS, a private-practice clinician in Mooresville, North Carolina, says the science for indirect restoratives has changed a lot. He recalls a time not so long ago when all a clinician had for indirect restorative material was gold and porcelain fused to metal (PFMs). Now, indirect restoratives include porcelain systems, lithium disilicates and zirconia that are much more lifelike and strong.

Dr. Lineberry knows some older practitioners who only use gold and PFM for indirect restorations. He feels these practitioners are disregarding the benefits of newer materials.

“You miss out on a lot of great materials out there that are stronger, more esthetic and have the potential of giving patients a fantastic restoration that’s going to be long-lasting, especially when it comes to the indirect materials,” Dr. Lineberry says.

Most of the crowns Dr. Chi did in dental school a few years ago were cast gold and PFM. Much of the literature supports the use of PFMs.

However, a common issue, Dr. Chi explains, is the porcelain will fracture off, and while it still protects the tooth, it loses the esthetic aspect of the crown. Dentists might continue using it, considering it a “normal” failure.

However, Dr. Chi says the newer, monolithic, single-material restoratives, such as a full zirconia crown, are more durable than a PFM. Zirconia is kinder to the opposing teeth and the esthetics are improved, so you don’t get that gray hue you can get with PFMs.

“Someone that might still be in that rut with an old material might not realize the huge improvement they would get by making that little switch,” Dr. Chi says. “The challenge is getting beyond their little bubble and giving it a shot, trying not to let that fear of this new scary material hold them back.”

Related reading: Change is good when technology is in the mix

Direct material developments

The science of direct materials has changed a lot also. Over the past four or five years, bulk fill composite resins have become a hot topic, Dr. Lineberry says.

Bulk fills allow the clinician to place larger increments of the composite resin, which means fewer steps. Bulk fills are designed to make direct restorations quicker and easier. Also, per Dr. Lineberry, research shows that when used properly, bulk fill composites are a viable option for direct restorations.

However, Dr. Lineberry, who writes about bulk fills and often lectures on composites, says clinicians have been slow to adopt bulk fills into their practice. He estimates there tends to be a five- to seven-year gap on average for new material adoption. He says there are two main reasons for this delay.

“Many people wait for at least three, five, or even seven years because they are watching to see what happens with the material,” Dr. Lineberry says. “The other problem is sometimes manufacturers rush materials to the marketplace. If you put a bulk fill out that doesn’t go well to start, it gets a bad name pretty quickly. Then, everyone starts lumping all the bulk fills in with the one that was rushed.”

Laura Olenderski, global brand manager for Dentsply Sirona’s universal composites and flowable composites, says sometimes improvements in restoratives fix one problem but then create another. For example, some advancements in restoratives are time savers, but they sacrifice the outcome or integrity of the procedure, specifically the durability of the restoration. Finding ways to avoid compromising integrity while improving the material is an area Olenderski focuses on every day.

“We’re excited about having found a way to improve these procedures but to do so without cutting corners and still providing the efficiency gains that clinicians are looking for to improve procedure profitability,” Olenderski says.

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New materials, renewed passion

Dr. Chi agrees, adding that with anything new there’s always fear or uncertainty. Dentists have questions about performance, what to do if it fails, how to prep or cement. Also, with that change in material comes the difference in technique and usage of tools.

“They might go to a CE about a new thing and hear about these 15 required bonding steps and that may put them off,” Dr. Chi says. “Dentists like to stay in their little bubble. They’re on the front lines, and it’s tough to change from things they learned in the very beginning.”

On the other hand, trying new things and improving your knowledge base can also help keep a dentist enthusiastic about his or her restorations. Nate Lawson, DDS, Ph.D., says when he feels like he’s in a restorative rut, he self-criticizes his work and feels demotivated about his skills in the profession.

“If there are aspects of your restorative protocol with which you are unconfident or you start trying to cut corners, your restorations pay the price and they don’t hold up well. Then you think, ‘Am I doing a service to my patient?’ and you get depressed about the entire profession.” Dr. Lawson says. “You don’t stay up on your game.”

Dr. Lawson is the director of the division of biomaterials at the University of Alabama School of Dentistry. His background is in engineering, and he has always enjoyed the materials side of dentistry, learning about them and testing them. New materials bolster his passion for dentistry.

“When you find something new and you learn to do a procedure better, it reinvigorates you and makes you a better dentist,” Dr. Lawson says. “But it also makes you more productive. It can make you excited about doing dentistry again.”

Dr. Cohn says dentists who have been in practice for a few years get comfortable and technically proficient about what they do day in and day out. She agrees that trying new materials increases the dentist’s excitement about working. New materials also make the day more fun.

“Let’s face it, doing that same procedure day after day can get mundane. It’s a little bit boring,” Dr. Cohn says. “Using new, innovative materials will kick it up a notch. When we have a product, material or a technology that is innovative and new, it gives that much more to our patient in return.”

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The impact of improved materials

Madden says 3M hears from clinicians that introducing a new restorative may require staff training, new techniques and changes to their inventory. Composite materials also have many considerations from handling to ease of use, physical properties to a range of shades. Customer service, price, staff training and practice workflow are all part of the equation, too.

“So, if a dentist chooses to change, they want to be sure what they choose will work for them and is made by a company they trust,” Madden says.

Collington says using improved materials can help fulfill patient expectations. She says patients are more educated about dental products that work to improve their experience at the dentist. It also means their expectations are higher, Collington explains. They expect their doctor to deliver optimal care.

“It benefits practitioners to deliver solutions using the most current, innovative tools, technologies and materials, which will also help them stay competitive,” Collington says.

“As patients, we go into a dental office with an expectation that the work that’s being done is going to last at least for a reasonable amount of time and meet our expectations visually,” Olenderski agrees. “We expect that the esthetic result will hold up not just physically but also in terms of appearance.”

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Benefits patients notice

From a positive standpoint, everyone involved in the process from the front desk to the assistant to the clinician gets excited about providing patients with the latest restorative materials, Dr. Chi says. Patients also like having improved materials that look more natural-especially those that don’t break from time to time.

“It’s a great opportunity to build that positive connection when your patients know you are providing the most updated thing that is available,” Dr. Chi says.

However, there’s a learning curve with new materials, Dr. Chi says. It changes the workflow. New adhesives might be necessary to bond the glass ceramics, which might mean it takes longer to deliver a crown instead of conventionally cementing.

Communication with the lab also changes as well as the preparations. For example, a PFM has parallel walls and sharp corners, but with zirconia, you round things over, which could mean different tools or brushing up on a different skill set.

“But in the end, if the outcome is better, it’s worth going through the extra effort or a lengthier appointment at the beginning to implement these new restorative materials in their practice,” Dr. Chi says.

Once you get used to the new workflow and the way to prepare your restorations, Dr. Lineberry says changing to an improved restorative material can provide a better patient experience. For example, when switching to porcelain indirect restoratives after someone has always had a gold or porcelain fused to metal crown, the patient will like having a new crown without black or grey lines around it.

“That can potentially help you build your practice,” Dr. Lineberry says, regarding how the patient responds to the improved esthetic. “When patients are excited about things, they tell people about it.”

Dr. Lineberry compares this word-of-mouth advertising effectiveness to hearing reviews about a restaurant. If you hear that a restaurant was okay but nothing special, you probably will not try it, or if you do, you won’t rush.

“However, if you hear that the service was fantastic and the food was unbelievable, you will want to see if it really is unbelievable,” Dr. Lineberry says.

“There are so many new opportunities in the materials area that are game changers for patient care, including new printing materials that increase accuracy in final restorations for PFM as well as printing models and new formulations in high translucency zirconia to help create superior esthetics in cosmetic dentistry,” Collington says. “These latest innovations support the ultimate patient experience in form, function and esthetics.”

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Recent material innovations

Dr. Cohn has been pleased with the performance of OMNICHROMA, a new universal resin-based composite for direct restorations by Tokuyama Dental America. The composite is a supra-nano filled composite that’s designed to match all 16 shades of the VITA shade guide with a single shade of composite.

“It acts almost as a universal shade match,” Dr. Cohn says. “So, we don’t have to shade match our patient when they come in, and we can decrease the amount of inventory that we’re keeping in our office because you just have that single shade.”

Dr. Cohn has begun to see patients treated with OMNICHROMA on their recall visits, and she likes the performance of the composite. The restorations are not only proving to be durable, but also the esthetics are excellent, too.

“Those are the two things that we want. We want it to look good. We want it to function well,” Dr. Cohn says.

Dr. Cohn only sees kids in her practice. OMNICHROMA has proven to be an excellent fit for her practice, whose patients need chair time kept to a minimum.

“It’s a no brainer. You’re seeing kids and the shade matches. They’re ready. It’s just so easy,” Dr. Cohn says.

Dr. Lineberry has been using new bulk fill composites from GC America because he likes how they handle and the overall outcomes of the restorations. The G-ænial™ Flo and G-ænial™ Universal Flo composites come in injectables and composites.

“The G-ænial Universal Flo product is stackable,” Dr. Lineberry says. “Flowable resins, when you put them in place, sometimes want to slump or run. This material has a much lower viscosity than a lot of the composite materials that you use, so it flows well, but then it stays where you put it.”

Dr. Lineberry also likes PANAVIA V5 from Kuraray, a dual-cure resin cement. He learned about it a couple of years ago from John Burgess, DDS, MS, at the University of Alabama who spoke highly of the product in his research. He uses it for bonding indirect restorations and likes it better than his previous adhesive.

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“It is easier to clean up, and it’s a more user-friendly system overall,” Dr. Lineberry says.

Like most dentists, 3M’s customers said they wanted to increase efficiency and productivity in their practice. However, they didn’t want these improvements to come at the cost of esthetics or clinical outcomes.

Madden describes their latest 3M Filtek™ Universal Restorative as a universal composite with a simpler system and creamier handling. She says the physical properties are similar to their well-known 3M Filtek™ Supreme Ultra, but the new resin has lower polymerization stress, and the filler system offers improved radiopacity.

Also, 3M wants to reduce the number of restorative composites a dentist keeps in his or her inventory. Madden’s global market research says dentists have seven shades of composite in inventory. However, they use a single shade and opacity for 54 percent of their anterior restorations.

3M responded with a system that has only eight shades. They also added a new pink opaquer for blocking metal and dark dentin and an even whiter extra white for patients who bleach their teeth.

“These shades have been scientifically proven to provide coverage for all 19 shades of the VITA Classical Shades and extended bleach shades. Also, our shades target an opacity that’s between dentin and enamel to make them easier to blend with natural dentition,” Madden says.

These improvements are part of an overall effort to simplify the restorative process. “We’re trying to make dentists’ lives easier,” Madden says.

Olenderski is excited about TPH Spectra® ST universal composite restorative with SphereTEC™ filler technology. Incorporating this filler technology into the universal composite formulation improved the way the product handles, the esthetics and the durability of the restoration, Olenderski says.

“We’ve utilized the SphereTEC technology to boost our performance in those areas so that we can help the dentist and make improvements in the areas that are important to them,” Olenderski says.

The newest TPH Spectra ST composite has viscosity choices, so the doctor can work with the handling he or she likes best. Also, the chameleon blending effect of the composite allows five shades to cover the 16-shade classical VITA range, which is what Olenderski says makes it easier to shade match the patient and streamline office inventory. It also has excellent stain resistance, so it will retain its esthetic appearance over time.

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“Research that we’ve done has shown that 88 percent of dentists are stocking more than five VITA shades in their office on average,” Olenderski says. “By incorporating this product, they’re able to reduce inventory expense.”

Glidewell Laboratories introduced BruxZir® Esthetic Solid Zirconia about a year and a half ago. Before the launch of the new esthetic material, BruxZir was used primarily in the posterior. The new product is more translucent than the previous version and can be used anywhere in the mouth.

Dr. Chi says this new material can make monolithic zirconia crowns and veneers rival the esthetics of the glass ceramics, such as lithium disilicate and lithium silicate. The translucency allows the material to mimic the appearance of natural teeth. However, it also maintains a 900 MPa flexural strength, double the amount of some of the glass ceramics.

“Those glass-based and feldspathic porcelain materials have been the go-to for esthetically demanding cases, veneers and anteriors,” Dr. Chi says. “But now we have zirconia that meets that esthetic requirement and on top of that gives you the strength of zirconia.”

Dr. Chi says that in the past, dentists had to decide if they wanted something strong or something esthetic for some of their restorations. However, the new materials give them a no-compromise option.

“It is so wonderful to practice at this time and know you can offer that for our patients,” Dr. Chi says.

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Getting outside your comfort zone

Change can be more difficult for some people than it is for others. Dr. Lineberry recommends a clinician who’s reluctant to change materials explore why.

“In other words, just because your restorative works doesn’t mean it’s the best. Amalgam still works too, but it doesn’t mean you keep using it,” Dr. Lineberry says.

He compares upgrading to improved materials to a dentist’s mobile phone. Everyone carries a phone, but few people carry the 10-year-old model. Most have a model from within the past couple of years.

“It’s the same thing. You have to evolve,” Dr. Lineberry says.

The stakes are high with new restorative materials. Many clinicians, including Dr. Lineberry, are reluctant to try new things because it’s going to be in the patient’s mouth for the next several years. He recommends doing your own research on the material or asking your sales rep to provide research before you give any new restorative material a try.

“That’s what I do when any of the reps come in and want me to try a new material. I say, ‘Show me the research and I’ll consider it,’” Dr. Lineberry says.

Dr. Cohn also thinks that clinical decisions need to be made based on evidence. Sound science should drive early adoption.

“But beyond that, you need to look to the advice of people like the key opinion leaders that have made it their business to do that very early adoption and learn from their experience,” Dr. Cohn says.

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Learning to use new materials

Dr. Lineberry thinks doctors should attend a hands-on course with the material. Continuing education is an excellent way to get comfortable with the improvements in restoratives.

Collington also believes a focus on continuing education will help a doctor who’s wary of trying new restorative materials. Fortunately, Collington says, the dental industry has numerous educational opportunities offered by leading clinicians, distributors and manufacturers.

“Clinicians can take advantage of these opportunities to better understand how innovative new products can create dynamic differences in their practices and patients’ lives,” Collington says. “For example, at Zahn Dental, we offer live classroom educational sessions, monthly webinars and Zahn Academy, a resource-rich platform that includes 500+ videos and articles to help labs thrive.”

Dr. Cohn advises doctors reluctant to abandon what they’ve always done but who want to try a new material to start using the new material on a small sample of patients, people you can follow closely during that test period. Depending on the procedure, you can determine an amount of time with which you’re comfortable.

“Always base your clinical decisions on evidence and seek the opinions and experiences of experts in our field. Begin with a small number of procedures that you are able to follow closely and once you are comfortable with the performance of a given material, then grow from there. Always balance science and evidence with an open mind and willingness to learn,” Dr. Cohn says.

Sparacino also recommends talking to your peers or calling your local rep or the manufacturer to ask questions. They can help make dentists feel more comfortable trying something new that can improve the way they practice and the patient outcomes they deliver.

“Everything evolves over time. Some new technologies will improve profitability for the practice by making them more efficient in what they’re doing,” Sparacino says. “Dentists should be open to exploring and learning new techniques so that they can realize those efficiencies.”

Related reading: The evolution of resin composites for direct restorations

Advancing materials advance the industry

Dr. Chi believes the profession of dentistry will not advance unless dentists are open minded enough to embrace change and try new materials. He also acknowledges that there can be challenges and a learning curve, but the opportunity to learn is worth the risk.

“You could end up finding something that changes your outlook on dentistry,” Dr. Chi says. “You provide something better for your patients, and it could provide a renewed sense of connection with the work. That’s a cool opportunity.”

Materials are improving all the time as the science moves forward. Now, dental schools teach different techniques using different materials than they did 20 years ago. Dr. Lineberry points out that they aren’t doing it for financial reasons.

“It’s not because the manufacturers are making them do it,” Dr. Lineberry explains. “They are doing it because they are evolving with the science that’s out there.”

“Do not be afraid to step outside your comfort zone and try new things. There is so much support for you out in the industry. Your patients deserve access to the latest innovations in digital technology and accuracy of materials,” Collington says.

“As dentists, we never stop learning,” Dr. Cohn says. “All of the innovations that our dental world has to offer, we owe it not only to ourselves to try them, but we also owe it to our patients to evolve with that dental world we live in."

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