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Choosing the right cements can go a long way toward a clinician’s ability to deliver great restorative care. Because this is such an important topic, DPR is interviewing three clinicians to learn how and why they use and choose the cements that they reach for when caring for their patients.
This is the first in a three-part series discussing cement selection and related issues with dentists from a variety of practices. We’re asking them about their individual priorities and techniques with cementation and how their practice focus affects the materials they choose.
In part one, we’re speaking with Josh Wren, DMD. Dr. Wren received his DMD from the University of Mississippi in 2005. He then completed his residency in pediatric dentistry from the University of Kentucky in 2007. Dr. Wren established Wren Pediatric Dentistry in 2007 in Brandon, Miss, and became a diplomate of the American Board of Pediatric Dentistry in 2008. In 2013, he founded Pediatric Dental Seminars, which focuses on educating general dentists on practical aspects of pediatric dentistry.
DPR: What considerations play a role when you are choosing a cement? With so many materials and choices, what should doctors look for?Dr. Wren: For me, in a pediatric practice, the No. 1 feature is fluoride release. That’s by far the No. 1 characteristic that I look for. Secondly, I would say ease of use, whether it’s dispensing, mixing and/or cleanup. Speed goes along with that, such as how long does it take an assistant to mix the cement versus auto-mix cement? Or how long does it take to triturate a cement versus auto-mix cement? And speed is especially of the essence in pediatrics. I also think about how much is wasted during an application; if it comes in a compule, how much of that is wasted each time you use it? Finally, of course, I look for bond strength. But efficiency and predictability is the name of the game.
DPR: Can you share more about the importance of bond strengths for pediatric cases?
Dr. Wren: It’s a biggie. We don’t want crowns debonding. We definitely don’t want to have failures at dinnertime or have a crown debond on Halloween. We need something that really holds up under sticky substances.
DPR: Nobody likes their crowns falling out, especially kids I imagine.
Dr. Wren: Exactly. And if it’s a kid treated with sedation or general anesthesia, and it’s a behavioral management case, the last thing you want to do is try to recement that crown on a 3-year-old.
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DPR: Talk about some of the cements you are using regularly and getting great results with. What are your go-to cements that you like to use in your practice?
Dr. Wren: For the longest time it was 3M™ ESPE™ Ketac™-Cem Maxicap™. And absolutely nothing was wrong with the product, and I have the mindset of “if it’s not broke, don’t fix it.” However, when 3M™ ESPE™ RelyX™ Luting Plus came out, that gave me the advantages of being auto-mixed versus triturated and also eliminated wasted material.
DPR: How does the cement complement other products you use frequently?
Dr. Wren: You know, you can use the best cements in the world, but you’ve still got to have a good crown fit. In pediatrics, you need to have a crown that crimps properly. The 3M™ ESPE™ Stainless Steel Crown is absolutely wonderful, and there’s nothing like it. I still put a little extra crimp in that crown, but some of the competitors’ brands just don’t crimp as well and don’t hold a crimp as well.
DPR: You’ve touched on how fluoride release is critical, but will you explain more about why it’s so important for your patients?
Dr. Wren: Things have really progressed over the last five to 10 years away from doing what I call prophylactic pulpotomies underneath the stainless-steel crown when the tooth is asymptomatic. Now, in cases when there is deep decay but you want to avoid a pulp exposure, with these fluoride-releasing substances you can leave a little bit of the affected dentin and cement the crown instead of using a glass-ionomer base. That is a time-saving feature, but is also a money-saving feature and just an added bonus to have fluoride in your cement.
DPR: How important is the pre-treatment of the tooth surface in creating a good bond?
Dr. Wren: The stainless-steel crown prep needs to be a textbook crown prep. Other than that, it’s important to have no blood in the field and use good isolation. With RelyX Luting Plus cement, you can have a little bit of moisture just as long as you don’t have a lot of hemorrhage on the tooth structure.
DPR: What roles do your assistants play in the cementation process, and how do the cement features impact that?
Dr. Wren: I’ve trained my assistants so that when I walk in the room and we’re doing a crown on the tooth, they have the 3M crown picked out, ready to go and 95 percent of the time it’s the correct size. After I’ve prepared the tooth, they hand me the crown, I try it on, and while I’m crimping it, they’re getting the cement ready. They fill the crown and then we cement. Another good feature of RelyX Luting Plus cement is that once excess spreads onto the gingiva as we cement, my assistant can tack cure it for five seconds, and then we just gently peel off the layer of semi-set cement. My assistant can then run floss between the contacts to make sure there is no excess cement in the sulcus.
DPR: It has to be nice to have products that you can reach for with confidence and expect good results on a consistent basis. There are so many items and choices and options and different materials and upgrades and updates; how do you stay on top of which cements are best for you?
Dr. Wren: As I mentioned earlier, I think if it’s not broke, don’t fix it. So if it’s a product that has worked for me for years, then I’ll stick with it unless one of the other variables that we mentioned changes. For instance, I’d look into it if a product has more fluoride release, longer duration of fluoride release, if it is a little easier for cleanup or doesn’t waste as much or costs a little less. I don’t change things very often, but I rely a lot on my local reps. For example, Liz from 3M ESPE covers Mississippi and Louisiana, and she comes in periodically to talk about new products. And I count on the reps a lot of the time for information.
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DPR: I imagine there is a confidence thing there too. She’s not pushing you to buy, but when she’s telling you something has new features and benefits, you’re more likely to give it a try.
Dr. Wren: That’s exactly right. Liz is not going to recommend a product she doesn’t believe in 100 percent. It would reflect badly on her if we used the product and it didn’t work, so I place full trust in Liz and a lot of the other reps out there.
DPR: Are there any other products that make a big difference in your pediatric practice?
Dr. Wren:3M™ ESPE™ Filtek™ Bulk Fill restorative has drastically changed my practice. That product is a godsend. For procedures like Class II restorations on tooth #J, we simply prep, selective etch the enamel, apply 3M™ ESPE™ Scotchbond™ Universal Adhesive and then Filtek Bulk Fill. There is no two-step cure or anything like that. I didn’t expect it to be as sculptable or moldable as it is; it’s just an amazing product.
Watch the video below to see cementing of a stainless steel crown: