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Medical Forum / General / Dentistry / November 2004New thread: composite fillings 'a failing
I think this is worthy of a new thread, cause I don't want anyone to miss my question: <stuff deleted, see old thread> > if he left the etchant on for 2 minutes, get a new dentist. > Stephen Mancuso, D.D.S. > Troy, Michigan, USA > > Writing on a tablet PC,so forgive me if the PC misreads my poor handwriting. Yes he left the sour tasting etchant on for 2 minutes... isn't that what he is supposed to do?? Don't they have to etch the teeth so the stuff sticks to it?? Now I AM worried! 1. first he drills the tooth out 2. then they put a metal band around, then drive a wedge in 3. he puts the etchant on for 2 minutes *exactly* (he has a stopwatch) 4. The etchant drips on my tongue after 1 minute 5. fills the tooth in several layers and cures it each layer 6. takes the band off 7. grinds the tooth down a little 8. checks the bite with contact paper, adjusts it Then I'm done. Then he's on to my next tooth. I've had at least 10 teeth done this way in September. >I think this is worthy of a new thread, cause I don't want anyone to miss my >question: [quoted text clipped - 26 lines] >Then I'm done. Then he's on to my next tooth. I've had at least 10 teeth >done this way in September. If your description is accurate, start walking. You are describing the technique used about 20 years ago. .. Stephen Mancuso, D.D.S. Troy, Michigan, USA Writing on a tablet PC,so forgive me if the PC misreads my poor handwriting. > >I think this is worthy of a new thread, cause I don't want anyone to miss my > >question: [quoted text clipped - 29 lines] > If your description is accurate, start walking. You are describing > the technique used about 20 years ago. OH GOD!!!! There went $6,000 out the freaking window? I have so many teeth done this way... . yOU Are kidding right? do these things have absolutely no chance of holding up? Should I have all these fillings redone? I've had 3 dentists do my composites this way.. two different practices. I'm in a major city.. I can't hardly believe everyone is behind 20 years!? yes, my description is accurate! How is it supposed to be done nowadays? What are the steps, how do they differ from what they did to me? Twenty year old technique. Make up you own mind. It is possible that the restorations will still last for decades (if done with enough care). I have one in my head from 1986 that is still fine. But, don't some people wonder if a practitioner does not update his/her techniques in 20 years?  Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... >> >> >I think this is worthy of a new thread, cause I don't want anyone to [quoted text clipped - 45 lines] > yes, my description is accurate! How is it supposed to be done nowadays? > What are the steps, how do they differ from what they did to me? I had a patient in five? years ago with a bunch of 'new' composites on which he could not chew and could not drink anything that was cold or hot. By the time I saw him, it had been 2-3 months since the work was done and the previous dentist just kept telling him that sensitivity after new fillings was normal. I replaced a couple using a rubber dam, 15 second etch, Bond 1, flowable, and layered Heliomolar. Everything felt fine after a few days and I went on to replace all of the other painful fillings. He was also a clencher and I made him an NTI as soon as I learned of them. I just saw him a couple of months ago for a check up and he's doing fine. Anyway, I decided to call the other dentist to try and let him know that this guy had a problem. He got huffy and said, "I've been doing posterior composites this way *FOR FIFTEEN YEARS*!" I said, "OK, bye". This guy practiced in a large Kansas City suburb and may still be doing the same thing for all I know. For a screwed up sensitivity case today, I might use SE Bond. Technique certainly might be part of this problem, but I suspect a sugar habit is in the works too, or there wouldn't have been *that* many fillings needed in the first place. In the wrong mouth, anything will fail. Fawks > Twenty year old technique. Make up you own mind. It is possible that the > restorations will still last for decades (if done with enough care). I have > one in my head from 1986 that is still fine. But, don't some people wonder > if a practitioner does not update his/her techniques in 20 years? >I think this is worthy of a new thread, cause I don't want anyone to miss my >question: [quoted text clipped - 12 lines] >is supposed to do?? >Don't they have to etch the teeth so the stuff sticks to it?? Yeah, but etching teeth should take no more than about 15 seconds! Lots of dentists are using self-etch products now. >Now I AM worried! > [quoted text clipped - 9 lines] >Then I'm done. Then he's on to my next tooth. I've had at least 10 teeth >done this way in September. Here's a technique using a self-etch bonding agent that I shameless stole from another dentist's posts. >1. Prep the tooth, removing all decay, extending, generally, in the >interproximal areas to "readily cleansible areas" or at least opening [quoted text clipped - 9 lines] >sometimes a sanding strip interproximally. >6. That's it. Back to your original post, since your dentist has offered to help fix your fillings *for free* I would at least have some faith in him. If all of them debond once again, I'd look into somebody who was a bit more state of the art in terms of adhesive dentistry. Adenosine Better yet, offer to buy him a bottle of SE Bond or Brush & Bond (if he promises to read the directions) and ask him to use a rubber dam whenever possible. ;-) Fawks > Back to your original post, since your dentist has offered to help fix > your fillings *for free* I would at least have some faith in him. If > all of them debond once again, I'd look into somebody who was a bit > more state of the art in terms of adhesive dentistry. > > Adenosine > Better yet, offer to buy him a bottle of SE Bond or Brush & Bond (if he > promises to read the directions) and ask him to use a rubber dam > whenever possible. > > ;-) > Fawks <RB> has some slight modifications of the SE Bond technique: We have SE Bond in 2 bottles: Primer and Bond. Place primer for AT LEAST 20 secs, keeping the tooth moist, with a microbrush imbibed with Primer on the occlusal for these 20 secs [no maximum time is suggested]. IOW, KEEP IT WET. Dry; [no comments on how to dry here]. Bond: we need 40 microns of width for best results- use microbrush, apply Bond, and wipe the microbrush with a 2X2 gauze. Using the microbrush, wick out the XS once or twice, again wipeing the microbrush using the 2X2. Place matrix band, WEDGE APEX DOWN, place ring. Place flowable composite on the gingival margin FIRST. Cure. Among the flowable composites mentioned are: StarFlow, HelioMolar Flow, Tetric Flow. It was not mentioned, but I assume all these Flowables are HYBRIDS and not MICROFILLS. [My favorite, Filtek Flow, was not mentioned, and I didn't put up my hand]. Mentioned in passing was that HelioMolar Flow is the lowest stress [what ever that means]. He then fills in the proximal boxes with flowable in 2 mm increments upto (and sometimes beyond) the pulpal floor (iow the dentinal floor under the occlusal surface, and what you'd pierce if you wanted to access the pulp). Cover the pulpal floor (cavity floor) with Flowable as well. There is an AUTOCURE ( StarFil 2B, made by Parkell) that is interesting, IHO, and he will evaluate it in the future for this purpose (iow replace the Flowable with StarFil 2B). However, you must modify your bonding to be compatible with the autocure composite. [I'm shaky on this part and will re-read the notes before talking about that... You use ClearFil Prime but in place of the Bond you use one of three other products, one of which is made by Bisco.. I assume these are activators/bonding agents]. Then comes the filled composite layer(s). He likes HelioMolar HB A1. [**** What is not clear is if he uses this as the final increment or from the flowable up to the occlusal****] At any rate, he uses HelioMolar filled composite to complete the cavity and he sees no advantage to the 'packable' composites on the market today. He feels that the optimal strength is achieved with a 55 PER CENT filled composite. [This rules out my Filtek Supreme and my Filtek P60, in his opinion.] He prefers ring systems (Parkell, of course...) but will use Contact Pro in a pinch. CURING: Dentin: is elastic. Dentin is no worries: 20 secs flat out. Enamel: is brittle, so we need to cure slowly. His take: 10 secs at about 2mm or so away from the prep; in this way, you are getting between 150 and 200 [light units], instead of 1000 or 1500. Then move in close for 10 secs. You should have a measurer of intensity to find out how far away your light should be to get this effect. Using a 'turbo tip' is misleading: the intense portion of the light is quite short beyond the tip. He recommends using the standard tip in all cases. [I have an Optilux 501 light that has a Ramp cure option, and that's what I use on the enamel]. So, in this way, one preserves marginal integrity, as it is more a result of XS contraction of composite cured too fast than anything else. [I attempt to palliate this problem using a final thin layer of microfill composite, to fill in the inevitable cracks, now, before removing everything and adjusting occlusion, ect. This is a Jeff Brucia technique. Interestingly, Karl Leinfelter suggests palliating the contraction issue by lining the whole cavity with flowable b/4 using the filled composite- kind of like having an elastic flowable layer, or diaper all around the filled composite. As the filled composite contracts, the elastic flowable keeps it stuck to the enamel]. There is a *research backed and proved* separator out that is avalable from Parkell. This prevents composites from sticking to your instruments. Don't know what's in it, but it won't weaken the adhesion between the various layers of composite. Won't be available in Kannnada. Pulpal exposures: Warn them: 'You can have this direct pulp cap now for 100$, or you can start a 500$ endo....' Take a cotton pellet imbibed with NaOCl 5 percent (Chlorox) for ONE MINUTE [.... like it's etched in stone...]; then: gentle water wash; NO AIR; Dry [microbrush? Cotton Pellet?]; SE Bond. [remember, SE Bond is water based, so the tooth being a bit wet is not a problem]. As a general <RB> rule: the younger the patient, the higher the probability of success for exposures. [Now, we all know what W_B says about this...] <RB's> clinic is free of Dycal (Dycal equals Die cal, as in kill the tooth... I wanted to ask about Eugenol based bases, but, not a chance...) and also free of Glass Ionomer based products. They are *almost* free of acid etch as well. <RB> on ClearFil SE Bond strength: SE Bond yeilds 20 MPascals vs 28 MPascals for proper acid etch and bond techniques. IHO, 20 MP is more than enough for good adhesion.... [I am not so sure... this is optimal, and in my hands, I don't think I'm getting anywhere near optimal conditions. BTW: what is the unit of bond strength- MegaPascals or what?]. <yawn.... listen, y'all please comment on this... I may have had things a bit bass ackwards, but I doubt it... this part was quite straight forward, if not F1 race speed...>. I gotta stop now, as I can no longer see straight... as I can no longer see straight... as I can no longer see straight... I'll look 'em over some more and see what else I can say a little later. HTH, Cheeahs SP SignatureNot a real Addy, yet >> Better yet, offer to buy him a bottle of SE Bond or Brush & Bond (if he >> promises to read the directions) and ask him to use a rubber dam >> whenever possible. >> >> ;-) >> Fawks <snip technique> ><yawn.... listen, y'all please comment on this... I may have had things >a bit bass ackwards, but I doubt it... this part was quite straight [quoted text clipped - 6 lines] > HTH, Cheeahs >SP Well, I'm not a dentist but.... >Oper Dent. 2004 May-Jun;29(3):301-8. > [quoted text clipped - 33 lines] >It was concluded that a minimally thin flowable composite >lining improved cavity adaptation and marginal sealing. Doesn't the above suggest that a thin layer is a better idea than a very thick layer of flowable? Adenosine > >cervical voids. Despite the reduction in interface voids, a thick > >lining may impair the marginal sealing, especially after thermocycling. [quoted text clipped - 5 lines] > > Adenosine ...This WOULD tend to contradict what I learned at the seminar, yes, if what they did is what was described in that lecture. However, what is unclear from the abstract is whether or not the lining is thick all round the cavity or just the floor. What <RB> was saying was that he fills the boxes and the cavity floor with Flowable. Neither <RB> nor Jeff Brucia advocate using Flowable on the side-walls. Indeed, Jeff Brucia specifically said that the research does not show a need for that. Perhaps this is why. I think most people use Flowable as Bill Combs described elsewere in this thread. ... One thing I found interesting is that CO-cured Flowable/filled composite was still quite good. This may mean that I can use Flowable as a separator for keeping filled from sticking to my instruments. En Passant, A-D, what did you use to ferret this study out? I ask b/cs I don't think I've ever seen an abstract from Operative Dentistry drop out of a Sherlock search that I've done. Thanks for the info. SP SignatureNot a real Addy, yet >> >cervical voids. Despite the reduction in interface voids, a thick >> >lining may impair the marginal sealing, especially after thermocycling. [quoted text clipped - 25 lines] >Thanks for the info. >SP I stole that abstract from DentalTown. There just happened to be a thread on using flowable composites as a liner going on the last few days. Adenosine I only consider flowable composite to be a "wetting agent". I use it to improve contact of the main composite to the walls and floor of the prepared tooth. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> >cervical voids. Despite the reduction in interface voids, a thick [quoted text clipped - 26 lines] > Thanks for the info. > SP >I only consider flowable composite to be a "wetting agent". I use it to >improve contact of the main composite to the walls and floor of the prepared >tooth. We agree. Less contraction upon polymerization as well ........ Joel >>I only consider flowable composite to be a "wetting agent". I use it to >>improve contact of the main composite to the walls and floor of the prepared [quoted text clipped - 5 lines] > >Joel I thought that flowables contracted more than the 'regular' composite??? Or do you mean keep the layer thin in order to reduce stress? Adenosine >>>I only consider flowable composite to be a "wetting agent". I use it to >>>improve contact of the main composite to the walls and floor of the prepared [quoted text clipped - 11 lines] > >Adenosine My guess is that it has to do with placement. One can squeeze out a smidgeon of flowable, but with the regular stuff or god forbid, packable, a huge dollup comes out and its impossible to get back inside the little tube. Especially if the dental assistant forgets to back-off on the squeezer screw. Joel On 'deep' restorations, I will place a thin layer of flowable and cure. Usually, I place a little flowable and condense Heliomolar into it. The Heliomolar forces the flowable into any small recess that might not have a perfect fill with the main composite alone. Wetting agent, void decreaser, whatever you want to call it. JME, Fawks > I only consider flowable composite to be a "wetting agent". I use it to > improve contact of the main composite to the walls and floor of the prepared > tooth. > On 'deep' restorations, I will place a thin layer of flowable and cure. > Usually, I place a little flowable and condense Heliomolar into it. The > Heliomolar forces the flowable into any small recess that might not have > a perfect fill with the main composite alone. So you cure the flowable and Heliomolar simultaneously? Steve > Wetting agent, void decreaser, whatever you want to call it. > [quoted text clipped - 4 lines] >> to improve contact of the main composite to the walls and floor of the >> prepared tooth. SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 >> On 'deep' restorations, I will place a thin layer of flowable and cure. >> Usually, I place a little flowable and condense Heliomolar into it. The [quoted text clipped - 4 lines] > >Steve Yes, but watch out for the black Helio-copters. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com I do that with CEREC restorations. I paint a thin layer of flowable, then fill with heated Z-100 and press the ceramic to place. Remove excess, vibrate with rubber tip on amalgam condenser and light cure. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> On 'deep' restorations, I will place a thin layer of flowable and cure. [quoted text clipped - 14 lines] >>> improve contact of the main composite to the walls and floor of the >>> prepared tooth. I would say, most of the time, yes. My technique is kind of like light body impression material injected on a crown prep and then having a heavy body tray material seated over it. That forces the light body into small crevices where it might not have flowed on its own. With composite, I still do this in layers if the restoration is more than 2 mm deep. Best wishes, Fawks > So you cure the flowable and Heliomolar simultaneously? > > Steve > Doesn't the above suggest that a thin layer is a better idea than a > very thick layer of flowable? > > Adenosine The study information posted does not reveal whether a layered technique was used for the application of the body composite after the flowable has been placed. The layered technique was developed to counter the effects of polymerization shrinkage. This can make a huge difference in the study results. - dentaldoc >> Doesn't the above suggest that a thin layer is a better idea than a >> very thick layer of flowable? [quoted text clipped - 8 lines] > >- dentaldoc Well, if you just want to compare no flowable liner vs flowable liner without considering the thickness of said liner... >Oper Dent. 2004 Mar-Apr;29(2):162-7. > [quoted text clipped - 26 lines] >the gingival microleakage was found to be statistically significant >for all restorative materials tested (p<0.05). If a thin amount of flowable provides the effect wanted (less microleakage), and the flowable shrinks more, why would one want to use a thicker instead of a thiner layer of flowable? Wouldn't that just add stress to the tooth? Adenosine > Back to your original post, since your dentist has offered to help fix > your fillings *for free* I would at least have some faith in him. If > all of them debond once again, I'd look into somebody who was a bit > more state of the art in terms of adhesive dentistry. > > Adenosine .... Why not print out this thread and leave it in a sealed envelope with his secretary? Ask him to read it b/4 your next appointment, and perhaps call you with his thoughts, again, b/4 your next appointment. Personally, as a dentist, I would pay particular attention to SFawks' thoughts on the matter, as he has been doing these things for twenty years plus. Further, there ARE easier chemicals to work with, and harder ones. If you want one *well known* lecture-circuit type dentist's take on this, the Self-Etch bonding systems are more time forgiving, and less sensitive to moisture, as they are water-based. This *guru's* main bonding agent is ClearFil SE Bond (so called because it is a self etch). I attended this *lecture* recently in Toronto, Ontario, Canada. If your dentist prefers staying with a OrthoPhosphoric acid etch (HOPO4) technique, then this same lecturer would suggest etching the enamel for 15 seconds, and the DENTIN for FIVE (5) SECONDS, and then rinse, then lightly dry, then bond , etc. .... Again, please note the five seconds on the 'alive part' of your tooth. FWIW, this lecturer is not the only one that I've heard cautioning against over-etching the dentin this way. Hope I haven't just confused you... SP SignatureNot a real Addy, yet > I think this is worthy of a new thread, cause I don't want anyone to miss my > question: [quoted text clipped - 4 lines] > > Now I AM worried! Many patients confuse the etchant with the primer. I don't know which you were referring to as "sour-tasting." Could be either one, or even the adhesive. Current bonding methods use either a separate etchant, or a combined etchant & primer ("self-etching primer"). 1. When a self-eching bonding agent is used, the timing is not so important because the amount of etching is self-limiting. As the self-etchant contains the primer, a separate adhesive is applied next. 2. When the separate-etchant technique is used, the enamel can be etched up to 60 seconds or more (depending on the strength of the etchant, although some authorities say 15 seconds is long enough for enamel). On dentin, the etchant is generally placed for a much shorter time -- some say 4 seconds, some say 6 or 8 seconds, and others say 15 seconds. Any way you look at it, the separate-etchant technique keeps the etchant on the dentin for a SHORT time. To simplify the technique, many dentists just apply the etchant to enamel and dentin together for 15 seconds or so, figuring that's the maximum for dentin, and probably sufficient for enamel. With the separate-etchant technique, the etchant is NOT self-limiting, so it has to be washed thoroughly away with water at the end of the timed etch period. Next, moderate drying is done, leaving the dentin moist (but not dripping) to avoid dessication. Then the combined primer/adhesive is applied. Many dentists use technique #1 (self-etching primer) and it works fine. I use technique #2 (as described by Dr. Fawks in his reply to you) and it works fine too. Also: > 1. first he drills the tooth out > 2. then they put a metal band around, then drive a wedge in > 3. he puts the etchant on for 2 minutes *exactly* (he has a stopwatch) Are you sure this is the etchant-only material? Etchant is generally not left on the tooth this long. Perhaps this is a self-etch material, which is self-limiting in its etching, so the long time merely lets the primer soak in. Does he WASH the tooth for a long time after etching? If not, perhaps he's using a self-etch material which is combined with the primer. Or is it possible that the 2 minutes is for enamel-only etching? Was the dentin being etched at all? I don't know. Without being able to watch, it's hard to tell. > 4. The etchant drips on my tongue after 1 minute > 5. fills the tooth in several layers and cures it each layer Somewhere between etching and filling, the adhesive needs to be applied. It can be a separate adhesive or a combined primer/adhesive, depending on whether technique #1 or technique #2 is being used. Bond-1 is an example of a combined primer/adhesive. After adhesive application, the use of several layers of composite is a good idea. This can help compensate for polymerization shrinkage and can ensure full-depth curing. Many dentists (like Dr. Fawks) use some flowable composite after the adhesive and before the layering of the main body composite. Flowables help eliminate voids in corners and ensure sealed margins. > 6. takes the band off Good idea. Don't take the band home. ;-) > 7. grinds the tooth down a little > 8. checks the bite with contact paper, adjusts it > > Then I'm done. Then he's on to my next tooth. I've had at least 10 teeth > done this way in September. Are all ten sensitive, or only a few? Regards, - dentaldoc > > 1. first he drills the tooth out > > 2. then they put a metal band around, then drive a wedge in [quoted text clipped - 4 lines] > which is self-limiting in its etching, so the long time merely lets > the primer soak in. Could he be using a lower strength acid, like malic or citric? Just a.... question SP SignatureNot a real Addy, yet |
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