Medical Forum / General / Dentistry / June 2008
How do amalgam fillings work?
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Robert - 05 Jun 2008 14:27 GMT Just out of curiousity, how do amalgam fillings work? Composite fillings need some sort of adhesive. How do amalgams adhere to the teeth?
Mark & Steven Bornfeld - 05 Jun 2008 15:11 GMT > Just out of curiousity, how do amalgam fillings work? Composite fillings > need some sort of adhesive. How do amalgams adhere to the teeth? When I was in school we in fact did NOT use bonding techniques with composite. Bonding was discovered in the mid 1950s, but I don't know if the early studies used unfilled resins as adhesives. Bonding can be done without a bonding agent, but it's much less effective. Naturally, resin fillings done without bonding were a pretty dicey proposition because of the amount of dimensional shrinkage involved. But since these were mostly used at that time only on small lesions on front teeth, the potential damage was minimized. Composite was still a big improvement in some ways over what was used before--acrylic resins and silicate cements. Amalgam does not adhere to the tooth, but it does expand on setting. The dimensional change is much less than that of even the best composite resins, but it cannot be bonded effectively (the Parkell company on Long Island was claiming for a while that their product "amalgambond" could bond amalgam, but I have my doubts about that--I can't even conceive of how that would work. Amalgam does leak--esp. initially, until it tarnishes. In the old days we would line the cavity with copal varnish to seal the margins until then, but in the 1970s some copper was included in the alloy mixes know as "dispersed phase" alloys. These had improved marginal qualities, esp. over time, and we stopped using varnishes. All restoratives leak--those that set in the mouth (composites, amalgams etc. may have setting expansion or contraction), and even those that are formed outside of the mouth may leak as a result of differences in coefficients of thermal expansion between the restorative and tooth structure. Probably the best restorative in this regard is condensed gold, but these are very labor intensive and time consuming to place, and are seldom seen in the world outside of dental licensure exams.
Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
Simplicio - 05 Jun 2008 16:51 GMT On Jun 5, 10:11 am, Mark & Steven Bornfeld <bornfeldm...@dentaltwins.com>
> Amalgam does leak--esp. initially, until it tarnishes. Do any amalgams installed every increase Hg release rate, due to factors such as crevice corrosion, galvanism etc.
I would agree that a *typical* amalgam would initially have the highest leakage, then it would decrease (as it expands) but, -this is something I also thought about, but haven't really investigated in detail-every surface on the amalgam "leaks". Therefore will a protective oxidative layer form on the surfaces inside the tooth?
Mark & Steven Bornfeld - 05 Jun 2008 19:25 GMT > On Jun 5, 10:11 am, Mark & Steven Bornfeld > <bornfeldm...@dentaltwins.com> [quoted text clipped - 9 lines] > detail-every surface on the amalgam "leaks". Therefore will a > protective oxidative layer form on the surfaces inside the tooth? I'm sure you realize that I'm using "leakage" in the sense that fluids percolate through the margin between the filling and tooth structure, not in the sense of mercury "leakage". Empirically it's clear to me that oxidation does occur some distance from the cavo-surface margin, but dye studies generally show less leakage the further one gets from the surface of the restoration, so the depth of any oxidized silver, mercury or other salts would be expected to vary.
Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
Robert - 05 Jun 2008 19:13 GMT >> Just out of curiousity, how do amalgam fillings work? Composite fillings >> need some sort of adhesive. How do amalgams adhere to the teeth? [quoted text clipped - 5 lines] > bond amalgam, but I have my doubts about that--I can't even conceive of > how that would work. That is interesting. I once had an amalgam filling that was put into a cracked tooth where half the tooth in the back was missing. I wonder what held the amalgam in since there was little or no "other side" of the tooth.
Does that mean that amalgams eventually crack teeth? If so, do they do so more or less than composites?
Mark & Steven Bornfeld - 05 Jun 2008 19:37 GMT >>> Just out of curiousity, how do amalgam fillings work? Composite fillings >>> need some sort of adhesive. How do amalgams adhere to the teeth? [quoted text clipped - 9 lines] > cracked tooth where half the tooth in the back was missing. I wonder what > held the amalgam in since there was little or no "other side" of the tooth. Sometimes it's magic. Seriously, I've seen restorations like this with no visible means of support that have remained for many years. Clearly there must be some retentive elements somewhere within the cavity preparation. Dynamics of chewing must also play a role.
> Does that mean that amalgams eventually crack teeth? If so, do they do so > more or less than composites? This one has been batted around for years, and I haven't heard a satisfactory answer. Undoubtedly this is because there are so many factors involved in longevity of a filling, fracture of teeth, etc. Generally speaking, the teeth that crack are the teeth where good guidelines for restorations are ignored. Bill (dentaldoc) alluded to cavity forms for amalgams, first codified by G.V. Black almost 150 years ago (and modified by Bronner). Specifically, because of the prismatic nature of amalgam, restorations should never be made that are more than 1/3 the distance between the cusp tips. Cavity preparations wider than this should be extended over the side of the tooth. These guidelines are routinely ignored, because people don't want amalgam showing on the sides of the teeth. In these cases, it is impossible to tell if the fracture has occurred as a consequence of amalgam expansion, or of leaving what's called "unsupported" amalgam in the prepared tooth. I suspect it's a combination of both, but for sure narrower amalgams are much less likely to fracture the teeth. I can't say overall that there is a greater or lesser chance of fracture with composite. In my office, there is certainly a greater incidence of recurrent decay in composites. This is doubtless mostly in those cases in which the margin ends partially on enamel and partially on dentin.
Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
DrMarvin/Natural Dentist - 10 Jun 2008 21:35 GMT On Jun 5, 11:37 am, Mark & Steven Bornfeld <bornfeldm...@dentaltwins.com> wrote:
> >>> Just out of curiousity, how do amalgam fillings work? Composite fillings > >>> need some sort of adhesive. How do amalgams adhere to the teeth? [quoted text clipped - 48 lines] > > - Show quoted text - I've experienced the same in my office. Composite restorations do have recurrent decay because they're so dependent upon the bonding technique (and with dentists trying to get them done faster... there will probably occur more often)
The amalgams do leak too but the corrosion does have something to do with the recurrent decay.
You would expect the opposite (more decay without bonding as in the amalgam). But the proof lies in the clinical world.
Dr. Marvin
http://www.drmarvin.com
Amatus Cremona - 10 Jun 2008 21:42 GMT Hey Marvin,,,,,,, have you checked out Dentaltown.com ??
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Amatus
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On Jun 5, 11:37 am, Mark & Steven Bornfeld <bornfeldm...@dentaltwins.com> wrote:
> Robert wrote: > >> Robert wrote: [quoted text clipped - 56 lines] > > - Show quoted text - I've experienced the same in my office. Composite restorations do have recurrent decay because they're so dependent upon the bonding technique (and with dentists trying to get them done faster... there will probably occur more often)
The amalgams do leak too but the corrosion does have something to do with the recurrent decay.
You would expect the opposite (more decay without bonding as in the amalgam). But the proof lies in the clinical world.
Dr. Marvin
http://www.drmarvin.com
Newbie@bix.nex - 11 Jun 2008 01:43 GMT >Hey Marvin,,,,,,, have you checked out Dentaltown.com ?? He prolly got kicked from there.
Dartos - 11 Jun 2008 15:17 GMT What you are seeing is probably more telling to the work done in many dental offices instead of the materials themselves.
My son's girl friend is starting dental hygiene school in August, and currently works in a suburban dental office as a hygiene assistant.
She was telling me last night how the office diagnoses sealants for a lot of teeth (which may be OK), but has the assistants (few of which have any formal training) place them. They had her place 4 sealants on a patient yesterday and she has only worked in the office for a month with no previous experience.
They are bonding over crud in the grooves without using air abrasion or a laser to properly clean them. She also mentioned that there seems to be a lot of sealants coming off from previous visits (big surprise...not).
She isn't on the operative side of the office, but one would suspect if they are sloppy on sealants, they may well be sloppy in other aspects of care.
D
> I've experienced the same in my office. Composite restorations > do have recurrent decay because they're so dependent upon [quoted text clipped - 8 lines] > > Dr. Marvin news.chi.sbcglobal.net - 11 Jun 2008 22:12 GMT Looks like your son will have to continue having his dental work done by his father, rather then let love take over and assure his girlfriend she is the best. Gail
Dartos - 11 Jun 2008 22:55 GMT She's aware of the type of office she is in, and my son is applying to dental school this summer, so I won't remain so important forever.
;-) D
> Looks like your son will have to continue having his dental work done by his > father, rather then let love take over and assure his girlfriend she is the > best. > Gail news.chi.sbcglobal.net - 11 Jun 2008 23:01 GMT You are such a sweet guy. you will remain forever important. Gail
> She's aware of the type of office she is in, and my son is applying to > dental school this summer, so I won't remain so important forever. [quoted text clipped - 6 lines] >> is the best. >> Gail Dartos - 12 Jun 2008 14:06 GMT > You are such a sweet guy. you will remain forever important. > Gail Thanks, but Bornfeld is the gentleman in this group.
:-) D
Mark & Steven Bornfeld - 12 Jun 2008 14:07 GMT >> You are such a sweet guy. you will remain forever important. >> Gail [quoted text clipped - 3 lines] > :-) > D STFU! ;-)
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
George - 11 Jun 2008 23:04 GMT On Jun 10, 9:35 pm, "DrMarvin/Natural Dentist" <powaydent...@gmail.com> wrote:
> I've experienced the same in my office. Composite restorations > do have recurrent decay because they're so dependent upon [quoted text clipped - 6 lines] > You would expect the opposite (more decay without bonding as in > the amalgam). But the proof lies in the clinical world. That is true and I know it from personal experience. I went through a spell of less than perfect oral hygiene and atrocious diet and any restorations that had to be replaced due to secondary caries were all composites - my old amalgams were fine. The corrosion process in amalgams produces silver salts which are highly antibacterial (indeed the antibacterial properties of silver have been known since ancient times). On the other hand, composites are not particularly antibacterial. Also, consistent bonds need cut enamel (I know that most manufacturers claim high strength on dentin bonds, but I don't think that translates to the reality of the oral environment very well) and that there is often very little to none enamel in a deep proximal box. Who knows how long a bond will be able to resist degradation from oral fluids at the interface before a bonded restoration reverts to unbonded status? Composites can work perfectly well as posterior restorations, but they're not for everyone. They require motivated patients with top oral hygiene. For what I consider the average patient who toils all day and by the end of it he may not have the enthusiasm to floss like an expert amalgam is a choice that may save him from trouble and expenses in the future (at least for a while). That's why I believe that if amalgam is banned there will be a caries crisis in a few years of unprecedented proportions.
Regards, George
Robert - 12 Jun 2008 00:41 GMT > that if amalgam is banned there will be a caries crisis in a few years > of unprecedented proportions. Interesting observation. In any case, as my composites become problematic I am having them re-replaced with amalgam. I went mad years ago so I'm not so worried. My new dentist uses some kind of amalgam that has gold and silver in it, I guess to cut down on the corrosion.
My old "factory" dentist (I call him that because he runs it like an assembly line) placed about 5-6 large composites in a single visit. I was not an educated patient then, but now I realize that he could not have been exercising a great amount of care.
Dartos - 12 Jun 2008 14:13 GMT > Composites can work perfectly well as posterior restorations, but > they're not for everyone. They require motivated patients with top > oral hygiene. Disagree. Bonding, anatomy, and finishing are key.
D
Mark & Steven Bornfeld - 12 Jun 2008 14:48 GMT >> Composites can work perfectly well as posterior restorations, but >> they're not for everyone. They require motivated patients with top [quoted text clipped - 3 lines] > > D I've probably asked this--you don't get de-bonding or marginal failure in deep proximal boxes that end on dentin? I'm sure using small increments to bond would eliminate contractive forces.
Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
Dartos - 12 Jun 2008 19:18 GMT Not that I can detect.
Band and wedge with no leakage Regular size restorations get total etch and wet bonding with Bond 1 (according to directions), thin layer of flowable (cure), more flowable with Tetric Evo-ceram condensed into it (cure), little more flowable and last layer of Tetric (cure).
Deep restorations get basically the same fill technique, but I only etch enamel and then use Clearfil SE Bond.
JME, D
> I've probably asked this--you don't get de-bonding or marginal > failure in deep proximal boxes that end on dentin? > I'm sure using small increments to bond would eliminate contractive > forces. > > Steve Mark & Steven Bornfeld - 12 Jun 2008 19:28 GMT > Not that I can detect. > [quoted text clipped - 6 lines] > Deep restorations get basically the same fill technique, but I > only etch enamel and then use Clearfil SE Bond. Can you keep the etchant off the dentin?
Steve
> JME, > D [quoted text clipped - 5 lines] >> >> Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
Dartos - 12 Jun 2008 21:36 GMT I won't say that microscopically I am perfect, but I use a gel etch in a syringe with a needle tip (22 guage?). I'm not interested in doing much etching on the cut enamel close to the dentin, but the cavo-surface areas.
SE materials don't bond well to uncut/unetched enamel, so I go for the etchant.
I see a lot of people who already have large restorations, and quite a few who seem to wait until *they* know they have a cavity. Lots of big fillings here.
No problems to date.
D
>> Not that I can detect. >> [quoted text clipped - 20 lines] >>> >>> Steve Mark & Steven Bornfeld - 12 Jun 2008 21:58 GMT > I won't say that microscopically I am perfect, but I use a gel etch > in a syringe with a needle tip (22 guage?). I'm not interested [quoted text clipped - 11 lines] > > D Thanks. You da resin man, fo sure. I think the only way I'm going to gain confidence in those large restorations is just to do 'em.
Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
Dartos - 12 Jun 2008 22:34 GMT I think the only way I'm going
> to gain confidence in those large restorations is just to do 'em. > > Steve I did lots of MODBL amalgams before I switched to composite. If you can do a good one of those, you can do a good composite. It just takes practice to get tight contacts and be 'smooth'.
Best of luck, Steve
Newbie@bix.nex - 13 Jun 2008 01:10 GMT > I think the only way I'm going >> to gain confidence in those large restorations is just to do 'em. [quoted text clipped - 7 lines] >Best of luck, >Steve After 2 - 3 years with Master D's technics and suggestions, can tell you that recurrent decay is not a problem.
Don't personally seperately etch the enamel, and am using Clear Fill Self Etch for all composite restorations regardless of size. But then again don't do many MODBLs, crowns for those.
One major endo thing, which I referred to in my quick endo missive, was sealing dentin over the gp in the chamber. CFSE and Filtek supreme plus flowable is great, easy to place, and is one of the best seal that can probably be achievable with our current materials.
Also am using a Chlorhexadine final rinse in the canals (agitated with patency file) <man you wouldn't believe the gunk that comes out> There is very little post of sensitivity after RCT. ~<10% especially in necrotic cases.
One way to introduce new composite technics to your patients is to tell them you would like to try a new technic, and if it doesn't work out you'll replace it with standard materials/technics @ NC If you follow D's recommendations you won't redo many. Bet <1%
Case selection is important. If you think endo may be in the future, chose another case.
Best wishes, because luck ain't involved ! ;-)
Steven Bornfeld - 13 Jun 2008 03:43 GMT >> I think the only way I'm going >>> to gain confidence in those large restorations is just to do 'em. [quoted text clipped - 35 lines] > > Best wishes, because luck ain't involved ! ;-) Thanks!
Steve
Newbie@bix.nex - 13 Jun 2008 05:08 GMT >> Best wishes, because luck ain't involved ! ;-) > >Thanks! > >Steve Good technic, attention to detail, and a bit of coaching from the masters, will bring you up to speed in no time.
Afterall, you are actually one of the grand masters now. You even have teaching experience, do you not ?
Check your fear at the door. You have the needed skills. Time to expand your comfort zone.
Luv ya bro,
-NwB
Steven Bornfeld - 13 Jun 2008 16:22 GMT >>> Best wishes, because luck ain't involved ! ;-) >> [quoted text clipped - 7 lines] > Afterall, you are actually one of the grand masters now. > You even have teaching experience, do you not ? Yes, ancient history. NYUCD in the operative dentistry department, 1979-81. I worked in DAU, where all the pretty ladies were.
Steve
> Check your fear at the door. You have the needed skills. > Time to expand your comfort zone. > > Luv ya bro, > > -NwB Dartos - 13 Jun 2008 13:28 GMT Be careful Newb, or you might start slippin' into that gentleman class yourself <G>.
Today I saw a couple of average molar class II's that I did in 1984 (Heliomolar) that are still functioning fine.
I know the restorations that I'm placing now are lots better. So it isn't much of a stretch to believe they should survive even better.
My worst problems early were with not getting tight contacts.
Palodent or Garrison rings work very well when you can get their matrix through the contact area. Pre-wedging, or wedging and leaving for a few minutes (and then wedging tighter before placing the restoration), plus using an instrument to really force the band against the adjacent tooth, conquers that problem (I use a double-ended ball burnisher to place posterior composites..you can 'lean' on it pretty good).
Of course you're right. It isn't luck, but it isn't magic either.
Rubber dams are nice too, especially when you're maybe a little slower with something new.
JME, D
>> I think the only way I'm going >> [quoted text clipped - 37 lines] > > Best wishes, because luck ain't involved ! ;-) Newbie@bix.nex - 15 Jun 2008 16:21 GMT >Be careful Newb, or you might start slippin' into that gentleman >class yourself <G>. I'd better be careful. Wouldn't want to ruin my rep as a sarcastic ba$tard. <bg>
>Today I saw a couple of average molar class II's that I did in 1984 >(Heliomolar) that are still functioning fine. > >I know the restorations that I'm placing now are lots better. So it >isn't much of a stretch to believe they should survive even better. With your help, have gained much more confidence in the composite restorations that I place. Thanks.
>My worst problems early were with not getting tight contacts. As were mine.
>Palodent or Garrison rings work very well when you can get their >matrix through the contact area. Pre-wedging, or wedging and [quoted text clipped - 5 lines] > >Of course you're right. It isn't luck, but it isn't magic either. right-O, Right-0 !! Can now place composite faster than previous amalgam placement. It's been a few years since an amalgam was placed in my shop though.
>Rubber dams are nice too, especially when you're maybe a little >slower with something new. RD is always a good idea. You can't beat a dry field. Just not always practical, but for the "challenging" case is almost always worth the extra effort.
>JME, Would have said JMNSHE, if I were you ! <vbseg>
>D > [quoted text clipped - 39 lines] >> >> Best wishes, because luck ain't involved ! ;-) Simplicio - 14 Jun 2008 23:41 GMT On Jun 10, 4:35 pm, "DrMarvin/Natural Dentist" <powaydent...@gmail.com> wrote:
> On Jun 5, 11:37 am, Mark & Steven Bornfeld > [quoted text clipped - 59 lines] > The amalgams do leak too but the corrosion does have something > to do with the recurrent decay. that's interesting because when I had the amalgam removed that caused me so many problems the dentist who removed it (not the one who placed it) said there was a tremendous amount of decay above it.
I assumed that one of 3 things happened
1-poorly mixed filling 2-bizarre extreme galvnism (it was placed next to another filling) 3-unusal amalgam/bacterail interaction
but I thought that 1 was more likely the cause of 3, then the other way around, because if there was a prevlance of 3, in well placed amalgam you would think it would effect a lot of people.
Are you aware of some effect where certain kinds of decay/bacteria tend to interact with the surface of the amalgam? I find it hard to believe that my mouth bacteria is that special.
Bill - 05 Jun 2008 16:35 GMT > Just out of curiousity, how do amalgam fillings work? Composite fillings > need some sort of adhesive. How do amalgams adhere to the teeth? Amalgams don't actually ADHERE to teeth. They are kept in place by the shape of the tooth.
In the process of preparing an amalgam restoration, the dentist removes the decay and shapes the tooth so the amalgam won't fall out.
The amalgam is the consistency of modeling clay when it is placed in the tooth -- it can be shaped and packed into the retentive recesses that the dentist has carefully formed in the tooth structure. In a few minutes the amalgam hardens, and then cannot fall out.
Think of an empty wine bottle -- the inside of the bottle is larger than the narrow neck opening. You can stuff modeling clay into the bottle, but after the clay hardens, you can't get it out. The neck opening is too narrow.
That's basically the same principle that holds amalgam in place. It is shape alone, as no adhesive is generally applied.
Today, most fillings are made of bonded composite resin, and the retentive grooves needed for amalgam are not needed for composite, so the shaping of the cavity by the dentist is somewhat different.
Some day, the shaping of the cavity to receive amalgam may become a lost art, much the same way that the shaping of the cavity to receive old-fashioned gold foil has almost become a lost art -- kept alive only by a few dentists who regard it almost as a hobby.
- dentaldoc
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