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Medical Forum / General / Dentistry / June 2008

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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

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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 ??

Signature

/

Amatus

/

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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