Achieving Predictable Clinical Outcomes with Your Composites

You're listening to the Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Direct composites are the bread and butter of every dental practice. At times, these procedures can be frustrating, time-consuming, and in some cases, create a less desirable result. Today, we'll learn some tricks of the trade to keep us on track so that our direct restorative procedures produce predictable and consistent clinical success and high patient satisfaction. Our guest is Dr. Lori Trost, who maintains a full-time private practice in Redbud, Illinois. Dr. Trost focuses on aesthetic dentistry with a wellness approach to patient care. She lectures extensively throughout North America, is a clinical evaluator for many dental manufacturers, and translates her knowledge and experience into authoring a wide variety of professional articles, as well as CE webinars and podcasts on vivalearning.com. To begin, I would like to thank our sponsor, Colteen. Colteen is a global company in the development, manufacture, and sale of consumables and small-size equipment for dental treatment applications. When it comes to composites, they offer an exceptional material called Brilliant Everglow, which delivers highly aesthetic and long-lasting restorations that can be achieved effortlessly. So thank you, Colteen, for supporting this podcast. Dr. Trost, it's a pleasure to have you on Dental Talk. Thank you very much, Dr. Klein. I appreciate that. Yeah. And I want to congratulate you before we get started on an excellent Viva Learning webinar and really, really good. I listened to it earlier today. You gave it on Monday, which was a week before Christmas, and you had an incredible turnout, which is just really impressive considering December 20th. Most speakers don't want to do a webinar that close to Christmas, but yours did very well. I knew it would. For those of you who missed it, you can watch the recorded version on VivaLearning.com. Simply type in the search bar TROST, T-R-O-S-T. The title of the webinar is Achieving Predictable Clinical Outcomes with Your Composites. And I got to tell you, Dr. Trost covers so many things in that webinar. So if you're looking to get a review or learn the latest on composite dentistry, there's so many aspects of that topic that's covered in those webinars. It's really quite impressive. So thank you very much. So let's begin with a simple question. How does a clinician choose a composite? That's a great question. That's a question that I get asked often. That's a question that I ask myself because I want to have, first of all, a composite that can be durable, but it needs to really, to be able to be durable, it's got to be able to handle correctly. And I have to be able to place it first. If you can't place a good composite correctly, work with it. It's not sticky. It can stay placed. It doesn't slump. Those are all critical factors, I think, in handling. And I think most dentists, I mean, there's a lot of good surveys that are out there that support the factor that handling is a number one issue. So we've got to be able to work with the material in our hands. It's got to be able to stay placed, whether it's anterior or posterior, whether, I mean, there's difficult access. I did yesterday a lingual on number two. I mean, it's one of the hardest teeth to work on, right? But yet I can get access into it. The material could flow, work, stay put, and manage and cure correctly. Handling, I think, is the number one issue. So that's where you got to start with. And then I think from there, you need to navigate into the realm of universal composites. So those are composites that can be either used anteriorly or posteriorly. So when you talk about composites that handle well, that also helps the clinician with less inventory as far as instrumentation, right? So they don't need as many instruments to manipulate the composite into place. Are you finding that in your practice? Absolutely. So, you know, when I first started placing composites, I had anywhere between five and maybe seven instruments to do that placement. And we were still in that realm of maybe using a packable type material. We didn't necessarily have materials that were able to be sculpted. You had to really kind of guide them in certain formats and placement issues. But the beautiful thing is now we have materials that we can rely on, first of all, that are universal. So they go into your posterior. They have wonderful like sub micron particles. So now the colorations, the mechanical properties, the compressive and the flexural strengths are really amazing. But now we're offering flowables married with the partner of the traditional placement resin. and that's a really great win now because those again mechanical properties they measure out so therefore it really reflects on how many instruments you use so i have two instruments that i use to place every composite i don't need any more than that i can get great results with two instruments so that cuts down It really creates a more efficient procedure, right? And it cuts down on infection control, on your turnaround, on your cassettes, on your setups, everything. And your assistants really can function and perform a lot easier because they have less, you know, instruments to work and process. And more importantly, you keep your setups just minimized. And it's really, I think, a much simpler and easier format to use that. Yeah, now you do a lot of restorative dentistry in your practice. Are you finding that these single shade or dual shade systems, are adequate to meet the patient satisfaction for those that are pretty discerning about aesthetic dentistry. How has that helped your practice? I do a lot of composite dentistry. I think it's one of the most conservative procedures we can still use and really great, you know, get great results. What I'm excited about is because of the mechanical properties of these sub micron particles we're placing and we're putting more filler load into that, you know, chemistries. We can go now into load-bearing areas. We can go into incisal edges, occlusal tables more confidently and don't have chipping or fractures. The improvements now with these color shadings, because they're duo shades, they are marvelous. I mean, when you consider and take an A1 or B1 and it can chameleon into that space. that's a beautiful thing so we're minimizing shading so we don't have the beta shade guide we used to have right um it seemed like even with me to shade guide you still needed even more than that initially but now We have such beautiful, just the optical qualities of these materials are excellent. And then, of course, their flowable versions are excellent as well, too. So you really can move into a greater, I think, realm with the minimized shading. Plus, now, you know, companies like Colteen, they're coming out with, you know, this brilliant Everglow. It's amazing in the fact that you have translucent shades now. You have... uh different bleach shades you have now also opaquer so you've got an ability to mask out many of us are removing older you know amalgams and they have the amalgam tattoo so you've got it when you're removing that often you know you had how did you block that out beforehand unless you put an intentional liner in that so now you can use the opaquer and you can again bond that completely from that substructure all the way up to the occlusal table you get a great result so i think again when you're choosing composites look at handling look at do shades, but more importantly, look at all of these different companies that are putting the opaquers and the translucents out and the bleach whites that are really true to color. So you're kind of a fan of using a system where you have the materials in that system compatible. You know they're compatible because they're manufactured by the company and they're made to be compatible, and you like to stay within that. You don't want to use one flowable from one company and then use the composite on top from another company. So when you do your class twos, you mentioned Brilliant Everglow by Colteen. Does that have a flowable that you would use in the box of a class two and then finish off with the composite? Yes, it does. It has Brilliant Everglow flow. And that again, see beforehand, we were nervous about placing any kind of flowables in a genital box in a class two because two reasons. One, it didn't have the mechanical compressive strength. that it offered second i mean we were doing it for adaptation which is right in theory but the problem with that is it wasn't always radio opaque so now not only is it strong with the compressive strength value you've got the adaptation these companies are offering a product now a flowable that is it's radio opaque so you're certain that you have no secondary carries in there complete coverage, et cetera. So I think with confidence now we can marry both of these flowables. And I see this just as being a really great win because now you have a predictable system. I think it's very important to stay within the silo, the vertical silo of that manufacturer, because I think the components are definitely compatible. They work together well. And I think when you start to crisscross and mismatch materials, you just don't necessarily know what chemistries are linking there, especially with polymer chemistries. Yeah, and having that radio opacity is really a confidence builder for the clinician when they're trying to do a diagnosis on a new patient that comes in the office that has a whole slew of composite restoratives in their mouth, and you don't know whether it's recurrent decay in that box, which is the most prevalent place for it to be, or is it a flowable that just wasn't radio opaque. So now using these newer materials, which you have been talking about in your webinars and other lectures that you give, Dr. Trost, it's important to have that radio opacity in that flowable. and also the fact that it has that additional strength is huge like you said it takes off the table that fear that we wouldn't have the compressor strength in that box area although we do get the adaptation so what are some of the current trends that you're seeing in the way of placing these composites for a while we were kind of navigating into the realm where we were taking bulk fills and because the factor that we weren't necessarily not uh having uh complete coverage or adaptation we were taking a flowable and and many of these bulk fills were initially put more into a liquid format that you could flow into a cavity preparation into a gingival box etc and really allow that to adapt and many of them were placed initially like in a four millimeter increment and then light carried well the problem with some of those are the factor you just don't necessarily know how much you are putting into that space. And not all of us are measuring with peri-probes. You know, if they say four millimeters, sometimes it's violated, sometimes it's five or six. I'm guilty of that too. I mean, I try to do the best, you know, the best I can. But I think that methodology has taken kind of a little bit of a turn. And I think we're still going now, we're returning to that idea now that the flowables are really, you know, performing much better because of the compressive strength and the radio opacity. i think we're now placing that adaptive flowing layer initially and then we're placing on top of that and it gives i think clinicians the option that if you want to do that more that packing type of motion that you like that placement packing initially with that material that works beautifully now you have a better measurement value that you think you can visually or you can measure itself however you want to do that when you're placing but i think it gives you a little more confidence a little more predictability that you're getting a the proper depth placed and more importantly you can cure that then so that's all what you know if you're if you're violating the placement rules of how many millimeters then you're not going to cure it and that's going to leave the post-operative sensitivity recurrent decay you name it all Yeah, and you mentioned in your webinar on Monday, which our audience can access on VivaLearning.com, the ADA did a survey back in 2002, I think, that almost 40% of composite restoratives were not fully cured in the box on class twos, which is a huge problem for post-operative sensitivity and for just plain failure due to the composite falling apart. under stress and then you're going to get recurrent decay. So that's a big thing. A couple more questions before we wrap up the podcast, Dr. Trost. One is on the labeling of universal composites. Are we at the stage in dentistry now where a dentist can use one type of universal composite for anterior and posterior teeth, get the aesthetic results they're looking for in the anterior and get all the benefits of what they need in the posterior? I think we absolutely are. I think it's a very exciting place to be. We can confidently say we have mechanical properties to perform, obviously, anterior. And as far as the occlusal stresses, that's one answer. But then we look at those incisal areas and that load bearing. I think we can match that now, which I think is just an amazing feature to have. I think what excites me the most is just the colorations are absolutely stunning, beautiful. And you can get like a liquid glass finish on some of these now. And we all know that the smoother that resin is once it's placed and polished, it's going to wear much better. And these just blend so nicely. You really don't see the margins on these anymore if they're placed correctly. I just think it opens up so much more opportunity for us. And as dentists, it minimizes our inventory. You know, we can keep things really sized down correctly where we need it. And in times when you're mindful of what you have and what you're spending, I think it's a wise choice. So undoubtedly, our goals as clinicians are to achieve the highest level of predictability in the work that we do. So having said that, how can we make composite placement even more predictable? What are some of the tricks you could tell us if you just talk to a dental student who just came out of dental school or even a dentist who's been practicing five years or so that's not completely ingrained in their own habits? What could they do to improve the predictability of their composite placement? First and foremost, use quality materials. Use materials that you know are from a good manufacturer and they're researched. They have good studies behind them that prove their performance. Secondly, I think... When you go to prep any tooth, I think you need to use your burrs as a measuring tool. And now we have great burrs across the board that can allow us to know exactly dimensionally what we're doing, how we're doing it. And that's really important. Work with a good handpiece that all reflects that. And it starts with that artistry. I think that you, for predictability reasons, need to have one and done burrs because then infection control is not an issue. I think carrying on for the predictability, you want to make sure that once you're prepped, you go ahead and you, for lack of better terms, disinfect that preparation. But I'm a real big believer in using some kind of cavity scrubbing agent solution. There's a lot of varieties that are out there in the market. You can go simply with 2% chlorhexidine. You can go to Consepsis. You can do a lot of great just cleansers. I think to get the tooth debris, any bacteria that's in there, around there, near there, just get that cavity preparation clean. Isolation is huge along with that too. I think keeping the tooth moist, that is a huge factor, and I've learned that over time. We don't want to desiccate anything now. And I think all of the universal bonding agents have really developed in chemistries that they marry very well now with more of a moist surface. Not a wet surface, but a moist surface. There's a little difference there. And that's critical for the success of no postoperative sensitivity down the road. And then place the composite like you're supposed to. Do the proper light curing. Don't shortcut. I mean, It seems like it's a very tedious procedure sometimes, and 20 seconds can seem like two years sometimes. Don't violate the time. You've got to pay attention to the time and really just properly do everything and follow just the protocols of what the manufacturers recommend, and I think that is going to really lend and yield a great result. Yeah, great advice, invaluable advice. Thank you so much, and you have years of experience, Dr. Trost, in teaching to back that up. um and keep writing those great articles we really appreciate reading them and keep doing these podcasts and webinars you've been a great contributor to viva learning and if i'm speaking to the audience now if you want some more information on some of the materials that were mentioned. I know Dr. Trost likes Coltene's brilliant Everglow. You can look that up online. You can Google Coltene and just look under their direct restorative materials. You'll find brilliant Everglow and then their flow material as well if you want to learn more about it. Thank you very much and have a very happy holiday and a safe one. Very good. Thank you.