Adhesive Dentistry Done Right: Virtually Eliminate Post-Op Sensitivity

You're listening to the Phil Klein Dental Podcast. I would assume that almost every GP listening to this podcast is doing some level of aesthetic dentistry in their practice, specifically direct restorative procedures. And we all have our favorite clinical techniques and materials to go along with it. But the question is, are we doing everything optimally? After all, our goal is to get the best bond possible while ensuring the patient is pain-free after the procedure. And many of us might think that at this point in modern dentistry, all bonding materials are essentially the same. So why not just buy the one that costs the least? It's a fair question, but it's still worth investigating. So to answer these questions and more, we asked one of the most experienced clinicians and educators in the field of adhesive dentistry to join us today to give us some insight in how to optimize our bonds, get long-term clinical success, and at the same time, virtually eliminate post-operative sensitivity. His name is Dr. Richard Young. He's been placing direct and indirect restorations for almost 40 years, and he is truly an expert clinician. He is an assistant professor of restorative dentistry at Loma Linda University in the undergraduate dental aesthetics program and practice management courses. In his daily practice, he uses simple advanced adhesion techniques with a focus on minimally invasive preparations. Dr. Young, it's a pleasure to have you on the show. Likewise. Good to be back. Yep. So you're still at Loma Linda teaching? Yep. Well, I co-direct the aesthetic program there. We've moved it to the D4 year and the International Dental Students. And then I'm just private practice and lecturing and things like that. Keeping busy in dentistry. Yeah, that's the way to go. So to begin this podcast, we're talking about the importance of bonding. As we all know, bonding, especially Denton bonding, is nothing new. Since 1979, there's been bonding that's been going on in the Denton level. It didn't pick up to be very prevalent until later, where it was proved through the literature that it actually works with the right technique and so forth. To begin this podcast, let's talk about some common reasons. for getting postoperative sensitivity, which is so important to the clinician because the last thing they want to do is do a beautiful composite restorative and have the patient go home and call the doctor. And for two or three days, they're experiencing all sorts of discomfort. So let's talk about postoperative sensitivity when it comes to bonding and composite resins. So I think the biggest issue and the reason this happens, I think there's kind of maybe two to three key issues. Number one, I think the bond, quality is extremely important and that the doctors follow directions on a bond. And I think the biggest issue with bond itself is that the doctors are cutting corners. And I know Ray Bertolotti told us, you know, in 85, put on an egg timer and scrub for 20 seconds. And I've done that literally in my practice ever since. And average American numbers in Europe too is between five and eight seconds. So number one, follow the directions of the manufacturer. That's the reason they put 20 seconds. I think number two is that we stress the bond. And we'll address that with the media dentin ceiling resin coating concepts. But we stress the bond by putting in too much composite at a time and getting that directed shrinkage that will pull that bond off of the dentinal interface. And especially with the bulk fills. and probably the most prevalent in class one composites. And I think really when it comes down to it is quality. Quality of bond matters. And I'm really a stickler to that. So you mentioned several reasons why there might be postoperative sensitivity. What is actually going on under the hood, so to speak, that's causing this discomfort for these patients after the adhesive and composite restorative procedure is over? Tubules probably didn't get sealed or there's a micro gap when the patient chews on that filling and that filling flexes. If the bond had been broken at the dentinal interface and now you've got a flexure of that bond level, you're starting to pump the movement in the tubules, which is going to send sensitivity to the patient. And, you know, I remember Ray always telling us with an occlusal composite, if they have bite sensitivity, when you put a, like a two sleuth or something in there, quit wasting your time. Take the composite out, start over, get the tubules sealed. Don't stress that bond so that you pull that interface off. And now you've got these open tubules that didn't get penetrated or that you didn't do your bond correctly to scrub and to get those tubules sealed. All those components lead to that micro gap. that doctors still chase to today, which is really hard for a lot of us to understand, who were taught how to do this in 1985, 86, 87. The idea of post-op sensitivity literally went out the door. But yet today, it's the number one question. Now, if a doctor does not remove that restorative work and redo that... seal like you're talking about, and they tell the patient, give it two to three days, it'll settle down. And let's say that's what happens. It settles down. What's actually going to happen next long-term or short-term to long-term? I think you're going to see it reoccur. I mean, you know, they'll adjust occlusion. They'll keep chasing it. The tooth will settle down for a little bit. Then they'll bite on something hard. They'll, you know, the interface is there. It's still there. And it generally is a cycle that goes on. And then the patient finally gives up and looks for another dentist. That's the reality of it. So as clinicians, what are the key things we need to keep in mind in order to get a reliable and durable dentin bond that can last? Give us some clinical insight into that. Well, number one, I'm pretty biased in my bonds. There's a very few that I consider to use. And within that group, I mean, I can name a number, you know, either Karari's products, Optibond FL. All Bond was around for quite a while, 3M, you know, Peak by Ultradent, Prelude by Danville. Those are all pretty top-notch in that gold standard quality area. So number one, start with those. and then understand each bond and its manufacturer's directions, and then follow that. And don't cut corners with that. Once you've done that and you get your bond strength right, then I think we're going to probably talk about resin coating and immediate end sealing, but that technique and how you place your initial layers of composite will... greatly affect your end result. And I think it's, you know, when we address that here in this conversation, I think that one single step will solve a tremendous amount of problems for people if they'll just kind of look at it and do it. It's not that hard. So I think a lot of dentists are preparing the dent and surface with the adhesive materials. They're doing what the instructions say, and they're going right to the bulk fill. Now, if everything is perfect, And in many cases, they don't have any post-operative complaints. They continue to do that because it saves them a step of doing what you have been recommending for years, which is using a flowable about, what, a half millimeter thick on top of the adhesive structure and then light curing that and then doing that again, possibly. And that would eat up about two minutes of chair time, right? Something like that. Yeah. at the most. And that whole concept goes back to, I have some slides in my lectures going back to 1991 with Bisphil 2B, which is a directed shrinkage self-cure. And that was kind of our first concept of putting that initial layer down. And it was a directed shrinkage that didn't pull it off the dentin. And then we would layer our Herculate. in two millimeter increments on top of that so then when flowable came along the concept which is in you know the the mid 90s um we would you know place our bond and that to today if you go in with your good bond you follow their procedures and you cure that and then you put down your flowable composite in half millimeter increments basically at the denton you know interface at the floor and If you do that and do your two layers of that flowable, you can pretty much, you can get away with a lot, especially in that bulk fill world. Because there is a lot of shrinkage and, I mean, all composites shrink. That's a given. The bulk fills tended to shrink more. So they even put more stress and strain on that initial bond layer. You know, it's made to seem like it's this incredibly difficult procedure. It's really, really simple. And I mean, I have my favorite material, Majesty Flow and posterior, and that's what I've used since it came out. But it handles beautifully. But if you do that step, it takes such little time. I mean, you can really probably be under a minute and a half. Now, inject your bulk film. But I think everybody's looking for a shortcut. And my joke has always been, if 40 seconds makes or breaks you in a profit margin for your office, you really need to relook at your numbers. Yeah, no doubt. And it seems so ludicrous to obviate that step for the purpose of reducing chair time when the downside, the risk... the end of the day, is having a patient call you with postoperative sensitivity, possibly having an unhappy patient, losing the patient, redoing the work. It seems like a very simple decision to say, hey, I need to invest a little bit more time, put these two layers, half a millimeter each of flowable, and the odds of my shrinkage causing postoperative sensitivity goes down dramatically. I don't know to what extent. You probably know. Well, I mean, I honestly, I cannot remember the last time we had post-op since. But what's fascinating in dentistry, and I have two cases that I'll never forget, is one, my assistant who became a rep for Henry Schein and had a doctor who had constant post-op sensitivity. She said, why don't you try this? She handed him a bond that she knew I used and said, this is the directions, do it. She came back a month later and he goes, wow, this is amazing. I've had zero post-op sensitivity. She says, great, so you can order the bond. He goes, are you kidding me? It's $290. My bond I buy is $40. I'm not paying that. And he went back to the old bond. Now, no logic in that. The other one, I got chased around in a lecture, a person who'd heard me three times, and she asked, her class fives kept falling out, but she goes, I'm using your technique. Everything you said, and I was getting frustrated, and I said, well, what are you using for bond? Oh, well, my husband, who's a prosthodontist, won't let me buy that bond. He said it's too expensive, and he has a better one. And I said, get a new husband and start using that bond. That's funny. That's funny. But you can't win those battles. If you cut the corners on the quality of the bond, and there's good bonds out there. That's really critical. And I see that as, you know, yeah, it's expensive, but time is expensive to redo things. Yeah. I mean, and also, you know, depending on your clientele, depending on the patients that are coming into your office, if you explain to them that this is what we charge, maybe you don't accept insurance and say, you know, this is what we, these are the techniques that we do. This is the finest material that's available. And in the long run, you'll come out way ahead. So what's your... armamentarium, and you can mention products. Tell us what you use as far as from the start to finish. You don't have to tell us what kind of burr you cut with. No, no, no, no. So, you know, I heard Ray Berlotti in 85, and that's when I was introduced to Karari with their original new bond. So I've never changed that product line in my 39 years now. Now I've tried, you know, all the other bonds and had good success with them. I mean, they work, but I've always... stuck with Karari. So my bond currently, if I have a lot of Denton, my bond is SE Protect Bond, which has a fluoride releasing, and you don't have to worry about the MDP monomers and that. So when I'm deep Denton, it's that. If I'm just a basic, you know, smaller restoration, it's the new UBQ2. Those are my two bonds that are in the office. And then... For my resin coating, it is always Majesty Flow A1 posterior. It's a filled posterior flowable, basically. That's what I do the 0.5 millimeter increments. That's light cured each layer. Light cured each layer. Then if I have to build up Denton in the restoration, I've used it since it came out, is APX. I keep that in A2 because it's basically a dentin replacement. So once I've built up in, you know, two millimeter increments with a large restoration with APX to replace the dentin layers, then you can, I don't care how you do it, you can injection mold, use a, you know, use a BioClear matrix system. You can use a Garrison matrix system, do it the way, you know, you're used to doing whatever your protocol is. In my world, I'm basically putting in the enamel layer, and that can literally be anything you want. I mean, Karari's got a great posterior universal. I mean, there's Kerr. There's so many, you know, Alter Dent. There's so many posterior composites. But for me to Denton Sealing and Denton Replacement, I haven't changed that on Armourarium and probably Armentarium since each of those products came out in the mid-90s, or no. So Majesty Flow came out in the 2000s. And APX came out, I think, before that. Just to shift a little bit towards indirect, what do you do for cementation as far as adhesion when you have a prep that's not particularly retentive? So I've always been in the indirect world for years with my first feldspathic onlay probably placed in about 85. But when Panavia came out in 87, I black marketed it out of Hong Kong. It wasn't approved by the FDA yet. And I have cemented every single onlay restoration since 87 with Panavia in its different forms. So I was always a person that I had really good labs making my restorations. So my fits were. And we just had a discussion in Ed McLaren's Rants and Raves last night or the night before about why would you use a heated composite posterior to seat an onlay versus like something like Panavia. And the argument was, is that as people were doing... milling their their micron thickness wasn't that great versus the people who are you know your lab techs who are making you really good fitting restoration so for me that was my world even today i cemented two um emacs onlays at the micron i mean you had no room for anything but panavia or their sa cement so i always use panavia um, for my cementation of indirect restorations. And how do you prepare the dentin for that? So with those, when that tooth was prepped, um, that's where, that's where the term resin coating, I mean, immediate end sealing came from Pashley and Tay and, you know, in 90, what two was sealing the dentinal tubules after you prepped a crown or an onlay. And that way back then we could cement our gold crowns with zinc phosphate without giving anesthesia. That's ironically. why immediate dent and sealing then was so exciting to us. You know, we just clean our margins after we put our bonds. So if I'm doing an indirect, I'm going to do exactly the same. I'm going to immediate dent and seal after I finish the prep or somewhere in the mid. I'm going to put in my resin coating if I need to replace some areas. And I'm going to then put APX if I need to replace dent. It just depends what I'm doing with the restoration. Similar to what I do at the direct composite. I think that's the misnomer with immediate dent and sealing. In a direct composite, immediate dent and sealing is doing your bonding, right? But in an indirect restoration, immediate dent and sealing is doing a step that most doctors don't do. But the biomimetic world now being coined that, I call it modern dentistry, but it was modern back in the late 80s. Early 90s, people don't realize that. It's interesting because in 1988, I got out of endo school in the late 80s from Penn, grad endo. And I went to different dental practices to do endo for them before I got started on my own in Philadelphia at the time. And I had a tooth that had no retention, an upper left molar. And this dentist that I worked for prepped it down. He said, there's no retention here. panavia had just come out it was some or at least he first got it well it was approved in 88 we bought first started bringing in 87 okay so it was like 88 is when he uses and he said phil this stuff is supposed to be the best thing he didn't even know what it was i never heard of it he put it there was no bond he didn't bond that he cleaned the prep and he just put this cement inside the gold it was gold it is gold it's still in there You're talking about 19, oh, let's just average it off 1990, and now we're in 2024? Yeah. Do the math. This thing's been in there 34 years with no bonding whatsoever and a poor retention prep. There was no walls there. I saw it through the mirror, and it's still in there. No problem, no decay. We used to shudder when guys were cementing their full coverage crowns because, you know, female or male, it didn't matter. You go to cut one of those crowns off the way we normally will do things and then pop them. You shuddered at the thought if it was cemented with Panavia because it'd blow the tooth apart. I mis-cemented a little weird facial three-quarter gold onlay, and it didn't catch one of my little indexing dimples. Oh, boy. And the self-cure Panavia started to set, and I tried to get it off, and I couldn't. And I literally had to cut that thing to powder. It was done. And you sweat right through your scrub suit. Yeah, and you wasted a complete restoration. You had to start over. Yeah, that's a nightmare. It was crazy. Yeah, that's a clinician nightmare that puts chills down into our bone. I quit going to a Tucker study club because I still use the concepts of how we finished our gold, even to this day. But I took all the retention form out. And I bonded all of my gold restorations going back to about 87, 88 with Manavia. Yeah, I mean, Curare, no doubt. Yeah, it's been a great company. Yeah, they have the chemistry. So what have you found that works? And I guess it's going to be somewhat redundant of what you've already talked about, but what have you found that works best for posterior restorations with patients that are actually Bruxers or difficult occlusion disorders? Well, I mean, I think when you're dealing with occlusion disorders, if we're raising vertical and we're trying to determine where we're going to get them to settle at, You know, I try to avoid reconstruction at this point in my career. I don't want to be married to him for the last 10 years of my career, however long it is. But in raising verticals, yeah, you start to pick and choose now. Let the young guy sweat, right? You get smart enough to realize that there's enough prosthodontists around you that that's why you don't become a prosthodontist, so that people don't refer to you. That's a good point. versatile for determining occlusion raising verticals we could we could make you know ed mclaren had his techniques way back um you know with injection i'm trying to think who he we all learned that from from the sorenson but you know john john sorenson from john might have been yeah i forgot the school what school was he at he wasn't he ucla wasn't he or was john ucla he might have been ucla because ed was ucla mclaren's a close friend of mine and but we would injection mold through a stent. You know, we'd make a suck down stent of our diagnostic wax ups and we'd use resin because now with resin, it was forgiving. I was a huge sculpture fiber core person. Ron Jackson was as well. And, you know, Ron Jackson and I, you know, we would talk every now and then if we'd met, he was a good friend of my mentor, Jim Dunn's. And we'd have, you know, sculpture fiber cores for 18 or 20 years. working beautifully but the beauty is if you needed to change something slight you could do that with resin so then it was usually you would open them with with resin get everything stabilized then convert to either gold or ceramic you know like an emax um so i've i've been a huge resin user over the years um because of its versatility and we just discussed that the other night about how I truly, I think all of us are hoping for that day. It's probably going to go to a hybrid resin as the ultimate material. Yeah. Do you think, with your knowledge of adhesive dentistry and your knowledge of using direct restoratives, do you think we could do more with direct restoratives and obviate the need for full? coverage or partial coverage, indirect restorations where they will last a long time. They're more affordable for the patient. They're less invasive as far as cutting down teeth. It's more of an additive approach. Do you think we have reached that time where we should be doing that? I think it's going there. And I think the materials, you know, additive is a huge thing. And I do a lot. I have a section of extreme bonding where I'm doing a lot with David Clark's BioClear Matrix. He makes this one called a 360 degree. And I injected a tooth the other day that I got a three millimeter ferrule on it, a lower central. And I injected it actually with 100% majesty flow. They do this in Japan all the time. But because that... is under compression. And I got the three millimeter ferrule with the matrix based on Pascal's research. So we have no post in it, no root canal, broken off just above the gum line, but I engaged three millimeters injection mold. I think when you see how long these last and the service to the patient, you kind of go, man, why aren't we doing more of this? But we also need, you know, the room for a resin. So I think as we all dream about the ultimate material, it's going to be a jet printing of some sort of a hybrid composite resin-based material. Right, 3D printed right there. It'll be, I think, but I know we discussed this the other night with Miguel Ortiz and Ed and I, and I mean, it's a ways off. I mean, I don't think it's that far off. Yeah, they're doing some amazing stuff with 3D printing. But that ferrule that you're talking about, that three millimeter ferrule, isolation is very critical now when you're doing it in that kind of situation. You have to have perfect isolation. Well, I'm a heavy rubber dam person. I have been since the late 80s. And it's funny how there's a resurgence. It's like the... like the renaissance of rubber dam in Europe and starting to come to America where many of us were raised in rubber dam and never left it. And so we're kind of fascinated by this new renaissance. And I don't dare present in a lecture almost if I don't show rubber dams. Well, I mean, that's the whole thing. And you're talking to an endodontist. Exactly. Talk about a profession that used rubber dams. It was your way of life. And I learned a lot from the endodontists and how to place rubber dams. Yeah, every time. Every time. There's got to be one on there. All right, well, listen. Yeah, that's been incredible information in 25 minutes. You can't beat that. That's why we do these podcasts. And we thank our audience for their attention. This show is growing rapidly. We're doing over 35,000 listens per month now on all of our platforms. Yeah, between Spotify, Apple Podcasts, mostly on VivaLearning.com, but it's continually spreading to other platforms. So we're all over the place internationally too. Cool. Yeah, so we got an email from the... of Education in Doha, asking us to change our time stamps on our certificates because thousands of citizens of Doha, Qatar, are taking our stuff. It's crazy stuff, yeah, the world today. Well, I hope we can simplify for people because that's one of my frustrations today is everybody's trying to make this all so complicated. And I get it. There's lots of research. But the reality of it is... It's not that difficult to do. Yeah. No, it's great having brilliant people like you, Dr. Young, who's been, you have so many years of experience and it was a pleasure to talk to you and it's an honor to have you on our show. Thank you very much, Dr. Young. Thank you so much.