The Benefits of Bulk Fill Composite

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Many of us are using bulk fill composite and universal adhesives for our direct restorative procedures. And our goal, as in any clinical procedure, is to create the best restorations in the most efficient way. And chair-side efficiency not only improves the patient experience, but also boosts productivity. and profitability. Today, we'll be discussing efficient aesthetics using direct composites. Our guest is Dr. Joshua Austin, who maintains a full-time restorative dentistry practice in San Antonio, Texas, not far from our headquarters in Austin. He is an editorial director and monthly columnist for Dental Economics Magazine, focusing on dental products and technology. Dr. Austin also lectures around the country on topics such as digital marketing and mental health. Before we get started, I would like to mention that Dr. Austin's webinar titled Faster, Better, More Profitable Bulk Fill Composite Is The Way is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Austin, A-U-S-T-I-N, and you'll see it. If you're doing a lot of direct restorative using composite resin, I certainly recommend this webinar. Dr. Austin, it's a pleasure to have you on the show. Good to see you again, Dr. Klein. So we're certainly talking about a topic that's very important right now because so many dentists are using composites for their direct restorative procedures, but there is an opinion difference among dentists about whether traditional incremental fill placement technique is the right way to go or bulk fill. So what's your feeling about that? Posterior composite really is the bane of my existence. You know, it's by far the procedure I do the most in my practice. There's a study done by the ADA Health Policy Institute that shows that three out of every four restorations done in this country are direct restorations. And of those 90 something percent are. resin composite. So we know it's the most common procedure in the office, but it's also the least profitable procedure I do. It gives me the most headaches. It's the most post-operative issues that I have are with direct composites, specifically in the posterior. When we look at incremental fill composites is that every time we place an increment, there's a risk of something going bad. And when I was taught in dental school, I was taught to do two millimeter increments. No increment of composite touched more than two walls of a tooth. And that's really, really easy to do on a typodon, but on a real tooth, on a patient that has cheeks and gums and tongue and blood and gingival cavicular fluid. And that gets way harder. And so every time we place an increment, we have a risk of getting contamination or a void. And bulk fill helps reduce that, right? The less increments I can place, the better for me as a clinician. And the better for the patient because we have less of a risk of contamination or a void. And these composites are built to be placed in four millimeter increments, double what we're used to having. So it just makes a ton of sense to me to use these in those areas in the posterior. There really is the most common thing we do in an effort to minimize post-operative issues that we would run into that eat up our time and our profitability. So what has changed to make bulk fill so acceptable or actually the preferred method of choice? when it comes to restoring, especially these larger cavity preps in posterior teeth? Yeah, there's kind of three things that have changed in the composites since the days of like the composites that I trained under when I was in dental school in the early 2000s would have been like heliomolar or Z100, kind of those classic legacy composites that have been around for 25 years now. Number one is the monomer systems have all changed. All these monomer systems are totally different than the monomer systems that were present. in those early composites that we did posteriorly and those monomer systems have reduced the amount of polymerization shrinkage, which is something we used to worry about a lot. You know, we looked at higher polymerization shrinkages. Now we're well under 2% on most products that are popular that are used today that are considered bulk fill. Second thing that's been done is our photo initiator system has become more aggressive. And so the average photo initiator system, the classical one we all think of, CQ, Camperquinone, is something that's still being used quite frequently, but has also had the intensity ratcheted up a bit to make these resin composites cure more aggressively because of the photo initiator system. Ivoclar incidentally uses... One of the only companies that uses a proprietary photo initiator system called Ivo Serene. So they're able to leverage that technology with some of their newer products. And then finally, they make these materials a little bit more translucent. Obviously, if you had a disc of composite, a four millimeter disc of A1 and a four millimeter disc of D4, which one of those is going to let more light do it? obviously the A1, right? And so we want a more translucent material that will allow that light to transmit all the way down to the floor of that four millimeter box. So that's really the ways that we have done it. And that tends to be what we see on the market today is our ability to play with that increment depth by increasing the translucence and by increasing the activity of the photo initiator and changing the monomer system to something. that causes a little less polymerization shrinkage than the traditional monomers that we used for many years. So at this point in time, the clinician should be pretty confident that they can get really good adaptation to the cavity prep with bulk fills today. They could use four millimeter increments confidently and get good polymerization, which is related to low postoperative sensitivity. So with this bulk fill technique, which is becoming more and more popular now, and using the right materials, What kind of advantages is the dental practice seeing from the standpoint of the patient, the clinician and profitability? Absolutely. I mean, to be honest with you, for most of us, patients don't want to be in our office. I don't care what we're doing. I don't care what kind of spa amenities we offer and the warm towels and the massage chair and the paraffin wax and hand treatments and all that stuff. They don't want to be there. They want to be in and out as quickly as possible. And so for us to be able to work efficiently and quickly. I'm not talking about rushing through a procedure and being sloppy. I'm just talking about working efficiently so as to minimize the amount of chair time that it takes. That's the number one thing. And when we look at all the data... it's, you know, we have a five-year randomized control trial out of Europe that shows that bulk fills have the same amount of success rate as incremental composites do, whether we're looking at Rosado's data on gap formation. There's lots of data that tells us that these perform equally well as incremental fill composites. And if we can do so... faster and more efficiently, it's better for the patient. And quite honestly, it's better for us. The only, you know, most of us who are on, like I'm on Delta. So I get a certain amount for a Kuzil Composita number three, right? It's 120 bucks, whatever it is. You know, they're not raising that rate. So if I want to stay as profitable as I was last year, where costs were a little bit less just based on inflation in the economy. The only option I have is to be more efficient in the hours I work. I can add hours. That's one option. Or I can be more efficient in the time that I do have. And I'd rather be more efficient than adding hours. Clinical dentistry is a beating. I don't want to do any more than eight hours a day. Well, let me ask you this. What you're saying all makes sense. Using the material and the technique that you've now adopted into your practice, your staff, your team, your assistants, they all understand how you do direct restorative composite dentistry. What are you currently doing to save you time? And how much are we talking about? Like how much chair side time are you actually shaving off here? Yeah, so there's really two ways that you can shave time by switching to... Number one is reducing the number of increments, right? Every increment we place takes a few seconds to place the increment, you know, 30 seconds to a minute to shape it depending on which increment it is and what the anatomy is and all that, give or take. And then our curing time, obviously. So if we can cut our increments in half, we cut maybe a minute and a half or two minutes on a procedure. The other way that we could reduce the time and our efficiency in our procedure is to reduce the amount of time that we cure. the restoration right when i was in dental school we used halogen lights do you remember those like lights that were like big boxes that sat on our counters and they had big fans and big huge cords and all that right and with halogen lights we had to cure for like 40 seconds and so then the advent of led curing lights came out now we could cure less time right we've kind of always had this barrier of like that 10 to 20 seconds right that's kind of where we've been floating around um you know since the led curing light came out Well, now that's one thing that we can kind of modify as well. There are now different curing lights and different systems that allow us to reduce the amount of curing time. So there was a meme that went around for a long time where it was like what my mom thinks I do, what my patients think I do, and what I really do. And like what my mom thinks I do is like Dr. House, you know, House MD, the TV show. Yeah, sure. I love that show. I do. Yeah. And it was like what patients think I do is like swiping their credit card or something like that. And what I really do, and it was just a picture of a bored dentist holding a curing light. Right. And I just think about the amount of time I've said in my life, just sitting and staring at the wall. as I'm holding a curing light on a tooth. And so we can reduce the amount of curing time we have, then we can reduce the intraoperative time and increase our efficiency. And so, you know, a couple of systems allow us to do that. One of those is the blue face power cure. They have a three second curing mode. So if you're using Adhese Universal. and you're using Tetric Power Fill and Tetric Power Flow restorative materials and the Blue Face Power Cure Light, your curing time goes down to three seconds, three seconds for the adhesive and then three seconds for your four millimeter increment. So that really starts to cut some time off. And so now we're talking two, two and a half minutes, three minutes of procedure or a restoration, you know, and that may not seem like that big a deal, but if you cut three minutes off of every composite you do for an entire year, That's serious stuff, right? I don't know if you've read the book Atomic Habits, right? Atomic Habits are like the little changes that we make that make a big difference in our lives. That's one of those atomic habits. So no doubt that's a huge time saver to reduce your curing time to three seconds from what is typically 20 seconds and 10 seconds and so forth is huge over time. I agree. Now there is something that our listeners should know that in order to get that three second cure, you need to use the blue phase power cure light. with the composite materials that are part of the ivachlor system, which is the tetric power fill and the tetric power flow. Exactly. Yeah. Which is not, it's not a bad thing. It's just, it's something that you can't buy that curing light and take it on any material that you currently use. And cure for three seconds. Right. But you probably could use it. You can use the curing light though, right? You just can't get three seconds. Absolutely. Okay. Yeah, just not in a three-second mode. Yeah, dentists love to think that they're Miles Davis and can just start improvising, you know, with whatever, like mix and match with this and that. Right. And the truth is, you know, that's fine. Like using an Imaclar light on. say uh you know 3m or dense fly composite will work just fine just not in that three second mode and the reason that is is because number one is there's a specific array of both violet and blue leds inside the curing light that are specifically made for the photo initiator system that is in the adhese and then in that tetrick power fill and tetrick power floor restoratives And in addition to that, there's a special monomer system inside those adhesives and that restorative material that is specifically made to be cured at three seconds at this very specific wavelength. So it's a system that's made to go together. Just out of curiosity, did you switch over to this system because of the time savings? Or what was the main impetus for your decision to use this as your go-to restorative material? Yeah. So, you know, when you try something like this, it's like, okay, well. Would I consider switching to a three second cure system like this if I hated the way the material handled? Obviously not, because then I don't know as if I'd save all that much time. I'd spend more time trying to shape the composite than I would saving the curing time. So it's got to be kind of all of it together. I like the way it looks. The Tetric Power Fill and Tetric Power Flow tend to opacify very well. So both materials in the beginning used to be pretty translucent. So if you had any darkness underneath that, the restorations would look gray when you were done. And these will pacify pretty well. So they look really good. The second thing is, is I do like the way it handles. It handles well. It's nice and creamy. It's not hard and waxy. And so it just handles well to my taste. And so I'm able to shape efficiently and then add that on top of the curing efficiency. And it's one of my routine go-to systems. I usually keep a few different composite systems in my office for different indications. And this is one that would oftentimes be one that I would pick up. So when it comes to direct restorative composite, many dentists use PACE systems. They also use flowable systems. At this point in time, do we need both in our practice? Yeah. You know, I think back to dental school, and I remember my dental school operative professor, my junior year of dental school, his name was Dave Overton. He's since passed away, but he was a tremendous educator. And this was back in like 2002. And so flowable composites had just kind of hit the market back then, and they were just crummy. They had high shrinkage. They had very low filler rate. They just weren't very strong and very good. And so he used to admonish us for wanting to use flowable anywhere. But God, these materials have changed so much since then. They're so much nicer. They have so much more filler. They're much stronger than they used to be. They have much less shrinkage. The original flowable composites used to shrink on 8%. Now these are shrinking at 1.6%. It's just totally changed. So I really like having flowable. and a paste together that can be used together, sometimes even within the same increment. So there are times that I need a flowable, right? Tiny little restoration, tiny little pit, hard to get paste into that. Sometimes it's way easier to get a flowable in there, right? Sometimes I need a liner that's a flowable, right? You're an endodontist, so I think you oftentimes encounter that around the floor of a chamber, you know, trying to get paste down in there just doesn't work very well. You really need a flowable to get in all those nooks and crannies. And in class twos, I really like to put a little dot of the flowable. I mean, just a small dot of a very small increment. And instead of curing right then, I go right to the paste. And so I use the flowable and the paste together in the same increment to make sure that we don't get any voids and that we fill everything. And oftentimes, a hydraulic pressure of the paste will push the flowable out of the preparation. And that's totally fine. If I waste that flowable, if I push it out and it ends up on my two by two on the scrap heap when we're done, I don't mind that. But anywhere where there's flowable left, it's probably a little area I would have had a void before. So using the two together, they're designed to be used together. They can even be cured together in the same increment. That's why I like having that flexibility. There's times where I use just flowable, times I just use just paste, and there's time when I use both of them together. And so having a flowable and a paste together really gives me that opportunity. to really take care of any indication that comes up. And that's what I like. It's really all about efficiency. It's a combination of a lot of things. Faster curing, bulk film materials, sectional matrices. The whole system works together. And the idea is to obviously cut chairside time, get the patient out sooner, because as you mentioned earlier in this podcast, no patient wants to sit in a dental chair longer than they have to. And it's just a matter of building more efficiencies into our everyday practice. Absolutely. I just think back to like when, when, you know, I don't know, 10 years, 12 years ago, how we would schedule patients for like a couple of class two composites, you know, be an hour at 40, 50. minutes to an hour in my in my practice and i'd be fighting toffle myers and placing all these increments trying to make sure i got a contact and now with the bulk fill systems that are are optimized and give me options like the tetra power fill and tetra power flow three second power cure system uh using segmental or sexual matrices um you know it's just really taken that time that now we schedule two class two composites for like 25 minutes 20 minutes so it's really cut off like half the time of that we get much more reliable contacts because the sexual matrices we get much better contours because of sexual matrices and when i can do these all in in one increment or or two at the most just makes these way easier we end up being able to shape the increments better so we adjusting the occlusions easier just everything's gotten way easier than it used to be And it's thanks to a lot of these manufacturers for making products that are based on problems that we have in our practice. I think all of us can identify with just the headache sometimes of direct restorative industry. It's hard. It's not easy. And so I'm glad that we have companies that are working to make our lives easier because there's a lot of other things in our lives that make it hard. All right, Dr. Austin. Pleasure to have you on the show. Thank you very much. We know how busy you are. Thanks for your time and look forward to having you on future podcasts. Thank you. Have a good one. If you've been enjoying our podcast, we'd love to hear your thoughts and feedback by leaving a review on your favorite podcast platform, whether it's Spotify, Apple, Google, or any other platform you listen on. Leaving a review is a fantastic way to support us and help others discover our show. Thanks for listening. See you next time.