The Latest in Composite Dentistry: Universal Composites, Bonding & Clinical Pearls

Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. Composite dentistry has changed dramatically over the past decade. We've gone from stocking dozens of shades and multiple classes of composites to universal composites, simplified adhesive systems, and new techniques that promise better results with less complexity. That all sounds great. But are these advances really changing the way we practice? Is one universal composite enough for most clinical situations? And does composite warming actually improve outcomes? And could something as simple as your curing technique be the difference between a restoration that lasts for years or one that fails prematurely? Joining us today is Dr. John Zalesky, who divides his time between private practice and teaching as a part-time faculty member at the University of Colorado School of Dental Medicine. He'll help us separate the science from the marketing, as we discuss today's restorative materials, the evolution of universal adhesives and selective etching, and why Bisco's new Quantium Universal composite is generating so much attention. and the practical techniques that can help every clinician create stronger, more aesthetic, and longer-lasting restorations. So if you're looking to simplify your composite restorative workflow without sacrificing quality, you won't want to miss this conversation. Before we get started, I'd like to thank all of you for tuning in. If you're enjoying the show, please follow us on Apple Podcasts and Spotify, and even better, leave a review. By doing so, you're not only showing support for what we do here, but your reviews are instrumental in getting more dental professionals to listen and benefit from our content. We really do appreciate it. Dr. Zalesky, welcome to the show. Thank you. Thanks for having me, Dr. Klein. Yeah, very happy that you're joining us. And we talked offline, and I'm talking to the audience now, that Dr. Zalesky attended NOVA. What's the full name? NOVA Southeastern Dental School? Is that what it's called? NOVA Southeastern University. Yeah, and the founder of that school was an endodontist. His name was Dr. Cy Oliot, who taught me at Penn. He actually was very instrumental in teaching a surgical. techniques. Amazing guy. And he was instrumental in getting accreditation for that school. So that was before your time there for sure. Getting into composites. You do a lot of very advanced dentistry. You do implants and surgical cases, but the bread and butter of a lot of what we do certainly is direct restorative. And we need to understand what our options are. Now in the past 10 to 15 years, we've seen a lot of changes. A lot of innovation in composite materials. And I'm talking about microfills, microhybrids, nanofills. And then, of course, we had bulk fills where you can cure four millimeters or so. And then flowables, you know, and now we have universal composites. And then, of course, even back in the day, we had entire shade kits for aesthetic layering. And you're laughing, I know, because it was in... amount of materials that came in these boxes. I don't know how the dentist did it back then. So a lot's changed. So based on where we are now, Dr. Zalesky, how do you determine in your clinical work, which class of composite is best for a specific situation? Or are most of us going straight to a universal? I think it's very interesting as much as dentistry or so much in dentistry that has not changed over the years. There's so much that has changed in the field of materials, adhesives, biologics, things like that, that we use every day. And you mentioned that we've gone from, you know, all these composites with shade guides and, you know, there's some composites that are still on the market that have, you know, 30 different shades. And now I think what we're trying to do. as a field in dentistry is that kind of simplify things and make things easier for us to determine a shade now a lot of these companies are going to universal composites to diminish the amount of overhead and shades in the past we had a bunch of shades you got with the composite that You used A1, A2, a lot of people used them, and then you had D shades and high A shades that nobody used and they sat and expired. What I think they're trying to do is group things into kind of a generality of shades that will encompass when patients come through the door, but the ability to then take those shades and have a body and enamel to blend. I think is becoming more and more common. It's simplifying the workflow and we're also getting a better material, better results aesthetically with just a condensed armamentarium. Yeah. Now I'm not a restorative dentist, but I would think that A2, A3 covers 90% of your patients. I want to say it's around 85 to 90%. Yes. Right. It's not bad for an endodontist, right? So having that A2, A3 shade, range in the systems that they're coming out with. And it covers such a large swath of your patients. When you think about it, what's the return on investment by having all of this other inventory that you use for such a small number of people? So are you using primarily universal now, a universal composite? Yes, I am primarily using a universal composite now. for the fact that they're able to blend so well and i use characterization in my uh particularly anterior composites as people come in and nothing is a straight shade so you kind of have to use a mix for incisal edges for cervical areas things like that now there is you know other composites on the market that is a one shade fits all and i've found that you know in some situations it's fine in other situations depending on what the surrounding tooth structure is it's just it doesn't blend well and it doesn't look aesthetic long term um because it just you have so many different shades you have Depending how deep a cavity is or what tooth structure is missing, you can't really use that material on a class 4 restoration because the dark hue from the throat shows through and it just looks like a dark triangle that you're adding on to a central incisor or something like that. So I've found that blending these universal composites really gives an aesthetic good result in the end where it's sometimes hard to delineate between the tooth structure. And this composite material. Now, do you use a cutback technique at all where you fill with the universal composite, cure it, and then cut it back and then do your characterization? I can do it a number of different ways. Yes, I have done that. I've also done, we're using a putty matrix, particularly for anterior, making a shell with enamel, using some darker shades to make sure we have the characterization that we need. It depends on what your skill and ability is to do that. Sometimes a cutback is a little easier depending on the size of it. So it all really depends case -to-case basis on what I'm really intending to get out of it for a finished result. To make the putty matrix, do you do a digital wax up? I can do it two different ways. Depends if I have... the ability to do a digital wax up or I can 3D print that rather quickly in office. Another way to do it is I've taken composite that shades that are not common that I don't use or are you know expired and I'll use those to kind of roughly build up the area I'm looking to fix make a putty matrix and then go about my restoration. with the proper shades. That is a great way to use expired composite. You go into that composite drawer and pull out a whole bunch of those corpules that you haven't used for years. Correct. Yeah, that's an excellent way to use that. Let's talk about the latest in adhesive dentistry. And of course, adhesive dentistry has changed the way we approach restorative dentistry in so many ways. You graduated dental school when? What year? 2014. 2014. Okay. So it's 2026. So you've been out 12 years. How has your restorative dentistry changed based on the different generations of adhesive bonding systems that you've used? And tell us where we are now and how are you doing it? When dental adhesives in general are really the backbone of our modern restorative dentistry and they determine our strength. our marginal integrity, and the long-term success of our restorations. So it's transformed our care by allowing us to practice minimally invasive dentistry. We now have the ability to have this adhesive that is super strong instead of the mechanical retention. So this gives us long-lasting conservative biomimetic restorations. When I went into residency, they had 3M Filtek. And then I went out in private practice, 3M Filtec. It was the big, best composite that you could get. Again, it came in a ton of different shades, most majority of which you didn't use. Adhesive-wise, went through a couple generations, but I kind of stuck with a sixth generation adhesive because it was the most, at the time, universal adhesive. You could use it in any situation. Now we've kind of gone to a we've changed etching techniques. Things are really going to selective etch because of hybrid layers and things like that. But it also allows our adhesive to really penetrate into tubules, get a good bond with our composite restoration. So we've gone to kind of eighth generation adhesives now. So with selective etch, from what I understand, you are preparing the enamel. with phosphoric acid so you can really get those strong resin tags, which we know from years of experience is incredibly retentive and reliable. But the issue is by having that phosphoric acid on the dentin, you can over etch. And by over etching, you're demineralizing some of that inorganic material that you would actually want there for the MDP to bond to because you do get a chemical bond between. you know, one part of that chain of the polymer inside that self-adhesive material, that universal adhesive, which is self-etching. So are you strictly now selective etch and universal adhesive? Yes. Are you finding less post-operative sensitivity because of that? A hundred percent. Less post-op sensitivity is the number one thing. And it was interesting when, you know, it was a beginning clinician, you'd get, do a... class two and you get a patient back and it's like you know i have temperature sensitivity and cold and it's really bothering me and you check the bite and you're like man i can't figure this out and the bite looks good and well give it some time and you know the patient comes back and they're upset because their tooth still hurts and it didn't bother them before you drilled on it and you know switching etching techniques to now selective etch it is night and day night and day come back right yeah because you just those sensitivities yeah you're just treating the dentin in a way where it's a more gentle etching process and the result is doing it that way you're getting a really good hybrid layer uh integration and uh and post-operative pain in many cases is virtually eliminated or at least drastically reduced yep so let's talk about a newer universal composite now i know Bisco has a relatively new composite. It's not brand new, but it's been out a little while. And I talked to you about Quantium. Why is this material getting so much attention when it comes to a universal composite? What makes it different? It is suitable for all restorations, but it has some characteristics that really set it apart from other materials. We've gone into nanofillers as a really good composite with great polishability. It's strong. um but what they've done is they've taken these nano fillers they've cured them crushed them um again smaller particles so we end up with what we call an aggregate filler so it's very different size particles each particle is a different size so what that allows for is we have um higher filler loading with smaller filler particles so it allows it to be better polished and it reduces the shrinkage there's not as much shrinkage as other composites so in posterior it gives us great strength very little shrinkage very little micro leakage because it's meeting the cable surface margin very well in the anterior we have amazing polishability it's resistant to staining and the shade match they've kind of condensed again like we mentioned earlier into kind of a smaller amount of shades that we have between body and enamel, which really give it a balanced formulation that we can use. What are the shades? We have A1, A2, A3, three and a half. Then we have B1, B2, and bleach. Okay, so there's some body shades in there for the dentists. Yes, correct. There's seven body shades. Then we have seven enamel shades. but they're all in the same A1. You have A1 body, A1 enamel, A2 body, A2 enamel. So again, probably the most commonly used are going to be the A2, A3. Yes. You know, A2 body, A2 enamel and so forth. A3 body, A3 enamel. The only real difference between them is that the enamel is a little more translucent of a shade. And A2 is obviously has a higher value than A3. Correct. Yeah. That's interesting. Now, what about the handling of it? The handling now I have in my office, I have a bunch of different composites because I get stuff to test. And there's been some other companies that come out with universal composites and the handling is it sticks to instruments and it pulls and it sticks to, you know, tooth that doesn't stay in one spot. I have found this handling to be the most elite, best handling of a composite I have used in my career. It stays where you want it to stay. It doesn't slump. It doesn't stick to instruments at all. So you're not having to use like a wedding resin at all for this composite. And that's without composite warming. When I add composite warming into it, it just, I love working with this stuff. You get to a point where, you know, doing composites sometimes can be monotonous. Like how many more class twos can I do in a week? No, that's true. Absolutely. This has made it fun again. I really enjoy working with this material. Yeah. And you've been practicing 12 years. How many different systems do you think you've tried? You started with 3M. Right. It's got to be in the 10 to 12 different components. So you found out about Bisco from being a tester? No, I found out about Bisco from college. of mine that, you know, like the composite, I used Bisco for some of their other cement products for crowns and things like that. And this came out, I was like, really want to try it. When stuff comes out, I'll try it, but I tend to work with it on a model first. I don't implement it right away. It's the same with like my iPhone. I wait for stuff to be worked out before I update it. Because I want to see some feedback first before I'm into it. I own my own practice before I'm into it for a bunch of, you know, redoing stuff that I, you know. Oh, absolutely. Yeah. And by the way, when it comes to downloading updates on my iPhone, it terrifies me because the last time I did that, my phone was running perfectly. And it was as slow as a sick donkey when that thing got downloaded. I mean, that thing just, I couldn't get any websites. I couldn't get my email. And then I found out from friends of mine that they also downloaded that. That was in the day where they were actually caught having you install stuff purposely compromising and sabotaging the phone. I mean, we don't really own our own phones. They own it. We just get to use it. We think we own it, but without Apple, if you're using an Apple phone, what good is it? No, but that's interesting. So you do it on models. And then when do you decide to go on your first patient and use a new composite? Case by case, I'll work with it on models first. You know, I talked to some of my colleagues that are also using it, what they've, you know, experienced and how they feel about it. And then I'll, you know, use it in a class two or something simple, class five, and see how we do. And I'll really do, you know, a couple cases. and see how it goes. Do I get stuff that's debonding? Do I, you know, have things that something pops off the anterior or I get leakage or something like that? I'll just look for kind of scenarios where it didn't work and I just haven't run into it with this. Now, do you think general dentists are reluctant to switch to a new composite for many reasons? I mean, it's human nature when you're used to doing something and you're getting success with it. Why switch? Why fix something that's not broken? That's a good point. The workflow in the office is all set up. The assistants know the products. The dentists know what to expect. So I think a lot of dentists, and correct me if I'm wrong, I'd like to hear your perspective on it, Dr. Zalesky, about changing this restorative material because this is a big part of what GPs do. Correct. I think it's twofold. I think the longer you're in practice, the more reluctant you are to change things unless it's like really going to change how you do a procedure. If it's really going to make a difference. Because if something works good in your hands, that's awesome. I'd stick with it. This composite may work well for me. It may not work well for others. That's like that for any material that we use or technique. It's also technique sensitive. Some people don't want to change their techniques and do self etch or total etch and they want to stick with that. They've had good results. Great. Are there better ways to do it out there? Yes. But if that works for you, fine. A lot of younger docs coming out, I notice that they go into an office and I was guilty of this. And this is the materials that we're using in this office or a DSO. You have no say in what materials you want to use. So you're stuck using those. So I think it's a combination of those two things. I don't know. Maybe I'm different, but I'm always open to providing the best care and offering the best materials to my patients. Sometimes does that come back and bite me because it's more overhead? It's more... you know, something like that. Yes, but I want my dentistry to last. I don't want a patient to come back and I want something to look good. My name's on it. If the patient moves and goes to another office, I mean, I've complimented people on dentistry before. I would appreciate that if, you know, someone moved to Austin, Texas and we're like, wow, you know, whoever did this. composite did a really nice job, but that's how I operate. A lot of people are just in it for the number. How quick can I get in, do the procedure, get out. I don't care about blending. I don't care about that sort of thing. So, you know, everyone's different. Yeah. And also what's really interesting is that you said that you're having more fun now doing this. What's fun about this material? Some other materials that I've used have just not been easy to manipulate and, you know, you end up taking a band off or you find a void or you know something comes off and this has been so easy to adapt and layer from anterior to posterior with you know great contacts between teeth particularly in class twos it's just made it easier i'm actually probably more efficient using this material than others just because of the ease of use and less you know post-op Yeah. I mean, when you said it was more fun, it's interesting because I mentioned this on a previous show, maybe it was about a year ago, that I'm a tennis player. And for a long time, I had these rackets and I used them for decades. And we knew how to string them. We have a stringer in our house because we break strings all the time. But we finally switched to a Yonex. And I actually told my son, I said, you know, I'm having more fun playing tennis now. I was going through a period of time where I don't know whether I just was feeling like I was getting too old to play this sport. But now the tennis racket, there's no question the racket has improved my game. People will say, no, it's not the racket, it's the player, but it's both. And I think in dentistry, it's the same thing. When you're using equipment, materials, whatever you're using, if you're using loops and you're seeing things at eight and a half X, all of a sudden you're seeing things in a whole nother light. And it's like. I'm starting to enjoy this profession. You did mention something about warming, and I do want to touch on that. Warming composites has been getting some more attention. And one of the reasons, obviously, is that you're going to get better adaptation. Correct. Do you use warming with this composite? And what's your feeling about warming composite as a direct restorative? It's an interesting question you asked. This composite was actually formulated to be used with a warmer. You don't have to, but... alters the physical properties. I'll never forget, in residency, my assistant always put the composite carpules up on the overhead light, and it really changed the material. Now, that light gets searing hot, way hotter than what a composite warmer gets material to. What it does is it increases the kinetic energy and we have a greater movement of the material. And the heated composites also have a greater monomer conversion and depth of cure. So it doesn't turn it into a flowable, but it makes it more flowable-like. So it allows you to adapt into a deeper... uh preparation as compared with a composite at room temperature so what does that mean you're going to get better adaptation at the cavo surface margin you're not going to get voids or bubbles and things like that and it also decreases the ability of a filling to have micro leakage if we had those voids do they sell a warmer with it or do you have to buy that separately no the warmers are sold separately um There's a bunch of different companies that make the warmers, but I have found Adent makes a warmer that warms the composite carpules. It has an attachment on there that holds everything. So you can put your composite gun in there that warms it. You can also put your carpules. flowable syringes instruments in there to heat so everything is warmed now the interesting part is when you warm something you have to be a little efficient and and kind of move a little bit because two minutes after removal from the warming source that we start to see the material go back to its original state so it loses heat quickly so the most ideal time is right after you take it out of the warmer right to the mouth to use it You're able to still form it and put your anatomy and things like that in it. And again, it will not stick to the instruments. So just the benefits of warming in general with, like I mentioned, increased depth of cure, surface hardness. All that is really beneficial for warming. Now, a lot of stuff is going now towards injection molding for composites, particularly in anterior cases. There's some really good systems out there for that, and this makes that even easier to do because it's a more flowable material into these matrices that we can do injection molding. Yeah, for sure. That is gaining popularity. Now, curing, curing without a doubt is an important part of composite restorative dentistry. What are the most common curing mistakes? Now, I know you teach at this dental school in Colorado. What do you teach your students about curing and what they should be aware of and what they should avoid doing? So the first thing to do is, and we're all probably guilty of this at some point, is one of the most important things is calibration of the curing light. You could have the best curing light on the market if it's not calibrated or it's older. You're not going to get the depth of cure of material. You may end up with a soggy bottom in a class two where it's not completely cured. So checking that's A number one. The amount of time. Some people go in and, you know, we have all these curing lights at one second, 20 second times. You have to follow the usage recommendations for that curing light. You go to some offices, they may not have that. Or the assistant's like, well, you have different lights in different rooms. Well, that one's 10 seconds. The one in room two is 20 seconds. And they're not applying the correct time for that curing light to the restoration. And not curing from every side. Even a class two, I take the band off. I cure from the buckle, the lingual, occlusal again. Make sure that every side is covered. So you want to make sure you're getting good depth of cure. The curing time is right. You want to diminish your shrinkage, your debonding, and make sure that, you know, the degree of conversion is also important. One of the other things too is the system puts a curing light in and they look away or are moving something and now the curing light is moved all over the tooth and it's away from the material you have. And that can also lead to a lot of issues also. So again, fillings are probably the, and composites are probably the most technique sensitive things that we do. Because there's so many little steps that have to be done properly to get a good result. Yeah, there's no doubt about it, including isolation. Correct. Yeah. I mean, isolation. I mentioned this also on several programs that Dr. Nate Lawson, who's a PhD in biomaterials out of, you know who that is. Yeah, he publishes a lot. He's pretty active on social media and he did a poll and 40%, only 40% of the dentists. were using rubber dam, and the other 60% said they didn't use it because it was inconvenient. Then I talked to some dentists on this show, and they cannot do without a rubber dam. I mean, they just can't. They do everything with a rubber dam. And as an endodontist, of course, I did. It's crazy not to if you're doing root canal. But again, a lot of restorative dentists. or just using cotton rolls and those things that go in the cheek. You can hear an endodontist talking. You say cotton, I got to say cotton pellet. There's no such thing as a cotton roll in endodontics. It's a cotton pellet. But I also think that part of not using a rubber dam is, one, a lot of people have a tough time figuring it out and putting it on properly. The other thing is, I think people look at it as time and because they're not good at it, it's taking more time. It's increasing their chair time and they, they have to roll. Right. Yeah. I mean, that's, that's that mentality though, that, that, that's not a good way of thinking when you're, when you're practicing dentistry, because that will come back and bite you every time if you get contamination. So as we're wrapping up this podcast, I want to ask you about building the ideal restorative armamentarium from scratch for the young dentists out there. who may be off the formulary of a DSO and they have the ability to order whatever they want, what materials and instruments would be at the top of your list? At the top would be a composite warmer. After using it, I don't think I'd go back to not warming my composites. There's just too many benefits to using it. I would get some great composite instruments. I use mine from Power Dental. They make a great number of instruments in general, but their composite instruments are very nice, easy to handle, comfortable. A polishing system is also great. I use the Kois Universal polishers. Ultradent makes a nice Jiffy system. Softlex discs I use a lot on the anterior. And make sure you have a quality curing light. Another big thing that I use are brushes. So particularly if you want to get good characterization on anterior for texture and things like that. But also when I'm applying my adhesive. There's a study that's coming out and I think Marcus Blatz has published something where they went through a bunch of different micro brushes. and regular brushes and like rubber tip micro brushes and it was astonishing to me to find how much of the traditional micro brush the particles of the brush actually come off the brush during the application of adhesive and really affects the bond and it was not really found with traditional like your you know watercolor brush benda brushes that we have The other big thing I like is I've converted everything over my office to electric hand pieces. This allows me to really control the speed and RPM, whether I'm polishing and things and not creating too much heat as opposed to air -driven things. When it comes to the composite that you're using, again, you have to use something that's comfortable and what you like to use. Everyone's different. I'm just recommending what I have found to work great in my hands with a great result, not only for posterior but anterior composites. And, you know, I think be open to change. Yeah, and I think that keeps the manufacturers on their toes. I mean, you're using Quantium, but if someone else sends you something to test and you think it's better. you might do some work on a model and eventually integrate that into your practice. Correct. I do have other composite systems. I do have other composite systems. And it's interesting, even though these are universal condensed shade composite systems, I have run into situations where I don't have the right shade and I've gone to a different manufacturer of composite and that has worked. It's the nature of dentistry. Right. You got to be open-minded. I like the fact that you recommended electric handpieces because what I'm hearing out there is just remarkable feedback on the newer electric handpieces. that are smaller, lighter. Yes. They have, you know, back in the day, they were very difficult and unwieldy when it comes to getting in the posterior part with these big heads, you can't see anything. And that game has changed now. I mean, it's a different world now with electric handpieces. That's great that you're using that. And I think that once a doctor starts using an electric handpiece, I don't want to mention any company names, but I know a couple that people just love them. So, I mean- I used to have a pedo handpiece. Because you get in a situation, particularly in an upper second molar, that you couldn't get the head of the handpiece back there, depending on the patient's anatomy from the coronary process when they open. And I had to switch to that. You could mention which electric handpiece. I don't want to endorse anything, but you can. I have NSK handpieces. That's actually the one, now that you mentioned it, that's the one that the last two doctors that I spoke to recommended NSK. Yeah. Apparently there's something to that company's handpiece because practitioners are loving it. They're selling them off the shelf. They have had extremely little maintenance. Yeah. There's an eye care system that goes with that, that apparently you just drop those babies in there and close the door and push the button in one minute. They're like purged, lubed, ready to go. Yeah. So that's the thing. I mean, you know, as human beings, it's human nature to buy things based on price to some extent. to some extent. You know, you don't want to overpay for anything. But when it comes to dentistry, especially the product, you're putting this in someone's tooth, which is being beat up on by chewing saliva. I mean, you know, that's not an easy ride that these composites take in a patient's mouth, even under good conditions. For that to last 10 years, If you can get a composite to last 10 years and yours may be going longer. There are some dentists that say they can get 15 years out of their composites. Insurance companies will replace a composite if you do accept insurance in five to seven years. But I think it's getting to the point where if your technique is really dialed in and all the variables that you're talking about are attentively performed, I think that... the materials like quantum and other universal composites out there, it's a different world now. You know, we're getting some really good longevity out of these composite restoratives. And don't get me wrong. I do have failures. We all have failures. So I'm not going to sit here and tell you that, you know, every filling is last forever. You still have, there's still, you know, one variable with any dental work that you do, and it's the patient, their home care, what they're eating. what they're using their teeth to to do extracurricularly you know opening bags and whatnot that way so there's so many variables that go into a long lasting restoration and i think the least you can do is is follow the protocols and not take shortcuts and take your time doing it, knowing that the patient walked out the door with that's the best you could do with the best materials in your hands. Outside of that, if something happens, it's kind of out of your control. Yeah. And what you said, your name is on it. And if someone moves from, you're in Colorado, if someone moves to Austin, Texas and comes to a dentist here and the dentist is looking in their mouth and seeing some beautiful dentistry, your name is on it and vice versa. We don't want that. Yeah. Dr. Zalesky, great conversation and really appreciate your candor. And you basically gave us a lot of clinical pearls here. And I think especially the younger dentists could benefit from this conversation in many ways. Have a very good night and thank you very much. You too. Thanks, Phil