Overcoming Sensitivity with Direct Restoratives and How to Use Silver Diamine Fluoride to Achieve Amazing Results!

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. In today's episode, we'll explore the science behind tooth sensitivity, dissect the various reasons why it occurs after restorative work, and arm you with the knowledge you need to navigate this common clinical challenge. We'll discuss strategies using glass ionomer for preventing postoperative sensitivity and silver diamine fluoride. for the use in arresting caries. Our expert today is Dr. Jeff Bruscia. Dr. Bruscia is currently an assistant professor at the University of the Pacific Dugoni School of Dentistry and is in private practice focusing on aesthetic and restorative dentistry in San Francisco, California. He is the 2011 recipient of the Gordon J. Christensen Recognition Lecturer Award and the 2021 recipient of the Goldstein-Burning-Bush Award for Excellence in Dental Education. In 2010, Dr. Bruscia was elected a fellow in the American Academy of Aesthetic Dentistry and presently serves as its president. Dr. Bruscia, thanks for being on the show. Excited to be here with you. Yeah, it's been a long time. We did some work on education many years ago and you've been on my radar, but for some reason you came up recently and I'm glad you did because there's no better person to talk to about glass ionomers and actually silver diamine fluoride for that matter. than you. So I'm excited to have this conversation. So to begin the podcast, when a dentist sends the patient home after a restorative procedure, there's always that possibility that the patient will experience some level of post-operative sensitivity. You know, nothing's perfect. We don't know what's going on on a microscopic level in the pulp. So even if you do everything right, there's still a possibility of the patient going home having post-op sensitivity. So I think it's our job to minimize that if possible. To begin, tell us what the main reasons why we have, generally speaking, postoperative sensitivity in the dental profession and what can be done to minimize it or even virtually eliminate it. Well, there's a loaded question. So being an endodontist yourself, we must always confirm that the tooth does not have any type of irreversible pulpitis. And so that's something that should be confirmed. very early on in the diagnosis before treatment. So assuming that the pulpal tissue is healthy, then we can make some assumptions that that sensitivity is reversible pulpitis. And then it brings to the podium two large areas of discussion. And you're going to have battles at the podium with one side of the podium saying, phosphoric acid for everything and and the other podium is going to be saying no phosphoric acid at least on the dentin and and i will tell you that that anybody that believes that phosphoric acid on dentin creates sensitivity uh is not uh has not mastered the proper adhesive technique I am a total etch person. I'm not saying that's the very best way to be. That's just a statement that I place phosphoric acid 100% of the time on dentin. And I've been in the same practice location now for 35 and a half years, seeing the same population of patients and not to ever. feel like i'm standing on a soapbox but sensitivity is just a non-issue in my practice it really doesn't exist and on those rare rare times that it might be an issue i know that it is not due to the adhesive interface the adhesive interface will cause the majority of sensitivity for most doctors. The only other issue could be a lateral interference. And so on that very rare occasion where a patient may come back with postoperative sensitivity on a crown, and I know that the adhesive interface was done to ideal, then I'll look for a lateral interference, I'll find it, I'll eliminate it, and the sensitivity is gone. But just to clarify, Dr. Bruscia, the adhesive interface may be the culprit as far as tooth sensitivity, but not if your technique is sound. Is that right? Correct. And that's what I'm going to take the deep dive into now. I have to eliminate the occlusal interference, which is extremely rare if you're always looking for occlusal interferences. But we do have patients with anterior open bites that will not have. anterior guidance. And then the shape and the anatomy that we place in our posterior teeth has to allow that guidance without an interference. So moving into the adhesive interface, there's the etch versus the no etch. And again, I think if technique is done well, that's not an issue. And I will support for any number of reasons, whether you elect to be a Total etch, or in today's world, a selective etch, because the chemistry currently available definitely is not acidic enough to achieve long-term bond strength to enamel without an etching pattern. So then you come down to the chemistry itself when you're looking at dentin bonding. And you have what I call simple chemistry and complex chemistry, and that's exactly opposite of what the audience will think. I think complex chemistry is the one-bottle systems. I think the simple chemistry is the multiple-bottle systems. But the manufacturers bring it to us in the exact opposite way. They tell us the simplified adhesives are the one-bottle systems, and the complex adhesives are the multiple-bottle systems. When you look at what you're trying to achieve with that chemistry, it's much, much more difficult to achieve the goals of that adhesive interface when the hydrophilic and hydrophobic materials are in the same bottle. Your technique has to be five times as good as it does when the bottles are separate. So anybody that knows me knows that I always speak and use separate bottles. And so when the bottles are separate, you're able to completely saturate that dentin with the primer. When you've saturated that dentin with the primer, you've resealed that dentin. And then the second bottle is your link between a hydrophilic tooth structure and a hydrophobic material. And that will achieve the highest density, most stable. what would be referred to as hybrid layer, that layer between your composite and your tooth structure. When the chemistry is all together, what I would call complex chemistry, it's more challenging, not impossible, but more challenging to get adequate primer to saturate that dentin because the adhesive is in the way. So we're not going to talk about the step-by-step techniques today, but understanding that Your technique has to be driven. by the goals and the goals are to saturate that dentin with adequate primer and then to seal with your resin. Bond strength is going to be critical when you look at sensitivity. So sensitivity for many people is a tug of war. Your bond strength versus your shrinkage stress of your composite. And if your bond strength is less than the shrinkage stress of your composite, it will open up a gap. And that gap will cause that sensitivity. So in reality, chair side, how difficult is it for the clinician to get a really acceptable prime against that dentin using a one bottle system? I will say it is much more difficult to achieve an acceptable saturation rate. When the primer is mixed with the adhesive, I choose to not use that. I know a number of lecturing key opinion leaders do. And so I would not want to say that they're not able to achieve acceptable levels. I will say that it is much more technique sensitive and much more technique driven. when the primer and adhesive is mixed. Is there any real study that shows that when using the single bottle technique versus the multi-bottle that you use, that in the single bottle, the primer is not reaching acceptable levels of activity, which in effect may result in tooth sensitivity? Not directly to sensitivity, but there's been hundreds of papers that look at bond strength. And what we were just going with was bond strength. Clearly, the adhesives with the highest long-term bond strength all have one thing in common. They are multiple bottle systems. And again, each one of these topics is an hour-long discussion. And I know we have this small window of opportunity, so I'm trying to give the cliff notes on it. So I'm just trying to pick the points. And then doctors that are struggling in each one of these points need to... up with an all-day program on these different areas. Which you give, by the way, and speaking to my audience, we're going to be giving some contact information on Dr. Bruscia’s training program at the end of this podcast. So if you have any questions or if you want to learn from someone who really understands what's going on in dentistry with these kinds of materials and getting the best results, there's no better person to talk to or learn from than Dr. Bruscia, and we'll be giving that contact information out at the end of the program. Well, thank you. That's nice. You know, one thing that I'm very proud of is I'm a full-time practicing dentist that sees patients eight to 10 hours a day, four to five days a week. And when this stuff works, dentistry is so much easier. I could not imagine doing dentistry when I was constantly struggling with problems. And post-operative sensitivity is something none of us want. I mean, that's just a... thing to have when you work so hard to make something look so beautiful. You restore the tooth. The patient's numb. They're thrilled when they walk out of their office because they don't feel anything. And then they go home and then they suffer from post-operative sensitivity. So continue on, Dr. Bruscia, because you were talking about getting into the bond strength and shrinkage issue. So again, many, many layers to this conversation, but bond strength is critical. So an adhesive that allows for higher bond strength will allow for greater shrinkage stress when you place the composite on. And we're getting into that if we have time. But if you have very low bond strength, then your shrinkage stress plays a much greater factor in forming a gap causing sensitivity. Chemical compatibility. You know, you have much greater challenges. with these complex chemistry systems when you get into dual cured, when you get into self-cured, when you're placing a buildup in there, when you're using any other type of initiator other than a light-driven initiator. And that's a whole different conversation. But these complex chemistry systems have a significant... with chemical compatibility when you start to change what you layer on top of it. So as this discussion evolves, a cliff note approach is what can dentists do? Well, you can learn the proper techniques. You can match your adhesives with your clinical needs. But there's a few simple things you can do to start off Monday morning. By after light curing your adhesive, lay a fingernail thickness of a flowable composite and light cure that. Using that basically is a second layer of adhesive, a hydrophobic layer. That's going to help a lot of patients. Something that's even easier than that is grab a glass ionomer, a glass ionomer liner placed over the horizontal floor. of every restoration. And for me, that's going to be the purple floor. And that glass liner liner can be in the form of a very thin material. I love the product Protect from Riva. Riva also has the only single dose glass ionomer adhesive. And that glass ionomer adhesive called Riva Bond can be really an incredible RMGI liner. You can use a good RMGI cement if you wanted to use as a liner. This goes directly on the Denton floor, the horizontal Denton floor. On the Denton floor. And so if I was using a glass ionomer, I would use that before I placed the adhesive. Right. That's what I was going to ask. Right. A blowable composite. I would use that after placing. Right. Because the glass ionomer. bonds with the dentin you don't need an adhesive correct correct right so that becomes just dentin replacement and you're you're kind of moving the pulp away from the interface a little bit further by layering that glass armor on i mean it's just relative you're doing so much more than that i mean we can call it a liner or a base but you are absorbing the stress when we talk about shrinkage stress The glass ionomer is going to absorb so much of the stress of that now curing adhesive because there's stress when your adhesive is curing and there's stress when your composite is curing. And so just looking at some bullet points with that first question you said, and I want to get to a couple of other areas. I think that's just looking, scratching the surface of that question. And what about the cytotoxicity of glass ionomer close to the pulp? So no material that has resin and even glass ionomer, pure glass ionomers that are relatively acidic should be placed within a half millimeter of pulpal tissue. We have some pretty incredible bioactive materials and we don't have time to get into that. That would be a whole nother program. When you look at the tricalc. calcium silicates, and like materials like that, they do have a place. But for me, I am less concerned about proximity to the pulp if my technique is very, very good, unless I have left some infected or affected dentin, or unless I have an exposure. And then my technique becomes very different and my material selection. becomes very different. And that's what I'm going to coerce you to do another podcast with me on because that's a very exciting topic to me as an endodontist and our audience always wants to hear about those cases that are very deep. And I've heard some dentists on podcasts where they actually know they're leaving infected dentin over. They know it, but they mentioned something about the Hall technique, which was something that was done on kids where they just... literally had to take care of these teeth quickly and they just put stainless steel crowns directly on top of decayed teeth and they came back whatever time later and there was the decay basically stopped uh and nothing went further on but anyway that's a whole nother discussion so discussion yeah so you covered you covered this really well dr brucha let's And you mentioned the importance of glasonomer. And there's so much that glasonomer does, obviously. It has strontium ions in it, and it enhances tooth remineralization and so forth. And we can talk about that on future podcasts. And you mentioned a product that you like, which everybody should take seriously because your recommendations go a long way. And I think that was Reva from SDI. Let's talk about silver diamine fluoride. Now, that is a material that's been used for decades in Japan, almost 100 years they've been using this in Japan. It got FDA approval in 2014 here, didn't really catch on tremendously fast in the States. But lately, we see more and more dentists using silver diamine fluoride. So could you talk about the uses and indications for this material? a wide open topic. You know, silver diamine fluoride, I will have to just reference my father because my father was 106 and just passed away in May. But he was a dentist that started practicing dentistry in 1946. And when he saw the silver diamine fluoride cover from the American Dental Association, that I believe in 2013, 2014, it received FDA approval. He started just with a gut laugh because he was using silver nitrate back in the 50s and 60s to arrest decay. So this whole thought is much, much older than most people realize and has been around for a long time. So the FDA is now allowing us on label. to use as a desensitizer? Well, for me, sensitivity really, as we talked about, falls into adhesive techniques. And I'm not going to really need a silver diamine fluoride product as a desensitizer. But off-label, silver diamine fluoride can treat active decay. And so now we get into why would we want to use a product like silver diamine fluoride? to treat active decay off label. And so pediatric dentistry. So one thing I don't see, I don't see any children. I don't see any patients under the age of 16 to 18. But if I were, and one of the main reasons that I don't treat children is... lack of skills in managing children. And so I would say working on a child is like changing a tire on a car that's moving and near impossible. And so silver diamine fluoride creates an opportunity where you may have a very unmanageable environment and you can simply buy time for that child without an aggressive medical approach to that. For my practice, it's adults and it's the older adults. And so I use silver diamine fluoride as a management, a triage. Sometimes it's long-term treatment with nothing other than silver diamine fluoride. Sometimes it's... managing spotting a deep area at a hygiene appointment, knowing that I'm not going to be able to get that patient back in my schedule on the restorative side for three or four weeks. So myself or my hygienist placing some silver diamine fluoride to arrest that decay. And then I can come back in and do definitive treatment. For my long-term triage, we have older patients and my dad being one of those patients for the last eight years where I was managing his. older dentition with silver diamine fluoride and then an anti-caries management pH control protocol. And so that's so important. Looking again at complex and simple. So right now I do believe we have two forms of silver diamine fluoride. We have one bottle and we have two bottles. They're very, very different. One of the big Yellow or red flags with SDF is going to be silver discoloration. Well, that silver discoloration can be managed with one of the two products much better than the other. The application time and technique is very different. remove of loose debris, you've got to place a one minute application of the one bottle system. In the two bottle system that has the potassium iodine in it, it's a rapid one drop of bottle number one. And then if triaging an area, it's a one drop of bottle number two without scrubbing. And you have provided an environment that now creates a much stronger bacterial shield. You are doubling the level of fluoride and you are sealing that environment. In fact, I'll take it one step further. If you were to do a 15 second phosphoric etch, as Dr. Knight has written about in several of his papers, you'll get even better bacterial seal with the two-bottle system. If you want to incorporate silver diamine fluoride in with a restorative procedure, then the only difference in my technique, per articles that Dr. Knight has written, is you continue rubbing the second bottle into the precipitate. The white precipitate is gone. And then you move to like a RMGI adhesive, like a Reva bond. I've done both ways. I've done triage care that's worked incredibly well. I've done long-term triage care. And then I've incorporated silver diamine fluoride in with the sandwich technique of glass animals and composites, sometimes a mix of it. Something that I'll do for some patients is when I'm getting this 360 root decay that's very difficult to manage and they have a crown on that tooth, sometimes I'll remove that crown and make a temporary crown like using a Luxa crown from DMG, which is a much more rigid, stronger crown. But then I'll cement that crown on with RMGI. I'll use my Reva Looting Plus. That becomes my definitive restoration. If I know that environment is unmanageable, now that procedure is going to cost the patient about one third, one fourth as much as a permanent crown. And now I have the opportunity every two, three, four years to take that crown off. If there is more 360 decay, make another one. And now I can go in and make a almost. replaceable crown. And I can do that over a series of nine to 12 years for what many dentists would charge for one permanent crown. What I've learned is root decay is not specific to anything. It will find a new crown. It will find a 40-year-old crown. It will find unrestored tooth structure. Those DMG crowns that you mentioned are super useful. They're relatively new. And I've heard a lot of doctors talk about those DMG crowns. And some of them say they've had them in for over five years and they look like new. I've got bridges that for the same reason that are in five years and doing well. Yeah, it's a great product. I'm really glad they came out with that. So this is really kind of exciting to hear that you could use. silver diamine fluoride for these kinds of cases where otherwise the tooth might have been extracted. And let me ask you this, over time, when you're using silver diamine fluoride for a long-term triage, how often do you have to rejuvenate that SDF with another application? So I really think it's product dependent. I will tell you from what I have read that The two-bottle system is going to be my preference. And I am finding that the two-bottle system is working so well that when I'm using it in triage, the protocol is basically reapplying, if needed, every six months. Okay. Who sells that? Is that SDI? Is that the Australian company, SDI? Yes. The Rebistar is the SDFKI product. And again, that has a very different application technique. You must align your application technique with your product. But if you're looking for the most rapid application technique, the SDFKI product, RevaStar, actually has a much shorter application time for a better result. Throw in some phosphoric acid for 15 seconds on the dentin, and that takes it to a different level. So even with a 15-second phosphoric acid, with the two-bottle system, my application time is still 30, 45 seconds. With the one-bottle system, my application time is a minute minimum. Right. And with the growing demographic of geriatric patients and root decay, like you said, it doesn't really discriminate. Where it's going to attack, whether it's a crown that's been put in or a major roundhouse or whatever, it's just going to go after the root, no matter what kind of restorations on there or how good it is. And this kind of treatment is really invaluable, really invaluable. Yeah. And I must say that if you're following the triage technique with the two bottle system, if you do not continue to. rub the KI bottle material until that white precipitate does form, you will see discoloration. But you will get a better seal in an open, exposed area if you leave that white precipitate there and not continue to massage it. So if I were doing my SDF application as part of a definitive restoration, I would place my second bottle and rub and reapply until the white precipitate was gone. That's going to greatly lower the risk of silver discoloration. The use of phosphoric acid is going to greatly reduce the risk of... of silver discoloration with the two bottle system. That's never been tested with the one bottle system. If I'm truly looking for triage and want a better bacterial shield in an open cavitated area, then I would simply place one application of the of the ki leave that white precipitate and not wash off the let that patient go home with that white precipitate so two very different techniques aligned with what my definitive treatment is this has been very helpful dr brusher tell us where our audience can get a hold of you uh through email or a website if they want to get some additional training so uh i'm still Relatively active on the large dental meetings, be it Henman this coming year. I think I'm going to be at ADA next year, California Dental Association. So I'm still doing some of the larger meetings, but those are very intense lecture programs only. I have had a study club. Many people may be aware of it, FACE, Foundation for Advanced Continuing Education. that was founded back in 1974 by my mentor. And so if you go on to the aesthetic professional site, face dentistry.org, just Google face dentistry and face dentistry.org will pull up. And then there's some contact information for me there. The face study club is a much more intense. minimum five-day program, but that's really the very, very best way to take a deep dive in all of this. Even in my all-day lectures, I still can just scratch the surface as we get into some of the more advanced areas. An excellent dentist has to be well-trained, not only in all the areas that we've talked about, but occlusion and so many other factors are so important for the long-term success of our restorative dentistry. And it can be a little overwhelming when you realize how many things you do not know. But dental school makes us all safe beginners. We hope we are safe beginners when we come out of dental school. And then it's a journey. I've been out of dental school 35 and a half years. And I just took a five-day hands-on program with Pascal Meunier, a good friend of mine. And I wanted to see what Pascal was now teaching. And there's a perfect example of someone that's been practicing 35 and a half years, been teaching most of those years. And I still want to take a deep dive into continuing education. And the way that I want to learn is in a small group. And I want to learn in a hands-on environment. I want to learn where I can interact with that instructor over multiple days and develop a friendship with those people. Just in closing, your father lived till 106. Did he practice dentistry until when? He graduated from dental school in 1944, was practicing in the Army for two years, opened up. His practice in San Francisco in 1946 with my mom and they continued to practice together until 1992. So I graduated in 1988 and we got to practice for four years together before I bought a computer and scared him away. Yeah, there you go. Yeah, unbelievable. 106 years old he lived to. That's remarkable. You got a whole long... career ahead of you, Dr. Bruscia. Dr. Bruscia, thank you so much for being on the show. Incredible amount of information you've packed in in these past 30 minutes. Have a great week and thank you again for your time. Great. Thank you. If you're enjoying our podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.