Deep Preps, No Worries: Pulp Protection Techniques That Deliver

Read the little slip that comes with it. Follow that protocol. If it says 15 seconds, trust me, it's 15 seconds. It's not 3 or 30, it's 15. I mean, they've really done the research to say this is the quickest, best, most efficient way that this material will work. Welcome to the Phil Klein Dental Podcast. We've all faced those deep cavity preparations where we know we're very close to the pulp. And it goes without saying, we all want to avoid postoperative sensitivity. or even worse, a blow-up that results in an emergency endodontic procedure. So the question is, what can we do as clinicians to best protect the pulp and prevent endocomplications? In this episode, we'll explore evidence-based strategies for pulp protection, discuss when and how to use liners, and break down adhesive dentistry protocols that can significantly reduce the risk of post-op sensitivity. We'll also briefly address the procedure known as the deep margin elevation. Joining us is Dr. Scott Coleman, a general dentist who has practiced in Houston, Texas for over 40 years. He's a graduate of UT Dental School in Houston. Dr. Coleman is a respected key opinion leader, sought-after speaker, and past president of the Academy of General Dentistry. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases, and our entire production team will really appreciate it. Dr. Coleman, it's a pleasure to have you on the show. Thanks, Dr. Klein. It's always a pleasure to be with you. Yeah, and again, we talked offline before this episode started, and I reminded you that we did a podcast in 2018 together. We have not done one since. But I think it was probably 20 episodes in when we did our episode. And now we're almost 700 episodes. So you're still doing your thing and I'm still doing my thing. There you go. And by the way, I want to tell our audience, Dr. Coleman has been practicing. He just celebrated his 41st year of private practice in Houston, Texas, which is amazing. And we will definitely do a series of podcast episodes. with Dr. Coleman to find out what his secret sauce is. How did he successfully continue to practice with such enthusiasm where he still does not want to retire? And he looks good to me. He looks pretty young. So I know you can't see him because this is audio only, but we'll cover that in a future program. So today we're going to be talking about pulpit protection, which is specific interest to me because I'm a retired endodontist. When it comes to restorative work, tell us the difference before we get too deep into this, Dr. Coleman, between a base and a liner. Sure. You know, Phil, I mean, I go back, and I'm sure you do too, way back when, when we were using metallic materials, amalgam, gold, things like that, which really transmitted a lot of thermal, hot and cold readily, quickly. So we were really, you know, concerned about protecting the pulp in any way we could. So we, way back when, I would put Dical and Copalite and things that obviously we don't even talk about anymore, just to try to help, you know, protect that. pulp from what we were fixing to invade it with. Over time, obviously, we've kind of gotten out of the metal world and more into the ceramic and plastic world. And so now bonding, right? I mean, we get in there and actually seal... tubules up and do our best to stick stuff on there and also to try to protect the pulp in a lot of different ways. And so liners and bases and all these terms have kind of been thrown out over the years. You know, I kind of break it down because people ask me all the time. I'm like, I think they're pretty much synonymous. I mean, to a large extent, a base really way back when we used it more to kind of fill undercuts in. I mean, you know, things like that if we really, you know, needed that. or just a liner on our base on the floor. Liners were kind of like, hey, we're getting pretty close here. And, you know, we were creating a little pulpitis. Maybe we want it to be reversible, not irreversible. And so we would, you know, try to dab some stuff on, you know, a little Band-Aid to some extent. And I agree. In the past, it was more of a semantic thing. Liner and base were used interchangeably. We heard it all the time. you know, it had some sort of meeting the word base that was thicker. When you put a base down, back in the day, really far back when we graduated dental school, we used some sort of cement base because even under amalgams, we used a base. Oh, absolutely. For thermal protection, for thermal protection. Right. So where are we now in today's modern dentistry when it comes to pulp protection? what are we talking about as far as the prevalence of using something to protect the pulp do we do this routinely or do we only you know what determines when we need to let's use the word pulpal protection or or or liner sure so you know in today's world i mean 100% of it or should be is bonding, right? We're going in, we're sealing. You can do an immediate dent and seal. I mean, there's all these topics that we can wade off into, but really we try to seal and protect it. You know, we don't want... the exposure that we used to have and so how can we seal it the best and what materials can we use and really you know if you're doing a good bonding protocol that should be really you know pretty much all you need i mean unless you get super close or super thin Then you're going to want something that you get a good pulpal response to. You want to, you know, something really basic. I mean, high pH that's going to stimulate some hopefully secondary dent and things along those lines. But for the most part, I mean, if you're at a, you know, a normal depth, you don't really need a liner or a base anymore. The bonding protocols that you use should really suffice. We can get into what generation bonding are you using. There's a whole lecture on that. But really today, most people are into the universals, kind of into the spectrum, which is great. And as long as you're using the protocol appropriate for the material that you're using, it really should work well. But when you're looking for that extra protection, Dr. Coleman, when you feel like you're really close and you want to use a liner, what do you typically like to use in your practice? The liner that I use the most is... one called TheraCal LC. It's a light cured version. There's a base that's kind of a dual cure, but I really like the light cured version. So when you're treating those deep cavity preps, what tells you clinically that it's time for a liner like TheraCal LC, where you need the help of a, in this case, a resin modified calcium silicate? Sure. Well, you know, there's several things. One, just an old school guy like me, just the clinical appearance of it plays a big role. Two, obviously, I'm going to count on radiographs to see, you know, how big the pulp chamber is or was, because you can get into areas and you've seen it very well yourself. An older tooth, more atrophy, you know, you can go further down in there without even getting close versus a younger tooth with big pulp chambers. You need to be, you know, pretty careful. you get there. So really it's a combination of clinical experience. Am I seeing things that are telling me how close I am getting? And then radiographic, you know, really how much room do I have to wiggle in? That's really a big, big part of it. I can't really determine clinically when I'm mowing through and, hey, the dentinal tubules are getting bigger because I'm getting closer. Certainly I never clinically see that, but I can certainly see if the pulp is retreated and we have secondary dentin formation there and I'm getting into something like that, that's pretty readily obvious. And it's like, whoa, we're closer than what I probably feel comfortable with. And I am going to want to line something here. OK, so when you decide you are closer and there's leathery dentin there, a lot of KOLs are talking about leaving that leathery dentin. alone. A lot of them are using the silver diamond fluoride stuff to remineralize that. And there's great evidence to show that that works. Do you put the liner on top of leathery dentin and just remove the infected dentin? So what are you actually looking for as the substrate for that liner? Yeah, you can do either. I've done it both. You know, I don't have a problem, and this sounds crazy, but I don't have a problem if I do get a pulpal exposure. I mean, it's not the end of the world to me. I mean, you know, a lot of people are like, oh, my gosh, I pulped it, and now I've got to do it. No, I don't find that at all. I mean, if you have mechanically, you know, cleaned stuff out and see a little bit of pulpal exposure, that doesn't bother me in the least. Because, again, I can go back through. do a little liner over that, light cured, and then just go seal it all up and I'm good to go. But I do understand, and certainly every case is a little different and it's really kind of a look and see. I mean, I'm a big fan of removing the decay and getting as much of the bacterial problems out of there as I possibly can. I don't intentionally go and expose the pulp every time. I certainly don't do that, but it doesn't, I'd much rather be on the safe. safer side to make sure I've gotten rid of all that and then seal it up and protect it. Then to say, well, you know, maybe I should have gone a little further or not. That's always a big question to me. So what, when you do get a pulp exposure mechanical, which, which is, you know, much better than obviously what, you know, a carious exposure, but if it's mechanical where you feel like the caries didn't infiltrate the pulp, when do you determine that you can go with a, a product like Theracel LC on top of it, which is that. calcium silicate material which which we want on there because we get you know we get some secondary bridge formation um versus sending it out to an endodontist or doing the i don't know if you do endo in house or however you yeah no i mean i do i do i'm gonna say 90 of my endo i do myself uh i'm a huge fan of the human body And so I'm going to give it every opportunity to heal itself. So if I do a pulpal exposure like that, I'm going to seal it up, finish it off, and then I'm going to sit the patient up and have a conversation. And I'm going to say, look, you know, the decay was deep. We're right on top of it. We've sealed it. The body's got two choices. It's either going to heal itself up and it may, you know, be fine. If it doesn't, then we're going to have to go in and remove the dead tissue that's going to form from that. And as long as I think you do an informative decision on that and then let it see. There's plenty of cases, plenty of cases where I thought, oh, my gosh, this is going to have to be in. I mean, there's no way. And then it surprises me. The human body can say, I mean, comes in, fixes it. You take an x-ray and a year later, you see some dentinal, I mean, it just takes, it repairs itself. And so I'm a big fan of giving it every opportunity I can to do that. I'd much rather have that healthy blood flow, you know, nutrition to the dentin than to go in and mummify it like we do when we end up doing a, you know, a root canal. Years ago, if you got a pulp exposure, you know what we used to learn in dental school. It was pretty much pulpotomy and then schedule for the endo. But you're getting... good results with this liner, but you do need to control the bleeding when you do get an exposure, right? Oh, yeah, right. And I'm not talking, yeah, I mean, there's a whole protocol that you need to go through. I mean, if you've exposed it enough or you get bleeding, then yes, you need to go through a situation to arrest the bleeding. Stop that. You need it as dry. I mean, you're not going to go through and do bonding first and then do like the TheraCal LC. That's not the way the system's set up. You just, you know, get it dried down, put it... it in, cure it, and then go ahead and then do your bonding protocol on top of that, and then come back in with whatever restorative materials that you're going to use in that particular case. Yeah. Now, some dentists like to stay within a given system. So you happen to like this Theracel LC as a pulp liner. Do you recommend that if you use a product like Bisco's, would you stick with the restorative material just to rule out any incompatibility issues down the road? Yeah, I mean, I always follow that if I can or if I feel comfortable with it. I mean, Bisco obviously makes, you know, they're all bond universal, which is a great one. They're one of the first bonding, true bonding companies that have been out there. So, I mean, they've got a track record that's impeccable. But yeah, I mean, I think that's a great idea. Can you mix and match? Of course you can. You know, it used to be way back when that they were amides versus, I mean, different bonding systems and you really couldn't cross them. Today, pretty much everybody's using the same. kind of goo i mean a little bit you know tweak it a little bit so you can mix and match if you want to but i'm a big fan of if you're going you know stick with that racehorse that you're on because they've already proven it in their labs that it's compatible and you may run across a case where it's not and you don't want to you know you don't want to take that chance if you don't have to yeah and i think that's a good point you're making and also if there's troubleshooting down the road and you reach out to the company, they'll say, well, what'd you put on top of it? Exactly. And then they'll blame it on that company. Oh, of course. Finger pointing happens all the time. You know that as well as I do. So let's talk about zero sensitivity bonding. Tell us what that is and how does that relate to the pulp? Yeah. So again, we go back historically, you know, we used to do, again, the metallic work, amalgams, gold, things like that. It was not that uncommon to have post-operative sensitivity. So that's why we would come in with the bases and everything. I mean, that was a fairly common... situation. And then when we started out, even with the bonding protocols, because, you know, they were really, we didn't know what the heck we were doing, and you would still have a bunch of post-operative sensitivity, curing abilities, I mean, all the factors that go into that. But in today's world, where we are today, there's really no reason at all, unless you're into an irreversible pulpitis that you're just trying your best to hang in there, that you really should have post-operative sensitivity. If you follow some of the protocols, that are there, you know, whatever manufacturer you decide to go with, make sure you understand what generation of bonding. What I find when I talk to people is a mix and match. Hey, I'm using a, you know, total etch system with, you know, one of the new universals or something like that. And I'm like, dude. You know, let's talk about total edge versus selective edge versus no edge. I mean, you know, you need to understand the materials and what you're using. If you follow that, trust me, in most situations, you're not going to end up having a problem. But people, you know, they're just like I'm used to doing this is my process and just here's the goo I'm going to use. And it's like, well, you need to understand a little bit more about it. And I think that's where people get in trouble with it. There's no question about it. So the technique is very important. Obviously, we've known this for a long time. maintaining the proper technique with the newer materials where we are today versus where we were yesterday, which you just pointed out, we're in a position now where we actually can reduce postoperative sensitivity to close to zero, right? Oh, yeah. Absolutely. What about the bulk fills where you get the polymerization shrinkage? Are we still in that stage where we have to deal with that? Yeah, so... Certainly, you can look at bulk fills, both in flowables and restoratives, and I've played with all of it. The stuff that I use today really, I mean, that works in my hands, and that's what I always tell people. Look, I can tell you what works in this set of hands right here that hopefully will translate into you, but it may or may not. But, you know, the materials that I use today, you know, I can do a restorative filling. It takes me maybe five seconds to fill it, and it's done. It starts out as a flowable, but then translates more into a restorative type where you don't have to do layering. If I have some kind of post-operative sensitivity issue... I'm going to say 99 times out of 100, it's an occlusion. Something that I've missed or not, they were numb and they weren't biting or some lateral interference that comes up. I'm going to say the vast majority of the time, that's what it is. It does not relate back to a bonding failure or some kind of misstep in there where there was contamination. I just don't have that anymore. I really don't. There's a technique that's been... popularized, if that's the right word, called it the deep margin elevation. And this is a situation where, I don't know, what is it, two or three years it's getting more popular now, where the doctor is raising up, let's say, a class two on number 19, and it's a distal occlusal. Is this something you're doing in your practice? Sure. Yeah. And you and I both know that if you can get your margins up above the tissue so that they can be readily cleansed or, you know, a much easier cleansability. And in boxes like that, you're not dealing with some kind of occlusal loads or things that you would have to deal with on really the occlusal surfaces. So you can get away with all kinds of stuff. You know, you can do a glass ionomer buildup if you want, you know, to get it up to the top of the gingiva and then go from whatever composite you want. from there that's not my first go-to thing i mean certainly if i can use the same material for for all of it that's what i'm going to do um but you certainly can do kind of a like you talked about raise the margin sandwich technique whatever term you want to use for that or you can bring it up and use a different material to kind of finish it off that works great i don't have any problems with that at all And I know we live in a composite restorative world now. That's what dentists are using. They love it and it looks beautiful and it bonds great. But glass ionomer still has a place in dentistry like we just described. And I hope dentists are still using it. I assume they are. Well, yeah, they should be. In fact, I'll tell you, you know, interesting comment. I mean, literally a patient I saw about two hours ago came in with a... DO or deep distal decay on a tooth number three. And I diagnosed it. She went to somebody else, did a filling, still was uncomfortable, went back, replaced it, came to me because it was still bothering her. And when you took the radiograph, you could see where the matrix band had kind of stopped because they couldn't get far enough down in the box. And the material had gone below that and squirted back out. So she had kind of like a little... J-hook of material, you know, almost, right almost at the crustal height of the bone. I mean, that's how deep it was. And I was like, yeah, you know, this is, you know, the depth that they're trying to get and what the materials and the technique that they're trying to use here really is not appropriate for that situation. They were trying to make something work that just wasn't going to work in that particular application. So you can go back in with a lot of different ways to fix that. But yeah, glass ionomers are one. What did you do to fix that? Well, I haven't. I said what I would do in her particular case is we can take that out, dry it all up. I'm a big digital guy, so I would digitally scan it and mill out a restoration, even if it's just a little DO inlay that's going to make sure that the margin is going to be great because you're never going to get some kind of... in the mouth way of solving that with everything you're trying to accomplish. It's just not going to happen. Yeah. There's one dentist in Brazil, Dr. Watanabe. He does what he calls an indirect direct composite, which means he, well, he calls it a direct indirect composite. And he does it on a silicone model, which sets up very quickly. So he doesn't even have to send it out to the lab. And he uses composite. And what he does is he raises, he does a deep margin elevation, then he scans it. Because now the scanner could see everything. And then he pours up a silicone model, which sets up very quickly. And then he sculpts this thing with direct composite. Light cures it on the silicone model. And then he does what you just did. Instead of milling it, he drops it in. And this thing, he has some beautiful cases like that. He says that it takes him 30 minutes total because he does so many of them. And one visit, and it's a crown. composite crown right yeah so uh no that's brilliant i mean and he's dead on there's nothing wrong with that i mean again it's a different skill set and not everybody's going to have that but you can certainly develop that right exactly but what you're saying though Dr Coleman is that you when you just saw this patient two hours ago it was clear to you that they went beyond what that material was designed to do with the armamentarium they had chairside. It was wishful thinking, in other words. Right, right. Yeah, it just wasn't going to make it. And she's still in pain. And it's like, yeah, there's no way that, you know, that is not going to work there. I don't care who you are. It ain't going to happen. Right. So let's pivot back to the liner that you talked about earlier, Theraquel LC. You mentioned that it has a very high pH. It has an alkaline chemistry. Why is that important to the pulp? and for pulpal protection. Yeah, so the stuff I use, or the Theracal LC that we've talked about, has a pH of about 10, something in that range, which is really, really basic. And you would think, oh my gosh, that's got to be dramatically detrimental. Well, really it's not. I mean, it is bactericidal. I mean, obviously most bacteria can't make it in that. But the pulpal response to that, and as an endodontist, you would probably know even better than I, the pulpal response to that is just the opposite of what you would, you know, what you would think. It stimulates, you know, dentinal bridging. It stimulates all these things that a neutral pH and certainly not an acidic pH will do. Yeah. And that's like what Dical in our day wanted to do. Yeah. Right. Yeah. You put Dical right on top of the exposure and you, you know, you pray for a bridge to form in three months. So as we wrap up this episode, Dr. Coleman, and it's been very enlightening, with your 41 years of experience, a lot of years, what recommendations would you give to our audience about adhesive dentistry that are so important to achieving retention, pulpal protection, and zero postoperative sensitivity? Right. So, you know, again, we can talk about a wide range of things, but to me... I don't care what protocol that you're using, what materials that you're using. There's two big, big factors that I find 100% of the time are going to make a major difference. And obviously, bonding to enamel is a no-brainer. You know, you don't have to worry about that. I mean, that's pretty much a given. But bonding to dentin is where the... Rubber meets the road. And in that factor, I'm a huge fan of once you've cleaned it up, gotten rid of whatever it is that you're doing, and you're ready to restore it. A lot of times it's real simple for people just to take their air syringe and just dry it down to nothing and then start to apply their bonding agents, either, you know, a two-step or primer and adhesive or universal combination, whatever it may be. And I've talked to too many chemists that are involved in all that, you know, to know for a fact you're way better off if you try to bond to moist dentin, not... wet and not dry even though the solvents that they put in you know in the bonding agents the water acetone alcohol and they do a great job with it but they will 100 tell you yeah if we could convince people to moisten the dentin a little bit so that we get those collagen fibers all fluffed up before we interject what we want to get in there and bond with, that makes a big difference. So step one, make sure you have a moist dentin bed before you, whatever protocol you're going to use that you start. That's number one. Number two is once you do your... Adhesive again, whichever system you want to use Do not move on. Do not go past that until you have glossy dentin. I don't care how many layers you have to put. I don't care how much you have to blow it dry. But if it's still dull, you need to put some more material in there. It needs to be a glossy dentin before you bond or try to, you know, whatever you're going to do, that's going to tell you that the adhesion of that dentin is going to be as good as it's going to get. So moist dentin to begin with. glossy dentin before you move on to the next step. Those are the two biggies that I find, you know, more people mess up on than anything else. Yeah, no, great advice. And how do you know that these dentists that you're talking about are missing out on this technique? Do you teach in front of a group? They all raise their hand, admit they're doing it wrong? No, no, no. Nobody admits it. I mean, nobody admits it, but when you get right down to it, it's like, okay, well, you know, tell me, show me what you do. Oh, well, I do this, and then my assistant does this, and, you know, they kind of walk through it, and I'm like, okay, and what material are you using? Well, I'm using this and this and this, and I'm like, okay, so you're mixing and matching. I mean, you know, again, you're doing a... You know, a total edge system that's really, you know, the materials designed for no edge or you're doing, you know, it's really becomes very obvious. And then when you say, okay. And, you know, if you graphically show them, here's what desiccated denton looks like. Here's what, you know, moist denton looks like. And here's what the material looks like when it's flowing in there. And here's what you're trying to accomplish. You can see the little lights kind of go off on their head going, ah. And you show them pictures. Here's dull denton. Here's shiny denton. And what do you think the bond strengths are in these two materials? And, I mean, you know, it's. It's an eye-opening experience for people because they'll say, well, I still have post-operative sensitivity a little bit, and what do you think? And I'm like, well, just explain to me what you're using, how you're using it. And 99 times out of 100, you can find steps that are like, okay, well, here's just change these few little things, and you'd be amazed at how well the system's going to work. Yeah, that's very well said. And the thing is, the research and development that goes into the chemistry in these materials, and then for the dentist, You know, I'm not trying to say that it doesn't take a lot of skill to be a dentist. It does. But you got to follow the technique exactly the way the manufacturers designed it so that it fits with all the R&D that went into developing those chemicals. Oh, absolutely. Yeah. I mean, they can't come into your office and put this in the mouth. That's your job. And so you got to pay attention and respect. the R&D that went into these materials, because the only way they're going to work where they get the results like you're looking for with zero postoperative sensitivity is to do the technique according to the way they were designed to be put in. And you have to respect that as a dental practitioner. Oh, absolutely. Yeah. And, you know, one of the interesting things, because whenever I talk to these, the true chemists that are doing it, they get so frustrated because dentists don't follow. And so that's, you know, if you stop and think about it, why are they adding itch and, you know, you know, why are they combining all this, trying to get it to one simple step? It's because they know that these dumb dentists out there are not following, you know, are not following what, hey, I'm the dumbest one of them all. I mean, are not following the protocols that they've come up with. So they're like, how can we dummy it? No, no, you're totally correct. And make this to where that, you know, it's as foolproof as possible because we know, and I mean, you know, I always tell people, hey. The manufacturers are not the evil empire. They're there to make money, granted, but they fully appreciate that if what they sell you doesn't work, you're not going to buy it anymore. So they're going to work really, really hard to make sure that you're going to get the result that you want. And that's why they work. You know, they do all that. So follow the instructions, read it, which nobody does. I got that. Read the little slip that comes with it. Follow that protocol. If it says 15 seconds, trust me, it's 15 seconds. It's not 3 or 30. It's 15. I mean, they've really done the research to say this is the quickest, best, most efficient way that this material will work. Yeah, and that's why you're practicing 41 years now, Dr. Coleman. You'll probably go another 20. And the reason is because you know that whatever you're doing in the operatory, you're giving the tooth the best odds of survival, and you sleep well at night, and you enjoy that. And if someone comes back with post-operative sensitivity, then they were doomed to have a root canal anyway. Oh, right. Because you know you did the best you could. and no one else is going to be able to do a technique any better. You're using the most advanced materials, and it is what it is. I mean, you can't save every tooth where they don't need a root canal, otherwise there'd be no endodontists out there. Right. And you'd have no files, endodontic files in your practice, right? Right. All right, well, listen. That's spot on, Phil. That's absolutely spot on. Yeah, we thank you for your insight. I mean, you know, it's really important that people like you talk about this stuff. You've been doing this a while, and it means it holds a lot of weight. to our listeners, to hear someone who's been practicing 41 years. And that's why they listen to this podcast show, hopefully, and they'll continue to listen to it. And we thank our audience for that. Again, Dr. Coleman, many more years of good practice to you. We need to get you on future podcast episodes on other topics. Anytime, Phil. Really enjoyed it. Thank you so much. Always love it. Talk to you later.