Composite Restorative Designed to Fight Recurrent Decay and Post-Op Sensitivity

Bioactivity is basically taking this concept of, you know, in the past our materials were very passive in the oral environment, but we're in an inherently dynamic environment with temperature and chewing and pH changes from bacteria, so there's nothing that is passive about our mouth. Welcome to the Phil Klein Dental Podcast. Today we'll be talking about two common challenges that affect, to some degree, every general dentist that uses composite restoratives in their practice. postoperative sensitivity, and recurrent decay. And to help manage these two challenges, dentists do have options in their selection of which composite resin material to use. One important thing to consider is whether your composite is bioactive. Does it actively participate in the oral ecosystem, helping to reduce post-op sensitivity and acid-producing microbes at the tooth composite interface? To tell us more about this is our guest, Dr. Neville Hatfield. Dr. Hatfield graduated magna cum laude from Boston University School of Dental Medicine. He completed a GPR at the Manhattan Veterans Affairs Hospital, where he provided interspecialty comprehensive prosthetic and surgical treatment to military veterans. He currently practices in New Jersey. Dr. Hatfield, thanks for joining our show. Phil, thanks for having me. It's been a while, but I'm glad to be back. So we've come a long way with composite restorative materials. But nevertheless, from time to time, we still face challenges with our direct composite cases. In the short term, postoperative sensitivity, which we all dread, that phone call after we do our direct restorative and we get that call that the patient's very uncomfortable. And then, of course, in the long term, we face the risk of recurrent decay. That's also happened to all of us if we're practicing dentistry long enough, I'm sure. So let's start with postoperative sensitivity following a composite. restorative procedure. What is actually happening at the tooth level that causes that discomfort? So if we're kind of going back to our dental school biology days, there's the big theory is the hydrodynamic theory of sensitivity, which is basically stating that dentin tubules, dentinal tubules have fluid within them. that dentinal fluid moves in and out and which can stimulate the nerve, which then causes pain or sensitivity or any kind of stimulation to the nerve of the tooth itself. It could be from temperature or biting or any of those things. So that's at a basic biological level. That's what's happening within the tooth. But when we're talking specifically about postoperative sensitivity, especially with composite restorations, We need to think about a couple things that are sometimes material in nature or sometimes iatrogenic in our hands. So there's a couple different things that could occur that could cause a sensitivity. The first and foremost is obviously material itself, say something like shrinkage stress, right? We've known since the advent of composite resident dentistry that shrinkage stress has been a big thing and they've been... fighting it heavily to not have as much shrinkage stress in R&D and various companies. But most companies have now kind of figured out to minimize the shrinkage within the resin chemistry, so you don't really have that happening anymore. Now, when we're talking about other forms of sensitivity, a lot of them can be iatrogenic, right? We don't use the proper technique. We rush things. We don't do the proper length of time. And that can all kind of lead to pulpal inflammation and then obviously post-operative sensitivity. So I think it's really important to obviously follow the instructions for use of the IFUs of a lot of our materials, but also just understand that, you know, sometimes it's not great to rush that extra five, 10 seconds and really count down the time that we need to properly go through our steps. Yeah. So in getting specifically into the technique and materials, we'll be talking about more materials in a few minutes. What is it about the technique that we could do as clinicians? Keeping in mind that, you know, the pulp has a live nerve in it and that fluid in the dentinal tubules excites that nerve. And there's a real person behind that tooth that we certainly, as I mentioned earlier, we do not want them to call us and tell us how uncomfortable they are after this restorative procedure. So we all know this. So what can we do clinically, technique-wise? Let's start with the technique. Things to really keep in mind to minimize that. I think the first thing is, is our bonding agent, because that's the first layer between the tooth or in theory, one of the first layers between the tooth and your restoration. So a really important thing is bonding agent, what kind of bonding agent you have, what generation, I guess you'd call it, that it belongs to and what it can really do for you. So there's various different bonding agents out there. I think the most common one nowadays is something called a seventh generation bonding agent. But essentially what that means for everyone out there who's not a materials nerd like me is that it can be used in almost any technique, meaning that you can etch with phosphoric acid selectively or total etch, or you can use a self-adhesive or the self-etch capabilities of your bonding agent in order to really do right by the patient in terms of having good bonding agent. Is that a single bottle technique? Yeah, so single bottle is probably the most common nowadays, but there are still... people out there, especially in the biomimetic dentistry space, that really say and live by the two-bottle bonding system. So it's really important to understand exactly what the primer and bonding agent and everything like that that's in your component of your bonding agent. But I, at my day-to-day dentistry, would use a seventh-generation bonding agent. And if you would, Dr. Hatfield, just briefly mention... the factors of whether the material, the restorative material that you're putting on is either self-cure or light cure and how that influences your decision on what bonding agent to use. Well, there's a self-cure material in composite dentistry and there's a light cure. Most of our composite resins that we use nowadays are light cure component. There's some kind of activator that would cause it to be activated. Now, in terms of bonding agents themselves, there's like one or two out there that are. self-cured, meaning that you don't need to actually shine a light on it. But most of them, again, are light cured. So everything needs to be cured at some point in stage. Now, most newer bonding agents out there actually have an additive to the bonding agent that allows you to use both light cure only materials and dual cure materials interchangeably without having to do an additional step. So let's talk about recurrent decay for a minute. And what I want to focus on is not the patients that have rampant decay all over their mouth or patients that don't have any oral hygiene compliance. I'm talking about patients that are typically fairly good at oral hygiene. They come in for their re-care appointments. But for some reason, one practice may be seeing more recurrent decay than others. And that could, as we said, could be partly due to technique and or materials. But if you're doing the right technique and you're vigilant about that, as best you can under the circumstances, and you're using materials that are designed to kind of stave off recurrent decay, are we in a state now where we should be pretty good and we shouldn't be really seeing too much recurrent decay for those kinds of patients? So the answer is yes and no. Okay, I'll take that. The recurrent decay is always going to be an issue, right? I think there's plenty of statistics out there that's saying recurrent... decay is the most common reason for composite bonding failure, and that still holds true as far as I understand it. Now, the research and development that all these companies out there that have done has gotten so good in terms of the aesthetics, the color matching, and many other things that you can basically almost pick any composite on the market and get a very nice result. But one of my biggest things, and I think that I look for mostly, is Finding materials or finding companies that really put the effort into the research and development to find how they can best help the consumer, which is the dentist, and then ultimately the benefactor of the consumer, which of the dentist. is our patients, right? So there are now a big component of research and development is going into bioactivity. And bioactivity is basically taking this concept of, you know, in the past, our materials were very passive in the oral environment, but we're in a inherently dynamic environment with temperature and chewing and pH changes from bacteria. So there's nothing that is passive about our mouth. So these companies and development into bioactivity have basically, there's a, let's say a handful that are really out there that are really in the bioactivity space that have done really well in terms of adding in bioactivity into their composite resins, turning them from a passive material in our mouth into one that's more of a symbiotic or active participant in the oral environment. And that of course was the big advantage of glass ionomer and continues to be that it recharges the tooth and it's an ongoing process. The problem is it's not as durable and it wears down and needs to be replaced over time. But you're saying that now there's composites that have that same recharging capability where there's an ion exchange that helps prevent recurrent decay and strengthen the tooth. Correct. There are. Glass ionomers wash out, which is why a lot of our cements went from just glass ionomers to resin-modified glass ionomers because that resin holds those... those components in place. And every single time our patients brush our teeth or they eat a certain thing or their saliva washes over these materials, they basically recharge these ions. But what these materials now can do is they can specifically lower the bacterial biofilm on the tooth and not allow as much adhesion in the first place, which then ultimately stops the recurrent decay or can help stop the recurrent decay. And I have a few, obviously a few favorite companies, but one of my big ones that I really enjoy is Shofu. Shofu, I think, has been a major player in the bioactive space for a long time. And they have a multitude of products out there that fit in that theory of checking more boxes, but also being a more active player in the oral environment. So Dr. Hatfield, as I've looked into Shofu's composite restorative material, it's clear that they have established... the ability for the composite to release ions into the oral environment, such as fluoride, which is not surprising, and then strontium, aluminum, silicate, borate, and sodium. And each of these ions play a role in the pH and helping suppress recurrent decay. So talk to us about this a bit so we can get a better understanding of this ionic activity that's going on from the composite. So I think we have to kind of back up a little bit from composite resin dentistry and think about amalgams, right? Amalgams are inherently bacteriostatic or bactericidal just from the metal alloys that they have in them. So something like an aluminum would be a component into helping stop the bacterial proliferation on the area. People at chauffeur are much smarter than I am. I like to say I'm a materials nerd. They are a step above, right? They understand that each of these irons is incredibly beneficial to an antibacterial effect. It's not bactericidal, meaning it probably won't kill it, but it's going to prevent the proliferation of bacteria. Now, obvious ones like fluoride. We talk about fluoride and hydroxyapatite and it changes over to fluorapatite and things like that. And those are responsive in terms of pH changes in our mouth. When the bacteria secretes acid, it also secretes acid onto the tooth as well as the restoration. That's what causes the release of the ions. The ions are directly in the area where they need to be, which is at the bonding layer of the tooth. And then that can go on and re-strengthen once the pH kind of increases again and the pH kind of goes back more towards that neutral 7.1. They have a term or a name they use, Giamer technology. Yes, Giamer chemistry. That's how I pronounce it. It's spelled G-I-O-M-E-R. You know, it's really a fascinating concept and it's not new. It's been around a long time. Tell us why you think that's important as a restorative dentist and someone who does a lot of direct restorative procedures. Is it just for those cases you're concerned about where the patient has a history of their high-risk caries, or is this something that has enough aesthetic qualities to it or very high aesthetic qualities where you can use this routinely? Obviously, the bioactive component is very important to me in my patient population. I do have patients who are high risk. I have patients that are low risk. It's not that I would pick Shofu's products like Beautyfield 2 or Beautyfield is what they call their line of composites. I don't pick one of their composites just because it's bioactive. I also pick it because it looks good. It'll look good for a low caries patient. It'll look good for a high caries risk patient. No matter what, I want it to look good. regardless of what the patient's home care habits are, eating habits are. So they've, you know, they're in their second iteration of Beauty Fill. They call it Beauty Fill 2. That's their packable composite. I love it. It's really easy to work with and really creamy and really important for me to be able to spread but not stick to my instruments, which, you know, is... You well know that was a bane of existence with the early composite resins. You couldn't get them to go where you want them to. They also even have like a gingiva colored resin composite, which is awesome. So I have a couple of cases and I've written about a couple of cases where instead of we've all heard of pink porcelain for very aesthetically compromised things, but also there's pink composite now. right which is great there's also their flowable composites are one of my favorite i think their beautiful flow plus x is their their newest iteration of a flowable but all indications composite that has that bioactive gymer chemistry in it but it also has it's a nano hybrid so it polishes beautifully it's you know it's thixotropic properties of going where it needs to go and being able to push it where it needs to go is amazing And I honestly, I highly enjoy it. I think a lot of people hate class 5 restorations. They're one of my favorites to do just because of products like, you know, Beauty Fill. How long have you been using Gymer technology in your composite? And the reason why I'm asking, Dr. Hatfield, is because I'm just wondering whether you see a difference in your patient population. after using GIMR technology regarding recurrent decay? Are you seeing dramatically less cases of that? And are your restorative cases lasting longer because you think that there's antibacterial activity going on at the margins? A hundred percent. I think I use it, you know, I use Shofu's products in all indications of composite resin dentistry. So obviously in the posterior, if you're doing a class two, it's really important. Or a large class two, having that recurrent decay fighting power is really great. But in the anterior where I've seen most of it, that's where I would probably say I've seen the most improvement and the most reduction in recurrent decay, right? Everyone's done those class five composites on the anteriors between six and 11, right? And then after like two, three years, you start to see the marginal breakdown of the bonding agent. And then it starts to really accumulate staining from coffee drinking or soda or bad habits that they have. And I don't really see that as much with these composite resins that contain gyma chemistry. They just really... an awesome job with fighting recurrent decay. And on top of it, I'd like to quickly mention that their bonding agent, Beauty Bond Extreme, is actually awesome as well because Beauty Bond Extreme is their newest iteration of their bonding agent. It doesn't contain dynamic chemistry itself, but it has a really low film thickness. really doesn't need like multiple layers like you sometimes need with some other bonding agents so it's it's super thin and it's very reliable and a thinner bonding layer along with a composite resin that has that recharging capability will actually fight those stains from occurring because it just stops the marginal breakdown right along that bonding agent. Yeah, and I think it's a safe bet to stick within the same company when you're using a bonding agent and you're using the restorative material on top just because you know it's from the same company and the compatibility you would think is greatly tested versus using your favorite bonding agent that claims to be universal, which it might be, and then using a gymer type composite that Shofu sells on top of that. So the fact that you're having good success with the bonding agent, it does. give you some peace of mind as far as compatibility. What do you think the charging capacity is over time when you put the restoration in? I mean, I know it's hard to measure, but I'm sure there's been literature published on this. I'm sure there's articles on this. So what have you read and what have you heard and what have you experienced yourself clinically as far as how long you think this material actually stays bioactive and continues to release those ions that we talked about? Yeah, so as far as I understand it, this recharging capability of Shofu's gymer chemistries is almost unlimited, right? I can't necessarily speak to the amount of strontium or whatever that is in our saliva. I'm sure it comes in some component, but as far as I understand, this... effect and recharging effect is unlimited. They have these pre-reacted glass foilo particles that is where the gymer chemistry sits on within the material itself. And, you know, the most superficial layer is obviously going to have the most exposure to pH changes. So I think because it's unlimited, almost... of its recharging capability, you almost have the antibacterial effect or that bioactive effect for the lifetime of the restoration. So failures don't often come from recurrent decay. They might come from physical injury, right? You have a class four, you bite into something, it pops off, right? That's where I think a lot of the failure comes with restorations when using something like Shofu's products. It's less so from recurrent decay, which is, again, a very common issue. So we've talked about the antibacterial effect of the gymer technology as part of the composite restorative by Shofu. What about the postoperative sensitivity? What does it do for that? So you do have some postoperative sensitivity reduction just inherent in materials that release ions because if, again, going back to tooth biology, anything that kind of would secrete ions that would be... bioactive in terms of stimulating the nerve tissue itself. Those are things like calcium. Those are things like sodium. Those are things that gyromic chemistry contains. It doesn't contain calcium. It does contain sodium. But those are portions of it that can actually help with post-operative sensitivity from a placement perspective. So if we use something like one of their flowable composites as a liner right before even doing any bonding agent, it has the ability to kind of you know, have some bioactive effect on the pulp. In terms of the threshold or the amount of it, I don't know. But I do know that I tend to see a lot less of that post-operative sensitivity with Bufill products. So I do want to ask you about cost -effective considerations when it comes to buying materials. Listen, we all have an overhead in our practice. We're all running a business. So is this something that is really an important consideration for composite restorative? Because I'm an endodontist, so I... obviously don't do restorative dentistry. If I did, I would be happy to pay more, of course, if I had the confidence that a material would provide me long-term clinical success. I'm not going to save dollars or cents on a material that's going to give me problems down the road. But what I'm hearing is about Shofu, and we've talked about this offline, I've talked about this with other KOLs, it's actually very, very cost effective. What's your thought on that? A hundred percent. I think anybody in the dental world, there's very few of us dentists that are, you know, always getting our full fee for things and the cost in the world is just getting increasingly more expensive. And I think one of the hardest parts is, you know, obviously playing that balance between the business owner and cost effectiveness, but also getting good materials. But, you know, the struggle with something like Shofu's products, because they tend to be a right around, I found like 30% less expensive. than maybe some of the other big names out there. And they also have that additional benefit of the bioactivity from the gymer chemistry, right? It just checks more boxes for me. It works on a business level. It works on a bioactive level. It just works for me in my practice. And I can't speak more highly about Shofu's products for that reason. Yeah, and I appreciate your feedback. And typically on these podcasts, we don't zero in on a particular product. We do occasionally. But this particular composite, has a unique gymer technology that other composites do not have. And we know that just from the surveys we've done at Viva Learning, what people are interested in. And one of the things is recurrent decay, like what are doctors doing procedural-wise? And what are they doing with materials to really try to make sure that this is a minimal problem down the road? It's good to talk to a clinical dentist who knows his or her materials. Because they're not necessarily being sold on the claims of a company that says this does this, this does that. You dig in deeper. You do your research. You've tried it. You do a lot of continued education, Dr. Hatfield. So we really do appreciate your feedback. And again, if you have any questions about GIMR technology, and it's spelled G-I-O-M-E-R. And these are those ions that I mentioned, fluoride, strontium, aluminum, silicate, borate, and sodium. They all work together in this ecosystem to really take hold of any bacteria that's getting into the area where the bonding area is or the margins, which are critical to the beginning of recurrent decay. And it kind of takes it out. early and maintains that environment so that it doesn't really get out of hand. And we're seeing it firsthand, the effects of it through Dr. Hadfield's experience with his cases. So any closing remarks before we wrap it up? I'd just like to say that, you know, bioactivity, I feel like is a big leap forward in dentistry, restorative dentistry in general. There are many great companies that are going on it. But like I said, there's very few out there that are doing it well and doing it effectively. But I would encourage you as I'm a full-time practicing clinician. I'm sure that many of your listeners are as well. I think just doing a little bit of research goes a long way in terms of helping your patient population and also helping your day-to-day headaches. No one likes hearing that a patient has post-operative sensitivity. No one likes hearing that the filming you just did popped out a year later and now is not covered by insurance because of frequency issues. Those are the things that drive us crazy in our day-to-day that we don't like to handle and our patients don't like to have happen. Dr. Hatfield, thank you very much for your time and your insights, and thanks for sharing your clinical experience with this technology. Have a great evening. Thank you, Phil. Glad to be here.