Temporization - How Do I Make Sense Out Of The Mish-Mash Of Information And Products?

You're listening to The Dr. Phil Klein Dental Podcast Thanks for joining us on the show. I'm Dr. Phil Klein. Today we'll be discussing the evolution of temporization for crown and bridge restorations. We'll also discuss some of the tips and tricks that help us make temporaries easier, faster, and better. Our guest is Dr. Gregori Kurtzman. who maintains a private general dental practice in Silver Spring, Maryland. He has lectured internationally on a broad array of dental topics and has published over 800 articles globally, written several e-books, and authored various textbook chapters. Dr. Kurtzman, it's a pleasure to have you on Dental Talk. Thank you, Phil. Pleasure to be here. Yeah, so you've written extensively on the restorative process. So from your perspective, why is it that clinicians continue to have that challenge of achieving the quote-unquote beautiful restoration. And let me add also into the question, is it partly due to some of the confusion and conflicting information around temporization? What's your view on this? Part of the problem is that Doctors don't read directions. They assume they know how to use products. They don't know how to use them and what applications. And I think dentistry has changed a lot. I'm judging that you probably graduated at the same time I did. I graduated in 86 and materials have changed drastically, especially over the last 10 years. When I was in dental school, we were using methyl methacrylate. That was the only temporary material we had. Tasted horrible, was hard to use, took forever to set. The patients didn't like it. And the materials we have today are much different. And we have temporary materials that we can use in the office. They have great strength, better aesthetics, really no taste to them. They're very durable materials. So I think the key basically is knowing the materials and knowing how to use them and when. how does a doctor typically know that their temporization material is not ideal or on the other hand they know that it's the best and there's nothing to switch to how do they make that assessment well i think the key is having something that sets well when you're taking it out As you're forming it, it doesn't chip or break. You can, if possible, add to it if you have a bubble or something. Some materials you cannot add to it. Some materials you can, like bisacryls, like Centrix's material. That basically, you can add to that with your flowable composite. So if you have a bubble, you want to change the aesthetics a little bit, you want to extend the margin or something, that gives you that ability. So I think the key is knowing the materials that you're using and knowing how to use them and simplifying your techniques. So when we talk about temporization as a general category of procedures, as the title states in this podcast, how does someone make sense out of the mishmash of information and products? What kind of recommendations would you make to our listeners so that they can get this mishmash of material and information and consolidate into something that would be used successfully so they can achieve that beautiful restoration? I think that it's really basically technique. If you develop the technique, like for a single crown, for example, what I'll do is the patient will come in. We're going to do a crown, whether it's anterior or posterior. If a portion of the tooth is missing, I'll stick some old composite, reshape it, take a preliminary impression. When I get done, then I fill it up with like access crown by Centrix. I'll reinsert that. I let it set for about a minute or so, pull it out, trim it. and then i'm ready to go very quick uh temporary i could have my assistant do this for when i'm doing a bridge let's say i'm doing a three inner bridge and i'm missing a pontic area i will take some wax or composite shape quickly shape a tooth in there before i do anything take my impression now i have a mold that's going to give me a very quick durable aesthetic temporary that's easy to do like i said you could pass that duty off onto your assistant You create the actual form of the tooth that's missing, and then your assistant takes the impression, or he or she could do both? Well, I usually do the shaping, and then I'll have them take the impression and then make the temporary afterwards. You can do it yourself. It depends on how good your assistant is and how much you want to put off onto your assistant to do. But it's very easy to make it temporary using this technique, so pretty much any assistant can do this. And I'm the one who cements it when I'm done, so I get to check it. Right, of course. Why is it so critical for our clinicians to put more thought in material choices, especially when it comes to temporization? Now, you mentioned a particular product, and maybe you can tell us why you like that or what are the characteristics or attributes of that material that work well for you? I've been in practice for 36 years, and what I like about Access Crown, it's a bisacral, great flexural strength, strong material, and very aesthetic. And they're durable temporaries. And sometimes the average temporary when we're doing something maybe isn't there for two to three weeks between taking the impression at prep time and inserting the final. We may have situations where we have to go longer than that. We may be temporizing a fuller case where we want the patient to, in a sense, test drive the aesthetics. let's say we do we have a very critical patient and we're doing uh six to eleven and they're unhappy with what their teeth look like that's why they're having us do this we may prep we may make our temporary take our impressions make our temporary and send the patient home let them come back in two weeks and basically say hey what do you think are you happy with the aesthetics if they're not we can make some changes and then what we're done and they're happy with the aesthetics of those temporaries we can now take an impression of that send that to the lab with our original impression and say replicate this so we have basically we're allowing the patient to make some fine tuning there and i think that really helps in situations or we may be doing implant cases where we're immediately temporizing something and they may be in there for four to six months so we want a durable material that they're not going to be coming back every few weeks and we're having to patch it or redo it So the key basically is selection of the material. Let's talk about temporary filling materials now. Is there any truth to the statement one size fits all in that category? Or is that also something that we have to be selective on as far as the temporary filling material? I think it really depends on the situation, what you're doing. If you're basically just temporizing something, patient comes in, you're temporizing, where you're saying, hey, Mrs. Smith, you're going to have to come back. You lost a piece of this filling. There's decay under it. I can't fit you in the schedule, but we're going to have to do endo or do a restoration. We may stick something in there that basically we only need to last for a short period of time, maybe a few days or a week until they get back for a longer appointment. So we may go with something like Tempit. in that that situation it's a putty you basically take a little piece out you plug it in there moisture in the mouth basically sets it hard i will instruct those patients no eating any sticky candy and stuff don't floss around that area you can brush it and business as usual although we have situations where we may be saying hey we're doing endo we want to seal the access i prefer something that is a little stiffer uh so i'll use the tempit lc in those situations where basically i know something is not going to break down it's very durable material so that basically is a pre-mixed temporary that i put in there shape it and then zap it with the light and it's hard That awesome material is great for sealing implant access in the abutments or if you're doing screw access. In the past, we used to use cotton pellets and we'd fill it with something else. Then we went to plumber's tape. and then some temporary material. I find that this is even better. I don't use the plumber's tape anymore. Just fill it with this. If the patient comes back and I have to access this, I just take an endophile, thread it in, and it pops right out. Makes it a lot easier management-wise. Right. Now, on Tempit, does that material absorb water where that could be inflammatory to the pulp if the tooth is vital? and you're not going to do the endo? No, no, it doesn't. Once the moisture hits the surface, it just triggers it basically a set. So it's not going to basically absorb any moisture, so we don't have that issue. And you could use this on a situation where, and they have a Tempit-E, which has eugenol in it. If I have a patient that we're doing a restoration on, and it's close to the pulp, and they're having some sensitivity beforehand, I may want to use that so it'll help desensitize that tooth. the pulp won't be as reactive in those situations. And, you know, the material like the LC also or their Ultra F, which is sets even harder. Those are great materials. So if I'm doing an inlay or an onlay, so I could put something in there that is very easy to, and you don't have to cement those in. You just form it, take an instrument, shape it, have the patient bite you around a little bit, then zap it with the light. And when I want to take it out, all I have to do is take a scala or something and it pops right out of the tooth. And they're fairly retentive. when a patient is eating where it doesn't pop out before the restoration is delivered? I'll tell them no flossing between those. You can brush with it. Try to avoid, like I said, sticky candies and stuff like that. I found that they're very durable materials. I've had very few instances. And the instances I have had, it's like they try to floss around it and they pop it out. But for the most part, I'd say 99.9% of the time, I haven't had that problem. This is a temporary filling versus a provisional, which we talked about earlier. The provisional, what do you use for that to cement in? Well, usually they're no mix, which is a pre-mixed cement that also with moisture. The key with that is you don't want to dry the preparation off. You want the preparation to have a little bit of saliva moisture on it. You fill the squirt this into the temporary crown or bridge, insert it, and that moisture will now set the material, and it's very easy to pop off. If you're going to be in longer term or you have something that's not as retentive, you may want to use a provisional temporary type glass ionomer cement. And GC makes one of those and some other companies that's a little bit more retentive longer term. But I find that the new mix, most cases works very well. Unless, like I said, I have a very non-retentive prep or I need it to be in there for a longer period of time. That requires no mixing, obviously, by the name. Correct. How is that delivered? Well, it comes in a syringe or a little tube. The good thing is with the tube, you can use it and there's a little bit left in the tube. It's almost like a single use. You can give that to the patient if they're worried and say, hey, I'm going out of town. I'll have the temper in. Well, here's the rest of the tube. If it comes out, just squirt a little bit in, place it in, bite it into place, bite for about two or three minutes so it sets and you're good to go. Yeah, well, that's actually a huge advantage because I actually had a... crown on number 31 and i traveled the temporary came out it was a difficult access to get in there to make that temp and the assistant who made it was kind of struggling it did come out it would have been really nice to have that it's also a sensitivity standpoint you know the temporary crown comes off some patients are going to have sensitivity on that and some aren't i'll give you a perfect example i had a patient came in who has a crown he thinks is 10 years old Short prep. We got to redo it. But he wants to wait till January in order to do it because of insurance. So I cemented him with the strongest cement I had. He calls me. He's out of town. He goes, it popped off again. I was flossing. Didn't I tell you not to floss around it if we're going to delay this until then? So I said, you know, we can get you some no mix. You know, how long are you going to be out of time? He goes, two weeks. All right, give me your address. I'll drop a little tube in the mail to you. You'll have it in a couple of days. And he goes, I'm not having any sensitivity. But things happen. It's just the nature of the beast sometimes. Patients listen to us or instructions, and sometimes they don't. i mean i'll give you a perfect example on not listening i'm a dentist for 36 years we tell people don't chew on ice i chew on ice all the time i've broken four teeth in my own mouth every time i'm chewing ice my girlfriend will look at me goes yeah i guess you know a dentist right i go yeah i know i shouldn't be chewing ice but who listens right yeah it's personal behavior uh but it's interesting how it's difficult to get patients to floss many patients do not floss and of course your patients that have these temporary crowns are picking up the floss every night before they go to sleep. So any other temporary filling issues that a dentist who's coming out of dental school should be aware of? Give us some scenarios, some clinical scenarios. You already did to some extent, but if you could give us a few more where they can anticipate some of the issues that you've... for the last 36 years, seen many of in your day? Well, I think that, you know, the direction is, when I was in dental school, we were doing a lot of inlays, unlays, cast gold. And now I think the direction has moved to all ceramic ones, zirconia and stuff, and temporizing those. The easy way to temporize it would be to use Tempit LC or the Tempit Ultra F, and I prefer in those situations the Ultra F, because it sets harder, is to make the temporary on that. And, you know, worse comes to worse. If you're adjusting the thing and it pops out, then just cement it in with the no mix. That's not a problem. Also, screw retained. A lot of stuff with implants has moved to screw retained. We sometimes have to access these holes. And I had a patient came in who lost a crown over an abutment, and it wasn't screw retained. It took me forever to drill through the composite that the guy had filled up the entire hole with, no cotton pellet or plumber's tape. The key with these materials is if you basically put in, let's say, the Tempit LC, It's much easier to get in there and re-access if you have to tighten that screw, and sometimes we have to tighten the screws. So the direction is use the right material under the right circumstances, and it limits our headaches later on. What kind of endodontic file do you use to remove that? Any endodontic file. You want to use usually a wider one. Let's say a size 30 or 35. All you do is just thread it in because it engages the material and tug, and it comes right out. Okay. So it's very easy to remove. And that's a hand file, right? Yeah, a hand file. The key basically is if you're doing a screw retain crown, you're going to basically fill about three quarters of that hole, the depth of that with the Tempit LC, and then you just put a little bit of flowable composite to seal the rest of it. Do you use photography at all on your aesthetic cases, Dr. Kurtzman? You mentioned how important it is to have a good provisional so you could evaluate the satisfaction of the patient and then even possibly use that provisional to send to the lab and say, hey, our patient was extremely... satisfied with this provisional see if you can make it look just like this so let's switch gears just a bit and i'd like to talk about photography in your practice do you use photography in your practice with your restorative cases especially the ones that are more focused on aesthetic dentistry I think it helps with communication with the lab if you take pictures of the retracted smile beforehand. So the lab has an idea of what they're starting with and what after you, before you prepped, especially with veneers. A lot of times we're doing no prep veneers. And this way the lab has an idea of what's showing. You want to basically show them the smile line. So when the patient's smiling, they see what it has to be. They can see the shade of the other teeth. If you're blending, let's say you're doing a single crown, what you want to do is you just don't want to say, hey, it's a Vita B2. What you want to do is flip that over so you put incisal edge to incisal edge of the tooth in the shade tab and take a picture so they can see the gradation of shading on that. The more you communicate with the lab with pictures and stuff, the better a result they're going to be able to provide you. That's the key. And also what happens is a lot of times you put the final stuff into patients, and even though it's been two weeks, they forgot what they looked like that drove them into your office to have the aesthetics. And what I usually do is I'll show them a picture. Hey, this is what you looked like before we even put anything in, and I show them the mirror. So now they remember what they started with, and they're less likely to complain about the result because they always think, oh, my mouth was perfect. before you did all this, no, it wasn't because you came in because they were crooked or discolored or whatever it was. So they have that fresh image in their head, even though they've had it for 30, 40 years, they basically forget about that. So now you're showing them and they're more likely to go, they see the transition you've helped them with. You have some interesting patients that visit you, Dr. Kurtzman. Well, you know, it's funny. I had a patient who was in her 80s years ago, and her daughter spent like two or three years trying to convince her to have veneers done. So finally they come in, and my mother, I've convinced her she should have veneers. So we're sitting there, okay, that's not a problem. We're going to do, I think, eight teeth. And she goes, I want the whitest teeth you could possibly have. So I pick out an OM1. I go, I would never pick this because it's not going to blend with anything else. And her daughter and her start arguing. I said, tell you what, I'm going to leave the room. You guys. come to a decision what shade you want. And when I come back, you make a decision. I come back in and the daughter goes, my mother wants that real bright white shade. I go, look, it's your mother's mouth that makes her happy. She goes, yeah, I guess you're right. It did not blend with any other teeth in her mouth. They were all discolored, but it made her happy. And I think she lived for another two or three years and she was happy with her smile. So we pick, you know, the patients pick out the stuff and sometimes it's not what the shade we would select, but. The key is making them happy. Yeah. No, there's no question about it. There's no question about it. But I think taking photography, taking pictures on every patient that comes in the office, I think is important. This is where the starting point is. Whether they move forward with aesthetic dentistry or not, you have those photos and you could always show them those photos on a screen. they could understand you know what you actually did like you said they may not really remember especially if it's a slow transition into a more aesthetic smile where it's they're not doing it all at once whether it's because of financial issues or timing for whatever reason they may not even remember like you said what they had originally what kind of camera do you use in your office I have it on Nikon, but I tell you, to be honest, I've been using my cell phone most of the time because it takes great pictures. So it's quick and easy for those things. Another thing that you want to consider, if you have a patient that is sort of vacillating on whether they should have the aesthetic stuff done, what I'll do is I'll take a picture and then I'll have them back. I'll use Photoshop and I'll alter that picture a little bit to show them this is what we can possibly do for you to improve it. And a lot of times that's what convinces them because they're like, well, I don't know if it's going to make that much difference. and they're looking at the picture in the mirror and they're going back and forth and go, yeah, that is a big difference. Let's do it. So I think photography definitely helps. Well, you're proficient in Photoshop. Many dentists may not be. I'm sure there are software applications out there that do that. Yeah, there's applications that will do it automatically for you. And there are services. You say, I don't want to mess with it. There are companies out there that will provide that service for you. But I think it really helps convince the patient a lot of times when they're like back and forth, because those are usually the patients that are in your practice. And you mentioned, hey, are you happy with your smile? I go, eh, I'm not really sure. Those aren't the ones that come in because they are seeking a change. So sometimes you can convince them, and sometimes it's food for thought. It may be a year or two before they finally come in and say, all right, I'm ready to do this. And I'll give you a perfect example. I just did a veneer case on a patient, I think about a month and a half ago, and we had been talking about it for two years. And she finally just said, and she's in her late 70s. She finally decided, I got to do something for myself. I'm tired of doing it for my kids and everybody else. I want to do it for myself. And the joke is, when I get done, I said, now you can smile, but I guess we're all wearing masks, so nobody's going to notice the difference anyway. And she thought it was funny and laughed. Thank God the pandemic is waning to the point where most of us have taken our masks off. And now she's got a beautiful smile. It's totally true, Dr. Kurtzman. We have to listen to the patient. Every patient has different needs and different desires, what they want their smile to look like. And it's not always up to us to say. what they should have. You know, I would like to say that it's really important to understand the materials that we use for temperization. And that's what your main thrust of this podcast was about. I do want to ask you about the trend among your peers. Have you seen same-day dentistry taking off as much as, and that's chairside milling, as much as was marketed? 10 years ago where they said we're all going to have these milling machines chair side and we're going to be delivering these crowns in one day. What are you seeing as far as that trend? I'm not doing that in my office, but I have friends that are. I think it's slowly we're seeing more of this. I think with printing, we're seeing a lot more versus milling. I think that because it's less expensive to get into the. into printing. You're virtually designing everything in the computer. It's a little easier. I think the direction is moving in that direction. I still think a small percentage of dentists are doing that. I think that it helps in some situations. It really depends on what you're doing. My patients aren't like, I want to come in and be done the same day. my patients are you know they understand the process we're going to do this you're going to be in a temporary you'll come back in a few weeks and finalize everything insert it so they're not having an issue with that but i i think it really depends on what you practice i think if you practice let's say in los angeles or maybe new york city where you get people that are just like hey time is urgent i want it i want it done yesterday I think those are the areas that you're probably seeing a lot more of this being done. But it's slowly reaching out into dentistry. So you think it's more demographics as far as location, not necessarily how long you've been practicing. So you've been practicing, you mentioned 36 years. Do you think that you're in an age group where you're not going to delve into that technology, whether it's milling, which I do agree, 3D printing, I think, will take over eventually because it is much less expensive and probably more efficient in a lot of ways. They just don't have the materials to work with the 3D printer yet to create these and fabricate these crowns that are comparable to what's fabricated chairside with milling, but they're getting there. Do you see yourself or someone that's been out there 36 years doing that? You know, I think that people and I tend to be more technology oriented than material and stuff oriented than my contemporaries or my age range. I think a lot of the older guys are just don't want to be bothered with stuff. I think the younger guys are more techie. So they tend to do it. The only problem is that a lot of these guys are coming out and they're working as associates for old codgers like myself and, you know, my age range. And those guys don't want to invest in it because the problem is they're figuring out you're an associate in the office. You could be gone in two years. And then I'm stuck with all this equipment. But I think the younger guys, as they're starting their practices on their own, are embracing a lot of this technology and it's moving forward. I do think a lot of the printed materials, we're going to start seeing stuff coming out that could be used as permanent crowns that are comparable to milled stuff. Yeah. When you say guys, you're talking about women and men, because I think there are more women in the profession now than men. Texas in general, it doesn't matter what the gender is. But I think the younger people are just more. tech-oriented than the older guys. And it's interesting, you know, I deal with people, and some of them are in their 70s, don't even do email. It's like, you have a fax machine in the office? No, I don't. I go, oh my God, it's like, I've had a fax machine for 30 years. How do you not have a fax machine? So I think that younger people embrace stuff, and I think the technology has gotten easier to use just in general. So I think that we're going to, and it's gotten less expensive. I mean, if you look at a lot of the stuff where it was 5, 10 years ago, it's much less, it's a fraction of the today. And the materials have gotten better. So I think that we're moving more technology-wise to easier, better quality dentistry. Yeah, I agree. I'd like to thank you, Dr. Kurtzman, for your insight into all this. I think the temperization discussion we had is very important. And I'd like to thank Centrix, a great company that makes these materials. They sponsored this podcast. And to our listeners, if you're looking to get more information on the temporization materials and cements and so forth that Dr. Kurtzman referred to, feel free to Google Centrix or just go to centrix.com. I'm not sure if that's the web address, but I assume if they Google Centrix, C-E-N-T-R-I-X, you'll find it. Yeah, centricsdental.com. Yeah, thank you. And it's always good to try the material first. I'm sure there's ways where you can get samples or pick up some trial kits and see what you think of it. But it is an important part of the restorative process, as Dr. Kurtzman pointed out. So we thank him for his insight. Thank you very much and hope to see you on another podcast in the near future. Thank you for having me, Phil.