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AUDIO - Ron Jackson - HSP #103
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VIDEO - Ron Jackson - HSP #103
Have composites completely replaced amalgam? Is amalgam obsolete? Listen to Howard and Ron discuss.
Dr. Ron Jackson is a 1972 graduate of West Virginia University School of Dentistry. He has published many articles on esthetic, adhesive dentistry and lectures across the United States and abroad. Dr. Jackson is a Fellow in the Academy of General Dentistry, a Fellow in the American Academy of Cosmetic Dentistry, a Diplomate in the American Board of Aesthetic Dentistry and is Director of the Mastering Dynamic Adhesion program at the Las Vegas Institute for Advanced Dental Studies.
Dr. Jackson practices in Middleburg, Virginia emphasizing comprehensive restorative and cosmetic dentistry.
Howard: It is a huge, extreme honor to be interviewing one of the biggest legends I've ever met. Ron Jackson. Basically you and Dickerson and [Hornbrook 00:00:19] basically are probably going to be credited for starting the whole cosmetic revolution. LVI was started in '95. You were the first big key name they brought on the year after '96. I mean, from '96 when you started to probably the peak of the NASDAQ in 2000, dentistry could only be summed up in one work: Cosmetic. It was the birth of the AECD. It was the cosmetic revolution.
On that entire cosmetic revolution, it was you and Dickerson that pretty much lead the whole things. Maybe if a company had to get credit for something, that was really Ivoclar. They were probably behind that 110%.
Now it's 2015. LVI was started in '95. You started in '96. What do you think of the cosmetic revolution now that it's twenty years past? We're in the second generation. There is dentists graduating that were just pretty much born right when this started. What do you think of the cosmetic revolution?
Ron: It's still going. There are people that want to enhance their smile, enhance their appearance. It gives them psychological self esteem. We all want to look our best. That aspect of it is still there.
Now, you hear about the economy. You know because you're the MBA guy here. It certainly did slow down during tougher economic times but doesn't go away. It comes back. People can table it because it's elective. That's what the definition of cosmetic dentistry is. It's 100% elective. It's not needs based from the standpoint of disease.
Aesthetic restorative dentistry, let's talk about that because that is now what defines dentistry. The reason why I suggested posterior composites as a topic is because that embodies aesthetic restorative dentistry. It's needed restorative dentistry. Has a lot of benefits. The adhesion technology, adhesion revolution. We talk about the aesthetic revolution. You could just as easily say the adhesion revolution. It started at the same time when we were able to bond to dentin in there.
Today, restorative dentistry has transitioned into aesthetic restorative dentistry. It's restorative dentistry. It's needed but it looks good. You get the advantages of conservative preparation because you can't pick up a journal or magazine, even you or Dentaltown, talks about minimally invasive dentistry, MID. There's an organization based on this whole concept. That's what the adhesion revolution allowed us to do.
Working with composite. I just want to say this one thing about it and then we can take it wherever you want to go, but this is a good introduction. Working with composite. Our profession tends to disagree on a lot to things. Very controversial. Just about everything people have differences of opinion on, but one thing all profession agrees on, Howard. That is that the most conservative restoration that can be done in dentistry, whether it be interior or posterior is direct resin.
That's why this restorative has become so prominent. I don't know whether you know this statistic or not and Gordon quotes this. He had it in one of his articles that in 1990 why 94% of dentists used amalgam, whereas by 2010 … This is United States statistics by the way. They come from a dental consultant, Limoli in Atlanta. 1990, 94% used amalgam. By 2010, posterior composite restorations exceeded amalgam by a ratio of 2 to 1. A third of dentists don't use it at all anymore.
I'm not saying amalgam is dead. I'm not going to even bad mouth amalgam. That's ridiculous. It served our profession well for a hundred years. It's still around. It will still be around for a while although in greater decline. Probably what's stopping it from declining even faster is the fact that it's much easier and forgiving than placing posterior composites. If posterior composites were faster and easier and more predictable, less time consuming, less tedious to place, you would see amalgam pretty much disappear, because it has drawbacks like corrosion and expansion and of course it's not aesthetic but it has some advantages.
If we can develop a technique that allows us to place a posterior composite in the same time and as easy and predictable as amalgam, why then, that's pretty much going to do it. We're getting closer to that, Howard. There's been a big movement in this regard, not just from adhesive standpoint, the matricing standpoint, but also from new composites specifically developed for posterior use. By that I'm talking about the [above fills. 00:05:52]
Howard: I want to back up a little bit and first of all say, I've always thought mental health was more important than oral health. I think one the cosmetic revolution gave us the most is when people cover their mouth when they smile and they don't like their teeth and whatever, they don't take care of them, but if they love their fishing boat or their bowling ball they'll polish it every day.
Ron: You're right.
Howard: When people get a nice truck that they love, they go out there every Sunday and wash it with a bucket of water. I've seen more people, that after they got bleaching or bonding or veneers or ortho or braces, whatever, they are the most faithful people getting their teeth cleaned, brushing. I think the human condition is, you're either in or out. When they don't like something about, whatever, they're either in or out.
I want to start with, the funny thing about amalgam, the reason I don't like bad mouthing amalgam is because we forget that there's 7,000,000,000 people on Earth and that 3,000,000,000 people live on less than $3 a day. I've been to countries in Africa where if you're going to take away amalgam, and when people bad mouth it and they're in rich countries like Geneva, Switzerland. It's like, "Dude, have you ever been to Tanzania? Have you ever been to Tan- Are you kidding me?"
Howard: No, I'm talking about these dentists in rich countries bad mouthing amalgam. It's market segmentation. For every Lamborghini, someone's going to take the bus. It's all in-between. Humans tend to be extremists. You almost never find a moderate.
Ron, let's start with, you said something very profound that the bonding revolution started with the cosmetic revolution.
Ron: It did.
Howard: What generation of bonding agent are we on right now? 847 or 912?
Ron: Something like that. What a ridiculous term. We talk of terms of generation. I'm totally against using that terminology. Those are marketing words, Howard, to make dentists feel like … A company comes out with the tenth generation and the dentist says to himself, "Oh my God, I'm on the fourth. I'm that far behind. I'd better buy this tenth." It's a marketing word. I suggest in my lectures on adhesive dentistry that we get that word out of our vocabulary and talk about whether something is an etch and rinse or a self etch or now the new class of adhesives which is called universal. That's it.
Howard: Ron, you're known as the cosmetic dentist. You're known as the real world dentist. I think it's cooler than hell that you've done all this while just practicing in Middleburg, Virginia.
Ron: One stop light town.
Howard: A one stop light town. What I think is even cooler dude, is I'm 52 and you're 68 and you're still doing it cause I you love it. You look younger than I do and you'll probably ...
Ron: I think it's the hair, though, Howard.
Howard: You're probably go to my funeral. Yeah, I just think it's so damn cool. You have enough money. You could've retired 10 years ago. Here you are, 68. You're not doing it for money. You're doing it for love. What you're even more known for is, again, instead of just the cosmetic revolution being veneers on the front on pretty girls, you just said in your opening that you applied cosmetic dentist to restorative dentistry in the posterior.
My first question to you is, walk us through that. Remember, tomorrow night I'm going to a graduation deal at A.T. Still, 5,000 kids are coming out of dental school. My first question to you is, diagnosing [inaudible 00:09:23] when would you do a direct filling? When would you do a indirect? Then, walk us through those techniques of a direct versus indirect. If you can, they want to know exactly what you're using. If you could name your bonding agent or your material. That's the number one complaint I get. "He said a micro-fill but he didn't say what brand."
Ron: Yeah. In terms of diagnosis, that bar is being moved. Our direct materials now are so good. They've reached a level where they wear similar or even better than amalgam. Consequently, fracture toughness, structural strength, density is reached the point now where they're so much better.
What I'm getting at is, there's really almost no size restoration like there used to be. You used to say that if the isthmus width of the cavity was more than one third the buccolingual width of the tooth, you really should think indirect.
Now, that's not true. I'm doing far fewer inlays. That's not to say that I'm not doing inlays. There's other clinical conditions, greater than normal inter-tooth distance and various things that would require me to do inlays.
Basically now, when I'm going indirect it'd be more like onlays and things. When you start to replaces cusps, that's when creating the correct amount of contours, pit and fissure grooves, contact. All those factors that go into developing a quality replacement of the missing tooth because remember, these things, we're not just doing filling. Posterior, these things have to function. Triangular ridges and proper marginal ridges, functional stops, the occlusal anatomy is all critically important, to goes to function. That's my definition of what a restoration is. A restoration is by definition, replaces the form and the original condition.
If you just pick a blob of composite and fill this gigantic hole. After you've done the tap tap, grind grind, tap tap, grind grind, you've got nothing but a flat surface with no proper contours or anatomy. You see what I'm getting at is, once you start replacing custom walls, that's when you start thinking indirect. There's still a powerful place for indirect onlays. Onlays are more conservative than crowns.
I consider indirect aesthetic onlays, whether it be ceramic or indirect composite, to be almost the Rodney Dangerfield restoration in dentistry. They don't get any respect but they should be done more often than say, full crowns. Where that line is today, you start out by saying, "Where do you stop doing directs and where do you pick up going indirect?" That's where I think it goes, what I apply anyway. It's different for different people but I would apply it whenever I'm replacing a major cusp and a molar. A minor cusp I wouldn't worry about. The major cusp, that's when I feel that I can deliver better restoration. A more properly contoured restoration, let's face it, when the technician is working calmly on mounted models at the bench without the time restraints that you and I have at the chair, they can create the kind of functional anatomy that's required for posterior teeth for people to chew with them.
That's really the issue. I can't give you a specific percentage of tooth structure missing and this is when you go indirect and this is when you stay direct. That's never going to work now. I hope I've answered your question. Does it make sense what I said?
Howard: It does make sense. Let's go through both of those techniques. Let's start with the far, far, far more common, which is a direct. There's probably 10 directs for every indirect. It's the most common tooth to get an MOD anything or a crown or missing or implant, is a first molar. It's a first molar. It needs a big MOD. You're going to go direct.
Ron: I'm going to go direct. You want to know my materials and step by step, how I go through that process?
Howard: Yeah. Go in more details because some of the things, just going by controversies. Some people swear by rubber dams. Some people say, "I can do it with a isolite." Some people say, "I don't need it." Young kids tend to think only old guys like us need loops, that they're 25. They're looking at some older guys saying, "Well, yeah. You don't have any hair and you're old and you're senile. You need lubes. I don't need them. I'm 25. I can see." Would you use a rubber dam? Would you use loops?
Ron: Absolutely loops. I go further than loops. I want to have a fiber optic LED headline on me as well. Back in the mouth, trying to see back there. It has nothing to do with young versus old. Name me a surgeon working in a small area. Name me any surgeon working in a small area that doesn't wear magnification. You won't find a surgical physician working in a small area without magnification. We should be using it, too. Besides that, it's not only good that you can see into small areas and when you see what you're doing, you can do a better job. That's just bottom line.
The other thing is, at the end of the day, you're not as stressed out when you're trying to strain and see back there. That's the same thing with the fiber optic LED and light. The nice thing about it, when you're doing composites in the posterior, where the light is a premium, you can't see, you bring your dental light down. It tends to set up your composite prematurely.
If you are wearing a fiber optic LED light with a filter on it, you're going to have much more illumination and be able to see. I turn my dental unit light off so that covers a visual aspects of it. Again, at the end of the day, your back is not as tired, your eyes aren't as strained. You also can feel better about your dentistry because you can see what you're doing. Our type of work doesn't lend itself to a Braille approach. It's as simple as that.
Now, as far as rubber dam is concerned, I know that 50% of dentists don't use it. I know that most dentists would rather walk on hot coals in bare feet than to put a rubber dam on. I use it. I use it because it's simpler, it's faster, it's easier and it's an absolute. I want the lips, the tongue, the cheek. I want to open up that quadrant. I can see, my assistant can see. When she can see, she can assist me better. It's expediency. Besides that, I don't have to worry about contamination during the process.
I know all these other things. The isolite and everything else is probably very commonly used. Certainly, it's better than cotton holes. There's alternatives out there that people use. The key is, you've got to have isolation. Adhesion requires isolation. I don't like playing games or worrying about it. When I put a rubber dam on, it's out of the picture.
MOD. After you've prepared this cavity which of course, the nice thing about composite again, I go back to that one of the benefits of composite is there's no required preparation geometry like there is with non-adhesive dentistry like amalgam where you have to use your undercuts. You have to create dovetails and you have to do all these kind of things, mechanical locks. You don't do that with adhesive dentistry. You take out the old restorative. If there's one there, you take out the disease. What's left is your prep.
After we've got that done, I like using sectional matrices. There's 2 of them out there that are outstanding. These are these companies embedded the sectional matrix. What they did is they perfected it. One is Garrison composite-type system and the other one is Triodent, the V3 system. Now, the Triodent system is marketed and sold in the United States by Ultradent.
Howard: Oh, really? They're Australian company so they're …
Ron: No. It's a New Zealand company.
Howard: Oh, New Zealand.
Ron: It's a New Zealand company but Ultradent distributes their product here in the United States. Destsply also has a sectional matrix system as well but I think that Triodent's making it for them. They're selling it as well.
Howard: Where's Garrison out of?
Ron: Garrison, I believe, they're Indiana. They're a father-son dentist. By the way, the other system, Triodent in,
Howard: New Zealand.
Ron: … New Zealand was founded by dentist. Dentists are very clever and, as a general rule, they oftentimes … Not myself. I tend to steal ideas but people that create them, very clever. They see a problem.
As I said, they didn't invent the sectional matrix system but both companies really perfected it. You just can't contact it. People have trouble with contact. They should really look at one or the other of those 2 systems. You can't use them 100% of the time, though. About 90% of the time, I use it as a default. I go and ask …
Howard: Would you say, if you ask a dentist, "What is your top 3 problems with a direct MOD composite? Contact?"
Ron: Contact is an issue. The problem is you don't know you don't have it until the end of the visit and you ask your assistant for the floss. You just hope there's some contact there because if there isn't, you're dead. The other one would be and that's my next step is adhesion. Once you've set your matrix in place, the next thing of course is placing the adhesive. Whether it's an etch and rinse or a self etch, fact of the matter is, etch and rinse is a little bit more exacting. It's not hard, by any means but you can't overetch, you can't underprime. You just have to do it right and you [crosstalk 00:20:06]
Howard: But go through that technique. Would you fill up the whole thing with …
Ron: You start on the enamel first because enamel needs a minimum of 15 seconds. Here's the problem with dentists in the past. Getting post-operative sensitivity following placement of a post-year composite is sometimes they'd over-etch. They fill up the tooth. Then, they just wait and they guess at 15 seconds. We can't guess at 15 seconds. That's ridiculous. My suggestion is you start on the enamel with the acid because you can't over-etch enamel. If it's longer than 15, 20, 25 seconds, it doesn't matter.
After you've done the enamel first, then you fill up the tooth. At that point, you can count to about 12. That guarantees that the enamel gets 15 plus seconds and the dentin, 15 minus seconds. Then, again, you have to wash it off and achieving the right because the etch and rinse adhesion is wet bonding. We're bonding to wet dentin.
Another problem dentists had was, "Well, how wet is wet?" In establishing that moisture content of dentin that the primer's attracted to. After you wash it off, you blot to a certain moisture content. No water on the surface but clearly the dentin is not dry. That's a point.
The third point is applying the primer. You can underprime. A lot of dentists will do that, too. They will just put one coat on. Then, they grab the air syringe because they say dry it and they blast it and when they blasted it with air, they blow the primer off the tooth. There'd be more primer on the wall than the tooth.
I happen to watch all these mistakes being made as I taught my courses at LVI, dentists doing live patient courses, you get to see what they're doing. They make these mistakes without even knowing it. You don't want to underprime. I always advise, put on one coat of primer, agitate for 10 seconds, dry it and then apply another coat.
Once you've done that …
Howard: What brand?
Ron: If you're going to use etch and rinse adhesive, there's 2 categories. Three step etch and rinse adhesive which might be Scotchbond MP multi-purpose. If you're going to use …
Howard: That's 3M, right?
Ron: That's 3M, Scotchbond 3M. If you're going to use a … You've got another one under etch and rinse, too. That would be OptiBond FL. That's Kerr. That's oftentimes considered the gold standard. Research uses that oftentimes as the control, OptiBond FL 3 step etch and rinse adhesive.
Howard: What generation is that, the 3 steps?
Ron: Those would be fourth but I …
Howard: But you don't like those terms?
Ron: I don't like the term generation. I'd rather call it a 3 step etch and rinse adhesive. How many steps are there in a 3 step etch and rinse adhesive? Three. What is it? It's etch and rinse. You call it by what you're doing with it and how you handle it rather than some stupid generation name.
As far as 2 step etch and rinse, you've got multiple materials there. 3M's also has a single bond OptiBond. Solo Plus would be Kerr. You've got Bisco's One-Step Plus. You've got lots of different ones there. I'm leaving a lot of them out but nevertheless, there's an example of …
Now, the other thing to do is go self etch. Tell dentists, if you're going to have a problem, if after trying to do it correctly and you still have a problem , your fallback position would be a self-etch adhesive. Two step self-etch adhesive might be clear fill SE bond or protect bond and secure RA. XGR, OptiBond XGR, that's a Kerr product. There's a bunch of them in that 2 step self etch.
The other thing about doing a self etch, though. The research shows very clearly and I recommend that dentists selective etch the enamel, selective etch the occlusal enamel first and then use the adhesive exactly the way the manufacturer states.
Now, with OptiBond XTR, that's a Kerr product, the one I mentioned a moment ago. You don't necessarily have to etch the enamel. Research has shown that it does in fact etch enamel adequately without the use of selective etch but any other self etch product out there, I recommend selective etching the enamel first, including the new universals. There's whole group now of universals. They are coming on strong. Research is showing these things are different than the one step self etchers in the past. Some may actually already be proven enough to be confident to go ahead and use them although there's a lack of clinical trials on them. A lot of research is showing these materials are different than the historical adhesive/
Anyway, after you've done the adhesive, when it gets to putting the composite in ...
Howard: I'm right there.
Ron: Question on it?
Howard: Yeah. What do you use? Ron Jackson in Middleburg, Virginia.
Ron: I'm using Kerr's OptiBond XTR.
Howard: Which is you said the gold standard?
Ron: OptiBond FL,
Howard: Is the gold standard.
Ron: … was the gold standard. That's what I used for many years.
Actually, Howard, I used a number of products because I have to know about them in order to teach them but I did use OptiBond FL pretty much exclusively for my directs for many years. XTR now is also a Kerr product but Clearfill SE, I use that for a long self etch product, a 2 step self etch by Kuraray. I use that for many years as well. XTR is classified as universal. I tend to use that quite a lot now.
Howard: What is the XTR stand for? Extra Terrestrial Resin?
Ron: Extra Retention, I guess. You know, I don't recall now.
Howard: But doc, would it be fair to say that the Clearfill SE or the OptiBond XTR, that those have less sensitivity because they're less tightening sensitive?
Ron: Yeah. Self-etchers, what makes them less tightening sensitive is the fact that you can't over etch and you can't under prime. Two of the most common mistakes dentists make. Also, there's no issue with trying to figure out what constitutes wet dentin or wet bonding. You don't bother with that with self etchers.
There is less land mines, if you will. It's a little less exacting. Both work very well. I should mention that the … We got into brand names and we're talking about what I use but I also want to make it clear that there's so many good adhesives in the marketplace. There really are. That what's more important is the dentists and the dentists doing it correctly. Whichever class they use. I just feel that they're getting simpler and this is where this new group of universals.
The whole premise behind a universal adhesive, why do we have them is because what we would like. You and I, dentists practicing in the trenches, we'd like one adhesive that does direct, indirect, you can bond a post, you can repair porcelain. In other words, we'd like to have one adhesive where we use it the same way every time. The protocol doesn't change, no matter what you're doing. You do it for everything. That's where these universals are going. That's a further simplification.
Recent survey that I saw about dentists was that most have 2 different adhesives. Some have 3 different adhesive, depending on what they're doing. That's complexity right there. The assistant has to figure out, "Let's see. Which one do I get off the shelf today?" The dentist then has to remember the different protocols for all the different adhesives.
We're headed in the right direction. When it comes to success with post year composites. That's where we started with this, simplifying the procedure, making a more predictable. We now have contact instruments and the instrumentation, these midsectional matrix systems that give us the contacts so that worry's gone. We've got better adhesives that are simplified. That worry is either gone or going, depending on the dentist. Most dentists don't have any post-operative sensitivity anymore. They've learned how to conquer this problem. They've learned the mistakes and they've gone to courses and the materials have gotten better.
The third part of the …
Howard: Can I back up on the adhesive that we're going?
Howard: Back to adhesion. How do all these bonding agents work when they're before the dentists is doing adhesion, they're doing other products like they might use Peridex to rinse of the breath or chlorhexidine gluconate or some rehydrate it with Tubulicid Red.
Some people say, "Well, here's an exact chemistry set that was designed for dentin enamel," but before you get the damn enamel, you're putting other chemicals on the tooth. Could that interfere with the bonding? Do you use chlorhexidine to clean out the prep? Do you use Tubulicid Red? Do you have other things that you're not talking about in between the prep and you start doing adhesive dentistry?
Ron: That's a very good question, by the way. I'll try to answer it in a short time without getting too complex. The short answer is, if I'm doing etch and rinse adhesion. If I'm using an etch and rinse adhesive where the phosphoric acid is etching the dentin, following that, either chlorhexidine, glutaraldehyde and a product common one is called Gluma but clinicians choice has 1G5 and Danville has one, MicroPrime which are lower in cost, the same thing. They're 5% glutaraldehyde and a primer. They call these things desensitizers but the active ingredient is the glutaraldehyde.
When the etch and rinse adhesive, after you wash the acid off and you blotted it to a certain moisture level, you could add either the glutaraldehyde or you could do a chlorhexidine. Neither one, or if you want to use the Tubulicid Red is a benzalkonium chloride. That's a very good anti-microbial. If you want to use those, fine. You would use them after you etch the dentin there.
Generally, I think if you just use a glutaraldehyde, you've covered all your bases but none of those 3 products that we just mentioned interfere with adhesion. Now, when it comes to the self-etch products, it's a little controversial there. There's not agreement in the literature whether those things do any good or not in terms of improving the dentin bond durability because that's what we're talking about here and dealing with bacterial component. Certainly, you would use them before you use the self-etch primer in the case of using self-etchers because you can't put it between the self-etch primer and the second bottle which is the bond resin but they also, if you use them before the self-etch adhesive, they're not going to interfere with bond either. We have science on that. The question is whether they actually are going to do you any good in the self etch category. In the etch and rinse, yes. I do recommend.
Howard: What exactly do you exactly recommend? The glutaraldehyde?
Ron: I use the glutaraldehyde. MicroPrime from Danville or G5 from Clinician's Choice, exactly the same as Gluma, half the cost.
Howard: Right on!
Ron: Gluma has expired and so other manufacturers are making it at a cheaper price but Gluma's still used by a lot of dentists. They're all the same.
Howard: Okay. I'll stop interrupting you now. You can go to the third part, the direct part, the filling.
Ron: The third part is I wanted to get to that because this, I think, is the … it's exciting. It's the newest part. Our problem with this whole post year composites is there's 3 parts to it. The contact issue, the adhesive issue and placement issue.
The placement has been where we start with a low viscosity liner, either a flow bowl or a low viscosity resin ionomer like a Vitrabond. We start the process with something like that to get adaptation to the pulpal floor and to fill in the undercuts.
Then, we place multiple 2 millimeter increments. Each increment has to be carefully adapted intimately to the cavity walls and cured. We end up with 2, 3, 4, maybe 5 increments. It would take so long and it was tedious and time consuming. It's very exacting. If you don't get it well adapted, you're going to have gaps and seams and microleakages and all these things.
The real time consuming tedious part has been the actual placement up until about 5 years ago. As I mentioned at the start of this, our composite materials, I take my hat off to the manufacturers. I'm talking about multiple manufacturers here. All the big names for sure. Ivoclar and Kerr and Kuraray and 3M and all of the manufacturers come out. These materials have gotten so highly filled and so strong and wear resistant that they're wonderful but they still require this tedious layering, blinding and layering, I call it, technique.
Manufacturers 5 years ago turned our attention to making it faster by creating what's called bulk fill, meaning you can place now 4 millimeters, even 5 with one of the products out there. SonicFill. At this point, we can do this process faster and easier and in far less time. We need to get to that point.
You talked about bringing this to the masses. Henry Ford said that, "Until technology's available to the masses, it's just an interesting curiosity." You talking about in countries like Africa and all these other places where they're lucky to have dentistry. Yes, I agree that maybe some of this dentistry we're talking about is ways off working there but here in our country and in developed countries, we've got to make it again for the masses.
What we're seeing now, you're all Dentaltown, I've got it right in front of me. The last issue. You had a question in your survey, your poll section asking, you said, "Do you place bulk fill composite restorations in your practice?" Fifty-three percent of your people responded yes which is a little larger than the other surveys of our profession right now but it's probably because your people are really on top of things.
That's over half now of Dentaltowners that are using bulk fill materials. The other half that aren't said they don't trust the technology is the main reason for not doing it. I've got good news for them. I listen to Gordon's year end review with him a few months ago. Gordon was, he's been little slow in this area to embrace the bulk fills. Here is where you talk about disagreeing with God. My Lord, I tread very lightly right now but in fact, the science on bulk fills is showing that indeed, across the board, they're meeting manufacturer's claims.
Right now in 3 of the journals that I get, Dental Materials and Journal of Dentistry and Journal of Adhesive Dentistry, every month, there's at least 2 articles on bulk fills. Over the last 12 months, it ruling out like crazy the research community has realized that clinicians are using these now. They're growing like crazy out there. They represent almost 30% of the mass market now are using bulk fills for post-year composites. Your people are, as I said, over 50% using it, bulk fills versus the layered. Consequently, they're here, they're working and the science is proving them out across the board.
The one issue's obviously with bulk fills … Is not one, it's 2. Depth of cure and shrinkage stress. If you're going to put in a big wad of composite into a tooth and you're going to bond it to that tooth, it is the shrinkage stress going to break the tooth or break the bond. The other thing is, is your light going to cure through that thick of material because historically, we've been taught this can't be done. Historically, that was true. I think with the listeners and people that I talk to and teach to and need to understand is that these materials are different. Manufacturers, there's been a breakthrough. They're changing the way they [plummerize. 00:39:12] They're changing photo initiators. These are not the same composites that we've been using. They're the same in the basic chemical platform, a fact relates to filler particles, highly filled materials.
In terms of performance, they will perform like the others. They also are, as they said, methacrylate so they'll work with any bonding agent. They work with each other. The thing is, they have changed the way the plummarize or they change the [plurization 00:39:47] kinetics of these things and they're working.
I could drown you with scientific references but I don't think that's going to get us anywhere. They've fallen to 2 categories, Howard. This comes to personal choice. Either the flowable ones and the first one in that category was Dentsply's SDR flow. I don't know if you're familiar with that but they were the first company to come out with what they call the flowable base. Four millimeters of a flowable. You're basically replacing the dentin with the flowable and certainly not strong enough for occlusal forces. After you put 4 millimeters of flowable in there which adapts very well because it's flowable. You cure it and they've controlled the shrinkage stress. That works. Five years into it, there's no question about that any more. Then, you put a regular composite, 2 millimeters on top. Fine. There's a whole category of those flowables like a name a bunch of other ones as well.
The other category are the high viscosity. Bulk fill flow materials. They're restorative composites. They're not flowable at all. They're extremely thick and viscous. All but one of those requires a flowable be placed first. In my opinion and even in the opinion of research that I could quote because they're so thick and viscous that trying to adapt them into the internal walls of the cavities is difficult. You end up getting some gaps or whatever. You put a flowable first. Then, you put 4 millimeters of shaded composite on top of it.
Those are the 2 categories. If we've got a couple more minutes, I'd like to,
Howard: Absolutely! We got all the time we want.
Ron: … full stop. By the way, I've used them all and they all work. Every one of them shortens the time at least a third. More importantly Howard, when you get old like me, you're not. You're still young but when you get old like me, it lessens the work, the effort. You put in a quadrant of composites. You put in a 5, 6, 8 composites a day. This is the most common performed procedure is post to your direct restorations in dentistry. General dentists, that's the most common procedure. You do a bunch of those in a day, you're tired at the end of the day. I've had dentists say, "You asked about an MOD." I've had dentists say that it's easier to do a crown. It's less great.
Howard: Don't you think that was even a big driving force of the CAD and CAM revolution,
Howard: … because why do you want to work for an hour and have insurance give you almost no money when you could do a CEREC and bill an indirect and bill out a lot more and make it out of … I think if you agree that's a huge driver of CAD CAM?
Ron: I do. I agree.
Howard: What would you say the average CAD CAM cost is versus direct? As far as what they're billing out for the patient?
Ron: An indirect could bill out, say, 800, 1,200, anywhere in that range.
Howard: Indirect and direct.
Ron: Direct is, you know, you're going to get $250, maybe, 300, depending on the practice. You're going to put in almost the same amount of time. That's why this placement, this third leg of the stool, if you will. After you've got the contact and adhesion, the third leg being the placement issue, needed simplification. It needed to be speeded up without compromising quality. That's what these companies have done with the bulk fill. That's why dentists are moving to them is they can actually place a restoration at the insurance fee. A lot of dentists place a post year composites at an insurance fee are making less money on that restoration than if they did the amalgam. The difference in the insurance reimbursement for a composite does not ... Between the composite and amalgam, that difference that the insurance pays, that little bit or more that they pay nowhere near compensates a dentists for the time and effort of placing the composite.
Howard: And the materials.
Ron: Yeah. We needed this. That's why I applaud these companies. Dentists are finding this out and I know Gordon still has concerns about depth of cure and shrinkage stress because science is there. In fact, his own newsletter in January of 2012, he reported in the CR Newsletter, depth of cure of I guess about 5 or 6 different bulk fills. All of them he showed met the company's specifications or claims of depth of cure.
I think he'll come around. I think he's doing it now, actually because he's usually on the front line when it comes to efficiency. Gordon works with 2 assistants. He's a terrific dentist. He's a terrific person. I've admired him and learned from him for years but I know that he's been a little slow in embracing this. I can understand that because it goes against what we've all be taught for years but they really have accomplished breakthroughs and much like we did with adhesion when it came to bonding to dentin, we started putting phosphoric acid on dentin. For I don't know how many decades, we were told you couldn't do that. Then, all of a sudden, we're all doing it but I think this going to be the same with bulk fills.
I want to talk about the last one. Here, I want to make a disclosure. SonicFill. I want to disclose that I acted as a paid consultant in the development of SonicFill. I still have a financial interest in the product. Kerr invited me about, I don't know, 6 years ago. This isn't the first composite that I've worked for, companies in developing a new material. This was certainly a breakthrough material because what SonicFill does is it uses sonic energy, uses a sonic hand piece. You get high frequency vibration. It lowers the viscosity of the material. There's special modifiers in the composite. That his very responsive to shear stress which is what high frequency vibration is. It's 84% fill so it's a very thick, viscous composite that sonic energy drops it instantaneously, 87% in viscosity, almost to a flowable.
Howard: Who makes that?
Ron: Pardon me?
Howard: Who makes SonicFill?
Ron: Kerr. I was privileged to work with brilliant polymer chemists and hand piece engineers. I was just a token dentist on this team. Of course, I'm the one that works with the material. They don't really work with it. It was an incredible sort of experience because it was new technology.
It lowers the viscosity 87% so it's going in, it's literally being vibrated into the tooth. You know how we pour models? How do we pour a model? We vibrate stone in the model. What does the vibration do? Give you adaptation. Gets rid of the voids. That's exactly what we're doing. We're lowering the viscosity of the material which starts out at a high viscosity, thick material, lowers it down to the flowable level, vibrates it into the tooth, fills it. SonicFill has a 5 millimeter depth of cure. One more millimeter than all the other ones out there.
Why is that important? Eighty percent of the cavities are 5 millimeters or less. What it means is 80% of the cavities can be filled with one fast shot. It literally will fill a 5 millimeter cavity in your MOD in about 5 seconds or less. It does not return to a very high viscosity immediately when you stop the hand piece. When you take your foot off the foot pedal, it slowly returns to a high viscosity. That's important that it retain the energy because you are going to sculpt this while it's still somewhat soft. Non-sticky because it's vibrating. You sculpt it. It doesn't swamp even though it's somewhat soft. As I said, it's totally non-sticky because of the vibration. You are going to cure this material while it's still energized.
The curve, the return to the original state takes about 15 minutes. You're going to sculpt and cure this within a minute or 2 at the most. You're curing it while the energy's still there. That's what gives it it's 5 millimeter depth of cure. It also causes it to really be the lowest shrinkage. By the way, the data I'm quoting now, I do want to reference this one. This'll be the only study I'll reference. The American Dental Association has a laboratory in Chicago. I don't know if dentists know this but our dues pay for the research lab that American Dental Association has. I'm totally in favor of it. I think it's wonderful because it's independent research. In fact, the ADA buys the material in the marketplace. They won't even let manufacturers donate the material. Their studies, when they're doing them, manufacturers don't even know they're done until they're published. They publish everything. It's really at arm's length. It's totally independent data.
October of 2013, a year and a half ago. They publish this 4 times a year, their research. A year and a half ago, the research was on bulk fills, the ones that were in the marketplace at that time. They compared them to standard layered composite. The data is really remarkable. I've referenced that one all the time because in their data, they show and this is the ADA. They showed that SonicFill actually not only cures to 5 millimeters. They agreed with Gordon and his CR report that it cures to 6 and actually goes a millimeter more than 5 but for safety, give you that margin of safety. Kerr recommends 5 instead of 6 but all the others also met the manufacturers claims in depth of cure.
Shrinkage stress. All the bulk fills compared to 2 very popular layered composites, all the bulk fills had shrinkage stress in the same range of our typical materials placed at 2 millimeters and the bulk fills being placed at 4 or in the case of SonicFill, 5. You had a situation here where it met specifications also on shrinkage stress, except one material. Extra from Voco had a little higher shrinkage stress than all the others but what's interesting, if you don't mind me bragging a bit, although I didn't have any much to do with it. SonicFill has a significantly less than all the other ones. There were 2 that one was significantly higher. SonicFill significantly less, otherwise the rest of the bulk fills were in range of normal.
The bottom line is you have an ADA, independent paper studying the physical properties these materials showing they have the high strength characteristics, that they actually meet manufacturer's claims. That pretty much should dispel dentist concerns, I think, about whether or not these represent a new class of materials. They really do. They shorten it, SonicFill, for instance because it doesn't require a liner and it doesn't require a second capping layer on top shortens it close to 50% of the time. It vibrates so you get good adaptation.
They're all worthwhile. They're all effective. They're being used well. They're performing well. This one, the sonic hand piece activation is just in a class by itself and its proving very popular.
Howard: Is that your choice, then, for your direct,
Howard: … posture you're doing Kerr Solo Plus bonding agent with Kerr SonicFill?
Ron: Not the Solo Plus bonding agent, really. I would be using the XTR or …
Howard: Oh, okay, The XTR. I'm …
Ron: Yes, the XTR.
Ron: Yeah. I used to use the OptiBond FL there and …
Howard: So, you're using the Kerr OptiBond XTR?
Howard: We think it stands for Extra-terrestrial Resin. We're not sure.
Howard: Then, you're using the SonicFill. Yeah. I like the SonicFill. I think it's fantastic. Okay.
Then, so you mentioned CR, clinical research, with Gordon Christian and CRA. You mentioned ADA research. Any other research that you pay attention to? We see Cochrain, we see Michael Miller reality. Any other things that you read a lot?
Ron: Yeah. Dental Advisor, yes.
Howard: Dental Advisor?
Ron: Yes. Dental Advisor have come up with the same kind of data. I've got probably, I'm in the process right now so all this is on the tip of my tongue of writing an article for the British Dental journal on posterior composite, mainly the placement process and an emphasis on the bulk fills. I've just done my literature search on this. I was blown away the number of papers that have come out confirming SonicFill plus all the other ones, too. It's just a question of … They're all working well.
Howard: Only the British get this article? The Americans are going to get it with Dentaltown magazine?
Ron: I've actually written 3 or 4 of them for our journals, too. This one is, I don't know. A good friend of mine is editing this particular special issue of the British Dental Journal and he asked me to do it but very likely, it'll get reprinted in one of our journals.
Howard: I hope it's Dentaltown. Let's … Then, I also want to ask you about the light cure. You're talking the light cure. Does the light matter or is there any type of lights that are better than others?
Ron: Yes. Absolutely, Howard. Boy, I'm glad you mentioned this because it's something I really spend more time on now in lectures. To be fair to Gordon, this is where he's concerned about. I had feedback why he's a bit concerned about bulk fills is more the curing depth and his worry is that dentists using inadequate lights. Quite frankly, they're still out there. I tried to shame my audience carefully. I try to phrase it as a joke. I'm not as good as you are at jokes but I tell dentists if they have in their pocket the latest smart phone and they're curing their composite with a light that was developed in the last century, then they're an idiot. Dentists have really got to quit using halogen lights. They need to go out and buy these high quality LED lights, minimum output of 1,000 milliwatts per centimeter squared. Most of them are going up to 12, to 1,800. They're several of them out there.
Howard: Name some.
Ron: The majors out there would be … Actually Kerr has one. Imatron Plus. Ivoclar, Ivoclar. I don't know how you say it. Ivoclar, Ivoclar. It depends whether you're on this side of the ocean or not. They've got 3 really good curing lines out there.
Howard: You know their names?
Howard: Do you know the Ivoclar names in the Curing line?
Ron: Yes, I do. The 20I. There's a brand new one out now that I don't know why. It's too bad. When you get 68, this is one of the things that's going now. It's not that my memory isn't there anymore. It's just on delay but the 20I is a very effective one. Oh, the style. One called the Style. Ultradent has one called Valo. Dentsply has a light and so does 3M.
Howard: Is Dentsply, is that out of their caulk division?
Ron: Yes, yes.
Howard: The caulk division?
Ron: The caulk division.
Howard: Ron, do you think it's okay for …
Ron: Smart light. I just …
Howard: Do you think it's okay for me. I used a light saber to prep and cure the composite. My Star Wars light saber that I got from Darth Vader.
Howard: It cuts the tooth and it cures.
Ron: You're using a laser. I just though. The Kerr is the Demi Plus, not the Demitron Plus. The call it the Demi Plus but all those ones I just mentioned, used correctly, first of all, using high output like that saves you time. You cut the time in half. You're going to get better, deeper cures. You have to use the light correctly. Often times, dentists delegate this to their assistants. They don't watch what their assistant's doing. If that beam isn't perpendicular to the target, it's not going to cure it. If it's waving around.
I can't believe what I would see sometimes. The dentists would just say, "Okay, now light cure," and then not even watch what's going on, not paying attention. Sometimes hasn't even instructed the assistant properly about how the light has to be. Its photons coming out of that light guide are like bullets coming out of a gun. You want to be perpendicular to the target. If you're in an oblique angle, it's going to careen off the target. You'll reduce the energy by 50% sometimes just by coming in at the wrong angles.
Howard: Could you say the same about sun tanning, that when it's 12 noon, you're getting burned but at 8 in the morning and 8 pm, it's not really doing anything.
Ron: If you don't mind, I'm going to steal that analogy. That's perfect.
Howard: I'm almost out of time but if I was to take anybody to overtime, if you got extra time, I'd love to stay. I wanted to take a whole 'nother direction with this because you and I have lectured around the world and some countries are more into glass ionomer and Americans aren't. A lot of people say that everything you've said, it almost sounds like you're a civil engineer. You're building a building. You're building a bridge. You're building a house.
At the end of the day, it doesn't matter how you build your barn because the barn's going to be taken out by termites. If you would have built an aluminum barn, when the termites came back, they couldn't have eaten anything.
Some people think that all restorative materials should be bioactive. They should have some kind of active ingredient to try to kill the bugs that are going to come back. When someone has a big cavity that needs an MOD and no matter how we fix it, we didn't change their behavior. They didn't stop drinking Mountain Dew. They didn't buy a Sonicare and start flossing and this. We didn't change their behavior so they walk out of this office with a new filling and it's still your Uncle Eddie who's got a Mountain Dew in his hand and doesn't know what floss is. What about active ingredients? What about glass ionomers? Do you think glass ionomers would last longer because they try to fight the biological side as opposed to the engineering side? Would you consider yourself a biological dentist trying to kill bacteria or more of a civil engineer dentists trying to build a structure?
Ron: It's a good point. I see the frontier, the next frontier is certainly more bioactive materials. No question about it and you're right glass ionomer. By the way, I just got back from Australia and New Zealand 2 weeks ago. If you don't at least mention glass ionomer from the podium, they'll give you the hook there. They're into it to such a degree.
Howard: Just for the audience perspective because I went there several time, going back in August. What percent more glass ionomer do you think they use than Americans and Australians?
Ron: I don't know.
Howard: It's a lot.
Ron: I know. They all ask me about it and there's nothing wrong with putting it in. It's not streamlining procedure. By the way, when we say glass ionomer, I'm talking about the acid based reaction. I'm talking about the auto cure glass ionomer. I'm not talking about resin ionomers, light cured glass ionomers that have a resin in them, yes, they claim to give off fluoride and they do but there's been no research showing that the fluoride that resin ionomers give off actually is effective but there has been with autocured glass ionomer so let's separate those 2 materials.
Howard: Okay. What is the auto cured? You talking about Fuji 9?
Ron: Fuji 9 let's say. Fuji 9 is a material that I use . My geriatric dentistry, root carries and this sort of stuff where we're not dealing with aesthetics. We're not dealing with engineering. Those areas don't get stressed down on root carries and so we're using the biological or the bioactive aspects of it there.
The issue with glass ionomers and the reason why in Western countries other than Australia and New Zealand, Europe and North America, it's using less of those things is because of the engineering side of the equation and just as much also the time side of the equation. When you're putting in auto cure glass ionomer as a base, you've got to wait for that to set, et cetera, et cetera, et cetera.
Let's talk a little bit too about the engineering because if you place a rubber dam and you do your adhesion correctly and you get total adaptation of your composite to the cavity walls that I'm talking about the external margins, proximal box margins because that’s what you're concerned with. You're worried about new decay because of the Mountain Dew on these gingival margins in the proximal area but if you seal that tooth, bacteria can't get it. That goes back to one of the biggest reasons why I use rubber dam and isolation is so important. Any compromise there and you have a problem.
Now, glass ionomer will make up for that to a certain degree but it also has a problem with moisture. You still have to maintain it to a certain degree but I don't have anything against, I don't want to talk down glass ionomer because I don’t have anything against it. It's going to take even more time to do your post year composite restoration using a glass ionomer basis. That's why I think that the American market and the European market is … We're not being paid for all that time. In fact, we're being penalized for that.
What I see now and you're right. You separated these very nicely. Bioactive from engineering. What we need to do is bring those 2 together. We need a bioactive material and continue putting in well-engineered restorations that are strong and durable and last and could be placed in an expedient, efficient way, not a … if it's time consuming, Howard and they're going to cut the crown, they're not going to put in the composite.
Howard: Yeah. Again, I think …
Ron: They'll butcher the tooth. That's worse. At this stage of the game, I'd feel a well-engineered, well-bonded sealed restoration done under isolation is the way to go and it's expedient. That's why dentists have flocked to this bulk fill area because of that.
The next thing we need to do is make that same material bioactive in the vein of a glass ionomer but I have ideas, thoughts on this and there's work being done on this to make it even more so. Not only will it be anti-microbial but it'll also be stimulating to the pulp. It'll actually recreate that which is what we really want.
You asked. Here I am at 68 and I'm still practicing dentistry. I'm still into this field as much as I've ever been into this field. I've every intention of staying into this field because I can't wait to see what's happening next. I want to be involved in it and be part of it and be doing it for my patients and talking about to other dentists like yourself on programs like this.
Howard: I'll tell you, you were with LBI for what? Eighteen years before you retired from them? We have 307 courses up there. I wish you would validate us someday by putting a course or a curriculum on there because you're a legend. You were my idol back in '95. I got out of high school in '87 and I remember going to LBI when it was in Bill's office with Hornbrook and a little dental office. I don’t know how many times I've seen you lecture, get my FAG, the MAGD but the neat thing about you is not only do you have all the knowledge.
Einstein said, "If you can't explain your subject matter, it's because you don't understand the subject matter." God dang it, you're just a down to earth guy from Virginia. You could explain it to me forever. For that I thank you and every one of my friends if I told them last time I was interviewing you today, they're just like, they'd beamed ear to ear. You're just amazing guy. Think you so much for all you done for dentistry. Thank you so much for all you've done for the cosmetic revolution and the fact you spent an hour with me today just thank you so much, Ron.
Ron: It's been my pleasure, Howard. It really, truly has. Thanks for inviting me to be a participant in your podcast.
Howard: If you ever want to do another one, you just email me, Howard, at dentaltown.com and we'll set it up.
Ron: Okay, Howard. Thanks.
Howard: All right. Bye-bye, Ron. Bye-bye.
Ron: Bye-bye, everybody.