S-PRG (Surface pre-treated Glass Ionomer)d1ue90e5sp4tcv.cloudfront.net/2855/images/Asset30655… ·...

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Daniel H Ward DDS

May 5, 2017

Uncommon Common Sense:

What YOU need to know NOW about Restorative Dentistry and Materials

Daniel H Ward DDS

May 5, 2017

Let’s Rock!

Things are not always as they APPEAR

It may be your PERSPECTIVE

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It may be your PERSPECTIVE

High Viscosity (Low Flow) Flowable Composite

Beautifil Flow 00

Unique glass ionomer filler particles

Releases fluoride and other ions

Neutralizes pH-Antibacterial

Good polishability

Visibly blends in well

S-PRG (Surface pre-treated Glass Ionomer)

You may never have THOUGHT about it

If we say it long enough we BELIEVE it

Let’s re‐examine some of our IDEAS we think we know

Common sense is often UNCOMMON

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Dentistry is Ever‐Changing How do you Choose?

Lifetime of tooth often determined by first dentist intervention

Minimally Invasive Dentistry

Fissurotomy bur

201.3VF

Conservative Tooth Preparation

169L330

Low Viscosity Flowable Composite

How do you restore? G-aenial Universal Flo

Homogeneous spherical particles

Good wear resistance

High flexural strength (167 MPa)

Filled 50% by volume

Good polishability

Blends in well

High Viscosity Flowable Composite

G-aenial U Flo

Conventional Nano-hybrid

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Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

WARMER Low Viscosity Flowable Composite &

Warmed Composite

Completed Tooth Restorations

15 Year Old


70% RED Proportion


Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5

Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)

Add special effects to simulate imperfections within tooth structure

Add translucent incisal hybrid or microfill

Multiple Step Layering Techniques Add dentin shade

•Aura Dentin 6

•Miris

Add General Purpose Shade

•Aura MC 3

•TPH Spectra

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Add Characterization

Important-Junction must be invisible

Add Facial Surface

•Aura Enamel

•G-aenial GT

•Beautifil II

•Esthelite Sigma QuickOptrasculpt

Finish and polish restoration

Restore adjacent tooth

Shape, finish and polish restorations

Restore opposite teeth

Pre-Operative

Finished Restorations

Post-Operative Sensitivity

Bonding Challenges

Hydrodynamic Theory

Hydrodynamic Theory

Fluid flow within dentinal tubules causes PAINBrannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481.

Hydrodynamic Theory

Opened, unsealed dentinal tubules causes PAIN

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Placement of Etchant

Total Etch Technique

“Moist” Dentin”

Rinsing of Etchant

Placement of Resin Primer

Apply multiple coats

Moist Moist

Placement of Resin Primer

“Overwet” Phenomenon

Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.

Overdrying

Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148.

Collapsed collagen fibrilsProper Moisture

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Moisture VariabilityAir only syringe Warm air dryer

Air/water syringe Air/water syringe

Evaporating the solvent with dry air

Acid-groupsHydrophilic end

etches tooth structure (self

limiting)

Spacer-chainlink between

functional groups

Methacrylate-groupHydrophobic end

connects to polymer-network

COOH

COOH

CH 2

CH 2

O

OO

O

Self-Etching Primer“Self Etching” Primer

Acidifying Primer accompanies etch

Acid reaction is self-limiting

Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .

Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion Self-Etch Technique

Challenges

Decreased bond strength to un-etched enamel

Marginal gap formation with un-etched enamel

Bond incompatibility to self-cure and dual-cure resins

More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time

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Self etching Primer

Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

Long Term Dentin Bond StabilityMMP-Matrix MetalloproteasesMMPs are naturally occurring proteases

involved in dentin formation and trapped during odontogenesis

Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers

Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils

Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated collagen degradation. Eur J Oral Sci 2011;119:79-85.

MMP-Matrix Metalloproteases

Carrilho et al., JDR 2007; 86; 529Brackett et al.,Operative Dentistry; 2009;34(4):381-385

In-vivo 12 m w/PBNT (Acetone)

Immediate (MPa)Control 29.3 (9.2)CHX 32.7 (7.6)

w/CHX in 12 m

14 mo (MPa)Control 19.0 (5.2)CHX 32.2 (7.2)

Potential MMP Inhibitors

Long Term Dentin Bond Stability

Chlorhexidine (CHX)

Benzalkonium Chloride

MDPB ((12-methacryloxydodecalpyridinium bromide)

GLUMA

Epigallocatechin-3-gallate (green tea polyphenol)

Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:219-241.

Disinfect to prevent MMPs

Use Etchant containing 1% Benzalkonium Chloride

TE-Apply 2% Chlorhexidine after acid etching for 30 sec

SE-Apply 2 coats 2% Chlorhexidine prior to application of primer

OR


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Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide)


Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.

Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer

Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

Universal Bonding AgentsBond strength same to total vs self etch

Dentin Bond Strength

Self-Etch Total Etch Moist

Total Etch Wet

Total, Self or Selective Etch Universal Bonding

Materials

Self‐etch Selective‐etch Total‐etch

Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding Materials

Total, Self or Selective Etch All-Bond UniversalTotal-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2

Becomes hydrophobic upon setting

Total, Self or Selective Etch

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MDP Universal Bonding Materials


Cross-linking of polymer chains

Hydrophobic upon setting

Universal Bonding Materials


Bulk Fill CompositesBulk Fill Composites

Allow many posterior restorations to be built up in 1 segment

Descriptions– “Stick the stuff in the hole and cure”– Evolutionary– Monolithic

Physical Advantages– Deeper depth of cure– Less Polymerization Shrinkage– Less Polymerization Shrinkage Stress– Reduced likelihood of air voids between layers

Bulk Fill CompositesBulk Fill Composites

Modes of Action– Improved initiators– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity

Materials– Flowable– Conventional

Advantages– Quicker, easier– Less chance of enamel and cusp fractures– Increased likelihood of adequate resin polymerization

Bulk Fill Flowable CompositesBulk Fill Flowable CompositesLow Shrinkage StressStress

•Surefill SDR

• Voco Xtra

•Beautifill Bulk Flowable

•Venus Bulk Fill

Surefill SDRSurefill SDR

•Reduced polymerization shrinkage stress

• Bulk fill to 4mm

•Increased sensitivity to light

Great placement with metal tips

•Self-leveling

•A1, A2, A3 Universal shades

Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.

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Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)

Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress

• Voco Xtra Fill

• Beautifill Bulk Flow

• Aura Bulk Fill

• Tetric Evo-Ceram Bulk Fill

• Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

Improved flowability of composites

Improved marginal adaptation

5mm depth of cure

Increased sculptability and ease in shaping anatomy

Composite designed specifically for use

ADVANTAGESADVANTAGESSonic Energy Assisted Light Sonic Energy Assisted Light

PolymerizationPolymerization


Sonic FillSonic Fill


Sonic FillSonic FillTriodentTriodent or or PalodentPalodent PlusPlus

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Multiple Medications

Oral Environment Challenges-Xerostomia


“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”

Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.


• Incidence increases with # of drugs taken

• 50% of patients taking 4 or more medications had Dry Mouth

Oral Environment Challenges-Carbohydrates

Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g

Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g

Oral Environment Challenges-Bottled Water

Fluoride-less water Fluoridated water

Oral Environment Challenges-Illegal Drugs

“Meth mouth” or chronic marijuana use

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Xerostomia patients

High carbohydrate users

Non-fluoridated water users

Drug abusers

Need TherapeuticRestorations

Composite Challenges

•Post-operative sensitivity

•Recurrent decay

•Achieving proper moisture

•Polymerization shrinkage

•Increased time-layering

•Technique sensitivity

Low post-op sensitivity

Fluoride Release

Moisture variability

No shrinkage

Bulk placement

Simple-more forgiving

Glass Ionomer

Fuji IX Self Cure Glass Ionomer

Glass IonomerBase/Restorative

SDI Self Cure Glass Ionomer

•More highly filled-reduced wear

•Self-curing in 2.5-5 minutes

•No polymerization (setting) shrinkage stress

•Expansion/contraction similar to tooth

•High fluoride release

•Bioactive

Glass IonomerCharacteristics

•Multiple cervical carious lesions

•Pediatric Patients

•Sealants

•Class V restorations

•Sandwich Technique

•Crown buildups

•Long term interim restorations

•Cements

Glass Ionomer Uses

High caries rate individuals

Glass Ionomer RestorationsGlass Ionomer Restorations

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Remove decay and place matrices


Treat dentin with PAA


Place, shape and wait 2:30


Shape with diamonds w/ water


Dry and place Surface Sealant

No phosphoric acid


Pediatric Patients


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Pediatric Patients


Long term interim restoration








Dentist-Multiple Radiographic Caries

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Equia Forte

Posterior Glass Ionomer

Stronger Glass Ionomer

For use in posterior teeth

Increased compressive strength (219 MPa)

Increased flexural strength

Greater wear resistance

Increased acid resistance

High fluoride release maintained

Stronger surface sealant

Better designed for Class II posterior restorations

Sudden Onset Caries

Posterior Glass Ionomer47 year old female

Been in the practice over 30 years

Regular re-care appointments

Significant changes in health history

No restorations in 8 years

Radiographs revealed multiple interproimalradiolucencies not present 12 months previous

Required 16 restorations

Need caries resistant restorations

Preparations


Preparations


Posterior GI Restorations


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How long do they last?• 8-12 years- single surface 65% 10 yr

• 5-8 years- multiple surface 35% 10 yr

• The larger the restoration, the shorter its lifetime

Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

•Acid/base and polymerization reactions

•Dual cured-faster

•Shortens time needed to control moisture

•More esthetic and translucent

•Fluoride release

•Higher tensile, bond strength and wear

Resin-Modified Glass Ionomer Characteristics

•Liner or Base

•Class V Restorations

•Restoration Under Crown

•Temporary prior to crown

•Sandwich technique

•Cements

Resin-Modified Glass Ionomer Uses

Resin-Modified Glass Ionomer Base/Restorative

Capsule

Fuji II LC RIVA LC

Fuji Filling LC

Resin-Modified Glass Ionomer Base/Restorative

Ketac Nano

Paste-Paste

Gingival recession & root caries

• 1st molar and bicuspid

• Remove decay‐place retention

Resin-Modified Glass Ionomer

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Gingival recession & root caries

• 1st molar and bicuspids

• Remove decay‐place retention

Condition with PA

• Pre‐treat with dentin conditioner (Poly‐

acrylic acid)


Material Placed and Light Cured

• Place excess material

• Light Cure


Final Restorations

• Shape restorations

• Hold back gingiva and shape with fine

diamond

• Etch with phosphoric acid, wash and dry

• Place surface sealant and light cure

Material Placed and Light Cured

• Place excess material

• Light Cure


Quick Temporary prior to Crown

Temporary placed 6 years ago Sandwich Technique

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•Exposed to occlusion

•Able to control moisture

•Not acid etching

•No shrinkage stress

•Highest fluoride release

•Out of occlusion

•Need quickness

•Need to acid etch

•Need to bond

•↑translucence/esthetic


Glass Ionomer

OH SH*T!

Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?

Asymptomatic

Single small exposure

Able to achieve hemostasis

Perhaps not IF:

Traditional Pulpal ProtectionIndirect Pulp Capping

Best not to expose pulp• Asymptomatic• Sound 2mm around margins• Stop when next scoop will expose pulp• Place GI or Ca(OH)2

Traditional Pulpal ProtectionIndirect/Direct Pulp Capping

What are we trying to accomplish?

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation

Traditional Pulpal ProtectionIndirect/Direct Pulp Capping

How does this happen?

• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2

OH-

H2O

Ca+2

OH-

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Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Dentin Bonding?• Dentin Bonding Agent-Composite

“Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy.”

Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31:291-307.

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Glass Ionomer/RMGI?

“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”

Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22:3191-6.

Improved Pulpal ProtectionIndirect/Direct Pulp Capping

Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent

Pulpal Protection – Indirect/DirectPulp Capping

MTA (Mineral Trioxide Aggregate)

• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco

Bismuth oxide Bi2O3

Gypsum CaSO4 · 2 H2O

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Tricalcium aluminate (CaO)3.Al2O3

Dicalcium silicate (CaO)2.SiO2

Tricalcium silicate (CaO)3.SiO2

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Biodentine

High concentration MTA (self setting)

Resin Modified Calcium Silicate

Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium

Theracal

Social Media Communication Cell Phone Text MessagingCell Phone Text Messaging Appt Reminder/Late Cancel

Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation

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Rescheduling/Reactivating PatientsRescheduling/Reactivating PatientsIncrease Production

$61,365.00 brought in from patients who did

not pre-appointin 2016

$61,365.00 brought in from patients who did

not pre-appointin 2016

Custom Email NewslettersCustom Email Newsletters Holiday Promotions

Custom Email NewslettersCustom Email Newsletters Regular Newsletters Custom Email MessagingCustom Email Messaging Birthday Wishes

Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment

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Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Online Patient ReviewsOnline Patient Reviews Monitor Online Reviews

Online Patient PortalOnline Patient PortalAutomated Post-Appointment

Pay Bills Online Management ResearchManagement Research--MapsMapsResearch Locale Demographics

New Mobile Apps

Mobile DevicesMobile DevicesIncrease internet marketing

HealthgradesHealthgrades

March 1, 2016

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Increase internet marketing

HealthgradesHealthgrades

May 1, 2017

Online Patient Scheduling

LimelightLimelight

Complete Phone

WeaveWeave

Syncs digital phone with your practice management system to instantly show caller information on computer screen

Looks like a phone app

Go down checklist

Complete Phone

WeaveWeave

Complete Phone

WeaveWeave

Ability to text message

Ask patients for recommendations*

Connects Phone to Practice Management SoftwareWeaveWeave

1.When the phone rings,

it tells your practice management software

who’s calling.

2.Prompt lets you know

who’s calling and gives you access to the

patient’s info with a click or by picking up the

phone.

3.Patient’s

appointment info, to-do list, insurance

info, notes, balance and more are

displayed.

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Other FeaturesWeaveWeave

Phone ServiceAppointment Reminders and Recalls

Conversational Text Messaging

Mobile App

Reports

Reviews

Connect your phones to your patient

communication software.

See positive reviews from patients and address negative

reviews before they are posted for others to see.

Texting works

like a smart

phone..

Set automated, pre-made or personalized text reminders and recall messages.

Easier for patients to communicate with your office.

See stats on phone usage.

ConsiderationsWeaveWeave

Advantages Challenges

•Ability to Maximize phone calls for scheduling and collections•Messaging Capabilities•Cost Savings•Excellent Customer Service

•Learning Curve•Internet Reliability•Weave Growing Pains

Thank You!

www.drwardhandouts.com

[email protected]

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