Quality dentistry: less is more
ANAHEIM, Ca? Esthetics has moved back to a ?less is more? dentistry, according to Douglas Lambert, DDS, a speaker at the CDA Presents session on May 12. His lecture, entitled Less is More: Practical Concepts for Changing Times, addressed the many different options available to delivery quality, esthetically pleasing results.
ANAHEIM, Ca? Esthetics has moved back to a ?less is more? dentistry, according to Douglas Lambert, DDS, a speaker at the CDA Presents session on May 12. His lecture, entitled Less is More: Practical Concepts for Changing Times, addressed the many different options available to delivery quality, esthetically pleasing results. ?Patients bring us back to the chair,? said Dr. Lambert, adding that patients see a lot of propaganda related to smiles in magazines. He also said there are a lot of options explored in the literature, and with so much to choose from, there can be confusion. With regard to esthetic dentistry, Dr. Lambert offered his 4 treatment philosophies?be conservative, provide function, be esthetically pleasing, and offer good longevity.
Dr. Lambert?s first topic focused on past, current, and present methods of caries detection and diagnosis. He provided helpful hints and insight from his own practice. Caries is on the rise, said Dr. Lambert. ?It is imperative to find better ways to get at the root of the problem,? he quipped. He first presented DIFOTI, QLF, and OCT caries detection devices, highlighting the uses of each. In his own practice, Dr. Lambert uses KaVo?s DIAGNOdent on a routine basis to pre-screen. Technology for caries detection is moving up a notch, according to Dr. Lambert, who used DENTSPLY Midwest?s Caries ID, Air Techniques? Spectra, and S-Ray Corporation?s S-Ray as examples. Keeping the focus on a ?less is more? approach, Dr. Lambert said that air abrasion devices continue to be a factor in minimally invasive dentistry and mentioned Groman?s Etchmaster as a smaller scale option and Danville?s PrepStartH2O as choices for minimally invasive prepping. He also said that GC America?s MI Paste and MI Paste Plus offer a minimally invasive option to remineralize teeth.
In selecting a composite and in using a composite resin in a conservative manner, Dr. Lambert provided several suggestions. He began by asking the question: Is it time for amalgam to sunset? Dr. Lambert said that Denmark, Sweden, and Norway have banned the use of dental mercury. He shared with the audience that he rarely uses amalgam in his practice, but still offers it as an alternative. Shifting gears, Dr. Lambert then posed the question: Why composites? According to Dr. Lambert, composite offers several advantages; it is conservative in nature, it offers flexibility to restore only what is missing, it has uses as a long-term or transitional restoration, and it is less costly to the patient than alternative tooth-colored materials. However, today?s composites should meet the requirements of the profession, said Dr. Lambert. Usability in the anterior and posterior, good abrasion and wear resistance, high radiopacity, user-friendly handling, and low shrinkage are just a few of the attributes dentists should watch for, according to Dr. Lambert.
Adhesives?Seal Open Tubules
Adhesives also play a large role in dentistry, said Dr. Lambert, adding that with regard to bonding systems, there are a lot of options and classification methods that could make selection overwhelming. However, Dr. Lambert cautioned the audience saying that bond strength may not be as important as we think. He discussed 3 traditional testing methods for shear bond strength, noting that the numerical results depend on the type of test. He said that in comparing bond strengths, it is important to know if the same type of test was run for each material. What is critical, however, is sealing tubules and getting a good seal, he said. Dr. Lambert explained that sensitivity can be caused by fluid movement through open dentinal tubules. He added that several events such as acid etching and over finishing can open dentinal tubules, thus, a proper seal is paramount to good long-term results.
Total-Etch vs. Self-Etch
Dr. Lambert also discussed the advantages and disadvantages of total-etch and self-etch systems. He said total-etch is often considered the ?gold standard? and provides consistent etch patterns on enamel and dentin. However, disadvantages, according to Dr. Lambert, include postoperative sensitivity and post etching technique issues. On the other hand, self-etch systems offer the benefits of less postoperative sensitivity and an easy-to-use technique, according to Dr. Lambert. He called Kuraray?s Clearfil SE Bond the ?gold standard.? He also mentioned Clearfil SE Protect, posing the question: Is this the ?platinum standard?? Dr. Lambert said disadvantages of self-etch systems include the potential for varying etch patterns.
He concluded that self-etch is not necessarily superior to total-etch, but generally provides less technique sensitivity and postoperative sensitivity. However, he added that when restoring an anterior composite, he many times still uses total-etch. ?Both systems are gaining traction,? said Dr. Lambert, noting that clinicians can choose either as long as they are comfortable with their protocol.
Glass ionomers also received attention in Dr. Lambert?s presentation. He noted that although glass ionomers shrink about the same amount as composites, there is only a 2 mPA tensile load on a glass ionomer bond compared with up to 18 mPA with some composites. When used as a dentin replacement, resin modified glass ionomers also help minimize technique sensitivity questions that are sometimes associated with total-etch techniques, according to Dr. Lambert.
Just as the clinician has many options with bonding systems, the clinician also can choose from different methods to obtain posterior proximal contacts. Dr. Lambert cited pre-polymerized inserts, pre-wedging of the teeth, and metal and clear matrices as a few of the popular methods that have been used over the years. He finds Triodent?s V3 Ring to be the most consistent system on the market for achieving interproximal contacts. Another gem that Dr. Lambert shared with the audience, which he referred to as the ?best kept secret in dentistry today,? is Ivoclar Vivadent?s Contour Strip. Made out of Mylar, the Contour Strip provides a perfectly sealed margin to work within, he said, adding that it is a ?great matrix to try.?
Dr. Lambert also offered methods to control polymerization and shrinkage. ?The average composite shrinks 2% to 4%,? said Dr. Lambert. Over the years, clinicians have used several methods to control shrinkage such as the use of flowable composites, incremental buildup, and chemical cure composites, according to Dr. Lambert. He added that today?s contemporary composites, such as DENTSPLY Caulk?s SureFil SDR flow and VOCO?s GrandioSO HF, create less stress and strain on the tooth when they are cured, leading clinicians to another exciting chapter in composite dentistry.
Making it Fun
Providing audience members with effective ways to use composite resins for simple and esthetic outcomes, Dr. Lambert closed by reminding the audience that ?dentistry is supposed to be fun.??Elyse Fetherman
Douglas L. Lambert, DDS, FACD, FASDA, ABAD, graduated from the University of Minnesota Carlson School of Management in 1980 and the University of Minnesota School of Dentistry in 1984. He is a Fellow in the American College of Dentists, the Pierre Fauchard Academy, the Academy for Sports Dentistry, the American Academy for Dental Aesthetics, and a Diplomat of the American Board of Aesthetic Dentistry. Dr. Lambert has authored and co-authored several articles on cosmetic and esthetic topics, and has lectured nationally and internationally. He also serves as an independent consultant and clinical researcher for many dental manufacturers.