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A restorative dentistry mini survey

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A Restorative dentistry mini survey was conducted in one of my presentations. It was conducted in Northern suburb of Dahisar in Mumbai.

Here are the reposnses: 

Do you use amalgam in your clinic ? 

  • Around 45% of the dentists didn’t use amalgam in the clinic. A small percentage use it some time.
  • Among those who use it, DPI was the most used brand. Solila & Aristaloy were also used.

Which brand of composite do you use?

Ivoclar was the most preferred brand & close to 70% of the dentists use it. It was followed by 3M. Coltene , Dentsply & Kuraray was also used by a small percentage.

Which brand of glass ionomer you use?

  • Close to 80% of the dentists use GC brand of glass ionomer. It is followed by fuji.

Which brand of glass ionomer you use?

.Close to 80% of the dentists use GC brand of glass ionomer. It is followed by fuji.

Do you use composite for posterior fillings?

                                                        

  • Close to 90% of dentist use composites for posterior filling.

Do you use composites for class 2 cavities in posteriors?

 

  • Close to 90% of dentists use composites for class II cavities. There was no uniformity in the responses. Brands used range from GC9, Infill molar, Amalgam. Sometime composites , miracles mix , Luxacore DMG, Para-pore, etc.

Do you use flowable composites?

 

  • Close to 90% of dentists used flowable composites. Brands of ivoclar & 3M were most popular.

Do you use a surface sealant?

 

  • Only 40% of dentists use surface sealants.

Which brand of composite polishing system do you use?

 

  • Shofu polishing system was the most popular with 80% of the dentists using it.

Do you use self etching adhesives or total etch adhesives ?

 

  • Close to 75% of the dentist used total etch. Brand of Ivoclar is most popular. Some dentists used total etch & self etch both.

Do you use resin modified glass ionomer cements.?

 

  • Around 45% of the dentists use RMGI.

Raise your practice level by a  comprehensive three session hands on  course on ADHESIVE DENTISTRY. It  will cover light cure composites, glass ionomers etc. The course will cover and the participants will get an hands on experience of almost categories of restorative materials. The course is conducted regularly in Dr. Veerendra Darakh's Dental clinic.

Contact darakh[at]vsnl.com for more details.

 

 

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Raise your practice level by a  comprehensive three session hands on  course on ADHESIVE DENTISTRY. It  will cover light cure composites, glass ionomers etc. The course will cover and the participants will get an hands on experience of almost categories of restorative materials. The course is conducted regularly in Dr. Veerendra Darakh's Dental clinic.

Contact darakh[at]vsnl.com for more details.

 

 

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A restorative dentistry mini survey

 Quite an interesting survey and findings.

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A restorative dentistry mini survey

A talk hosted by the University of the Pacific Arthur A. Dugoni School of Dentistry head of technology during the ADA 2012 Annual Session in San Francisco highlighted the breakneck pace that technology development in digital restorative dentistry has reached.

"Sure enough, changes took place this week where I had to update my talk," said Parag Kachalia, DDS, vice chair of preclinical education, technology, and research in the department of integrated reconstructive dental sciences.

Digital impressioning is changing because the marketplace has a better understanding of dentistry, he emphasized. "They're asking questions like, 'How can we take scanning into the office?' And now we're getting to the point where digital dentistry is like an iPhone."

Parag Kachalia, DDS, discussed digital restorative dentistry at the 2012 ADA Annual Session in San Francisco.
The existing hardware of the phone is very good, and new advantages will primarily be software-based, Dr. Kachalia noted. "Updates will come in the future where you add the functionality that you want."

(In fact, during the ADA meeting Dexis previewed Dexis Go, a new iPad app for the Dexis Imaging Suite that will be available for free from the iTunes App Store in January 2013.)

According to Dr. Kachalia, the industry could see another 20 digital impressioning systems enter the marketplace during the next five years. "Acquisitions have made smaller companies more viable," he stated.

In the meantime, new product introductions abound. 3M ESPE's release of its True Definition intraoral scanner "changed my opinion of digital dentistry overnight -- the prices dropped in half," Dr. Kachalia stated. "We so-called tech experts were shocked." (The scanner retails for $11,995, with data plans starting at $199 per month. Other scanners on the market sell for $20,000 to $30,000.)
In addition to improvements in the cost of the equipment, the technology offers practical advantages that make it increasingly attractive in clinical practice.

"Studies show that digital impressions are equally, if not more, accurate than traditional ones," Dr. Kachalia explained. He described a clinical case he participated in involving dental students in which 100 restorations were performed with a 22% decrease in time.

"Students do everything I tell them not to do," Dr. Kachalia said. "They were asking about digital impressions, so we let these students not take a traditional impression. The learning curve was better, the need for multiple visits was reduced. One did six units in less than an hour with zero adjustments for occlusion. We thought, 'Great, now this student thinks six unit cases are easy.' But the technology worked."

In his opinion, the Trios by 3Shape will become increasingly competitive due to its quality. "It's not prevalent in the U.S. (yet), but lab techs know," Dr. Kachalia said. "And it has a huge presence in Europe and elsewhere abroad."

In addition, the Trios is powder-free and takes 3,000 2D images per second, "so it's essentially video scan, and there's no minimum distance from the tooth required," he said. "Plus, the scan clears out redundant information and faster uploads are the result."

The Trios offers other user-friendly features, he added. "Scanning is comfortable -- the wand looks like an impression gun and that's very familiar to dentists." It also has an autoclavable scanner tip, he noted.

The E4D by D4D Technologies also received praise. "It's the first in-office, powder-free scanning and milling system," Dr. Kachalia said. "It has the ability to design multiple restorations at one time. The red laser scanning works through image acquisition, so the camera fires anytime it's in focus."

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A restorative dentistry mini survey

Developed by researchers from the University School of Dental Medicine at Charité Medical University in Berlin, the technique -- resin infiltration -- has been exclusively licensed to DMG, which is commercializing it under the brand name Icon. The company introduced the Icon system to the European dental community at the International Dental Show (IDS) in Germany earlier this year and plans to launch it in the U.S. this fall at the ADA meeting, according to Wayne Flavin, director of scientific affairs for DMG America.

Proximal tip of the Icon caries infiltration device from DMG. Image courtesy of DMG.
"This is a completely new technology and treatment option," Flavin said. "It is not intended to replace remineralization or the attempt to remineralize early lesions. It is intended for when the doctor has decided that remineralization is not working."
Invented by Sebastian Paris, D.D.S, and Hendrik Meyer-Lückel, D.D.S., resin infiltration utilizes the concept of capillary forces -- "similar to a sugar cube soaking up coffee," Dr. Paris said in an e-mail to DrBicuspid.com. The pseudointact surface layer of the caries is first eroded by etching the lesion for 120 seconds with 15% hydrochloric acid gel (this layer would otherwise hamper penetration, Dr. Paris said). The lesion is then desiccated with ethanol and air blowing and the infiltrant -- a proprietary resin -- is applied, penetrating into the porous lesion via the capillary forces.

"The secret to Icon and to infiltration is the resin, which has an extremely high penetration coefficient," Flavin said. "The best bonding agents on the market today infiltrate 10 to 12 microns into the tooth structure. Icon infiltrates 600 microns, and it can fully infiltrate a lesion in only two to three minutes."

After three minutes, the excess material is removed from the lesion surface and the material is light cured, leaving no resin coat on the lesion surface. Rather, the resin occludes the lesion pores inside the lesion body, thus preventing diffusion of cariogenic acids into the lesion, Dr. Paris explained. In the process, however, the sealing process also eliminates the possibility of remineralization, he said.

"Infiltration is not indicated for lesions where remineralization is the first choice. Of course we aim for remineralization of lesions first, by local fluoridation, oral hygiene education, and dietary control," Dr. Paris noted. "However, if this approach fails, at a certain point lesions have to be restored with fillings. Using caries infiltration, we want to delay or even prevent this first operative intervention."

Although remineralization works well on shallow lesions, Flavin noted, "when you get to deeper lesions, such as one that has progressed through the enamel-dentin junction and into the first third of the dentin, you are probably not going to have great success with remineralization. And this is where infiltration comes in. Rather than reaching for a handpiece, this offers the option to treat the lesions using very minimally invasive procedures."

But Douglas Young, D.D.S., an associate professor at the University of the Pacific School of Dentistry, disagrees that deeper lesions have less success of remineralization.

"Remineralization can happen at any stage, and the important question should be not how deep the demineralization goes, but is the lesion cavitated," he said in an e-mail to DrBicuspid.com. "If the lesion is not cavitated, then bacteria are physically too big to get into the dentin; therefore, remineralization can (and perhaps should) be done first."

Resin infiltration is intended for use only on noncavitated lesions, Flavin noted.

Clinical research

Dr. Paris and his colleagues have been publishing on resin infiltration since 2006, addressing various aspects of the infiltration technique, such as evaluating different etching gels for pretreatment purposes (Journal of Dental Research, 2007, Vol. 86:7, pp. 662-666); comparing the penetration coefficients of a proprietary resin formulation to commercially available adhesives (Journal of Dental Research, 2008, Vol. 87:12, pp. 1112-1116); and validating the ability of fluorescence confocal microscopy to analyze the infiltration of caries lesions with low-viscosity resins (Microscopy Research and Technique, July 2009, Vol. 72:7, pp. 489-494).

More recently, at this year's International Association for Dental Research (IADR) meeting, they presented two additional studies involving resin infiltration: "Progression of resin-infiltrated natural caries lesions in vitro" and "Modern detection, assessment, and treatment of initial approximal lesions."

In the first study, they applied the infiltration process to extracted teeth, etching the teeth with 15% hydrochloric acid gel for 120 seconds and then infiltrating with one of four experimental infiltrants -- bisphenol A glycidyl methacrylate (BisGMA) 25%, triethylene glycol dimethacrylate (TEGDMA) 75%; BisGMA 20%, TEGDMA 60%, ethanol 20%; TEGDMA 100%; and TEGDMA 80%, ethanol 20% -- for five minutes. Specimens of the teeth were then exposed to a demineralizing solution (pH 4.95) for 200 days. After imaging with microradiography, they found that the lesions treated with the latter three infiltrants all showed lower progression rates in a demineralizing environment in vitro than lesions that were not treated with infiltrants.

The second study, sponsored by DMG, compared resin infiltration to flossing and sealing of approximal lesions around the enamel-dentin junction as part of an ongoing three-year, split-mouth study on approximal-posterior surfaces and preventive procedures. The study concluded that "the infiltration technique has been described as a clinically feasible method for treating approximal enamel-dentin junction lesions."

While resin infiltration clearly offers dentists another minimally invasive caries treatment option, because it is such a new approach there needs to be more research, Dr. Young said. Additional studies are under way in the U.S. at the University of Michigan, Case Western Reserve, and the University of Alabama and in Germany, Denmark, and Colombia, according to DMG.

For more information about the science and research behind the resin infiltration technique being commercialized by DMG, go to www.dmg-dental.com.

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A restorative dentistry mini survey
A steady change is taking place in the restoratives market as patient and practitioner preferences for dental materials evolve.
Not surprisingly, the use of gold continues to diminish, according to Michael DiTolla, DDS, director of clinical education at Glidewell Laboratories.
"In 2011, gold was 3.5% of the restorations that we did here and that dropped another half percent [in 2012]," Dr. DiTolla said. "Compare that to 2007, where it was 8% of the crowns that we've made, so that's a significant drop over five years."
And it is not just the rising cost of gold, which was pitched and purchased as a less volatile investment in the midst of the global economic downturn. In fact, the gold market continues to be quite volatile, dropping 9.4% in on day in mid-April, the largest plunge in 30 years, according to news reports. Even so, gold's gains during the last 10 years are still far greater than the recent loss.
Dr. DiTolla believes that the decline has more to do with the consumer than the price.
"Take a theoretical situation where gold is $200 per ounce," he said. "Dentists would be buying it personally and sticking it in a safe, but I don't think those [crown] numbers would go up much for us. Maybe a percent or two, but there are enough patients that don't want it in their mouth. Price is part of it but so is push back from the consumer."
That push back, combined with the actual price of gold reaching nearly $1,800 per ounce as recently as October and currently hovering around $1,500, is a "recipe for the unfortunate death of a restoration," according to Dr. DiTolla.
 
PFM crowns
Use of porcelain fused-to-metal (PFM) crowns also has declined.
"It always shocks dentists to hear this, but the PFM made up 65% of crowns we made in 2007, and in 2012 it went down to 20%," Dr. DiTolla noted. "That's a precipitous drop for a crown that was the default crown for crowns and bridges for 40 years. An amazingly rapid change in dentists' prescribing habits."
He attributed the continued usage of PFMs to dentists who are patiently awaiting the data from researchers examining the durability of all-ceramic materials. Dentists who have dealt with underachieving materials in the past are cautious about making the switch.
"We've been hearing about the death of the PFM for a long time," Dr. DiTolla acknowledged. "Then we'd try some of these all-ceramic systems and we'd have a lot of fractures upsetting the dentists and patients; and nobody wins when a crown breaks. Dentists have been burned over the years by some of these systems, so it's surprising how quickly the switch is taking place."
That change is due in part to the success of monolithic restorations, such as IPS e.max by Ivoclar Vivadent, which hit the market in 2007, he noted. While the two first incarnations of the product as a bilayered material proved to be flawed and prone to chipping, the company changed its approach.
"The third time, they released it as a monolithic material made of lithium disilicate and that's when it took off," Dr. DiTolla noted. "It gave us the idea for BruxZir, to take zirconia coping out from underneath a porcelain-fused-to-zirconia crown and just build the whole crown out of zirconia."
 
Class II composites
While the shift is gaining momentum, many practitioners are taking a wait-and-see approach. Meanwhile, Gordon Christensen, DDS, MSD, PhD, said in no uncertain terms during the 2012 ADA General Session that composites should last longer.
"Class II composites only last about seven years. I think we can do better," Dr. Christensen said at the time, while noting that typical revenue for a class II composite is $200. "Maybe that's why they don't last so long -- we're in a hurry to get it over with and move onto something that will earn an income. Otherwise, we may have to drive a cab at night."
Dr. DiTolla agreed and stated that direct placed large class II restorations is an area of restorative dentistry that needs improvement. However, he predicted that it will be some time before a better solution arrives.
"We have really good solutions for small and large cavities, but that middle size, so far there's not a lot exciting on the horizon," he said. "Part of what Gordon is looking for is something the dentist can do in one appointment to help keep costs down. There's no revolution about to occur in indirect place composites. It's a void we'll have for maybe the next decade or so."
 
Rise of zirconia
Zirconia-based restoratives also are growing by leaps and bounds.
"Zirconia has been the fastest-growing product that we've ever had here at the lab," Dr. DiTolla stated. "If you look back to 2007, zirconia-based restorations were 13% of the crowns we made. Zirconia has gone from 13% to 56% of our crowns and is now the largest category of crown that we make."
The exponential growth of BruxZir since its 2009 introduction was credited in part by Dr. DiTolla to its extreme popularity among young dentists. Dentists are "bullish" on zirconia and are ordering it in record numbers. The appeal to patients is in its appearance and as an alternative to cast gold. While three-year test results have not been published, there is little to suggest that the material will fall out of favor after reviewing the one-year performance of it.
"Dr. Christensen and his research group have been testing it and recently came out with their one-year results and they are promising; Dental Advisor recently released an 18-month eval and its doing well," Dr. DiTolla stated. "The five-year mark is an important mark in the clinical history of any product, so when we're five years out we'll breathe a little sigh of relief. Problematic products start to fail even in the first year or two, so we're optimistic."
As the results of those tests start to roll in, once-popular materials are likely to see their use further reduced.
 
Amalgam going away?
And what about that old standby, amalgam? Having become one of the most controversial materials in dentistry, it is already banned in some European countries.
U.S. legislation regarding amalgam may be influenced by European stakeholders of an antiamalgam persuasion. At a United Nations forum in Geneva in late January, the United Nations Environmental Programme unveiled a draft treaty -- known as the Minamata Convention on Mercury -- that includes a section specific to dental amalgam. The treaty, which has been four years in negotiation and will be open for signature at a special meeting in Japan in October, addresses the direct mining of mercury, export and import of the metal, and safe storage of waste mercury.
The treaty also pushes for the phasedown of dental amalgam, such as incentivizing amalgam alternatives through insurance, focusing on these alternatives in dental schools, restricting encapsulated dental amalgam, focusing research on improving alternatives, and promoting dental caries prevention. In addition, the treaty specifies a best-practice approach to minimizing the release of waste dental amalgam, currently typified by the use of amalgam separators in dental practices that permit the capture, separation, and eventual recycling of mercury.
And the proposal elicited a positive reaction from the ADA. However, its effectiveness and a lack of legislation limiting its use in the U.S. so far indicate that amalgam will continue to play a role in restorative dentistry.
"I think there definitely is still a place for amalgam," Dr. DiTolla said. "I lecture around the country and the majority of dentists still use it -- maybe not as their only direct restorative. But those larger restorations, they feel more confident with the long-term clinical success of amalgam. If you look at what Gordon was saying about the longevity of the typical class II composite restoration, if you look at the amalgam restoration, it lasts long beyond that."
It's also affordable, which is of significant importance to the typical American family that has an average household income of around $50,000 annually, he noted.

"For patients going to dental practices that aren't a 'boutique' practice, I think amalgam is going to be around for a long time," he said. 

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