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Second Opinion Dr. Dan E. Fischer

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Strive to Mimic the Natural


by Dr. Dan E. Fischer  



Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dentists to share their opinions on various topics, providing you with a “Second Opinion.” Perhaps some of these dentists’ observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.

–– Thomas Giacobbi, DDS, FAGD
Dentaltown Editorial Director

 

 

 

 

 

 

 

“The Majority of dentists have moved away from amalgam. Sadly, the majority of our schools still teach it as the material of choice for posterior.”



When searching for the best solution for our patients, we must often address a number of realities. The most common “reality” that determines whether our patients accept our suggested treatment plan is money. Another reality that impacts our patients’ treatment decisions is their belief system – how they feel about dedicating time and money towards the procedure we choose to apply. Many of these advancements have been made in dentistry during the last 20 years. A few of these advancements are embraced in specific circles of our profession, whereas in others they are seen as a threat. It is certain that change often comes with struggle. Unfortunately, illogical resistance can ultimately affect our patients.

Conceptually, what could be more stimulating to the restorative dentist than the opportunity to rehabilitate a patient’s dentition with materials and procedures that closely duplicate tooth structure? The opportunity to embrace this concept is now. Marketing is important, but it can often derail the professional and compromise the quality of care their patients receive. This is notable in dentistry and most pronounced within the practice of adhesive dentistry. Some have followed the quest for speed or the latest numerical “generation” of bonding agents. Others have been entrenched under the guise of “evidence-based dentistry.” While this is a concept of
noble purpose, when generously applied or in other terms misused, it becomes a barrier to progress. Our teaching institutions promote this practice more than anywhere else. Sadly, the mentality dedicated to “amalgam or die” will probably have to do just that – die off before others around them will be able to move forward.

Some clinicians have come to believe that strong adhesion to dentin isn't important, or worse yet, inconsequential. It’s common to hear, “If the bond strength is over 25 MPa, it doesn't’t matter anyway.” How many of us really know what bond strength numbers mean and how they relate to the strength of dentin? The truth is that high bond strengths do matter because making restorations an integral part of the tooth is important. Listen to Mother Nature; know how she makes teeth and then, understand the needs of the tooth. The questions we need to ask with regard to restorations are, “What is the inherent strength of dentin?” “How much does dentin flex when it is loaded?” “How strong is the dentin enamel junction?” and “What has been the success rate of these tissues and designs?” There is a lesson we can learn from such evaluation. We've learned a great deal about the inherent strength of dentin. We’ve learned that it is much stronger than most researchers ever thought. While traditional research and literature has addressed the sheer strength of dentin between 20-30 MPa, it is a little known fact that these low values are related to how the test is performed. Jessop, Denehy and Vargas found the strength of dentin to be closer to 100 MPa.4
With a handful of non-compromising adhesives, one can bond to dentin at two-thirds the strength of contiguous dentin with resultant bond values greater than when bonding to enamel. This is possible because of the continued improvement of non-compromising adhesives. I believe that whatever we can do, taking into account the financial situation of the patient, to mimic nature is a positive, and that includes the important aspect of aesthetics. Time and experience has proven the success of doing so.1,2,3

In both a conceptual and realistic sense, nothing is more important than paying serious attention to the interface between our human-made restoration and natural tooth tissue. It is certain that the margin is the most critical aspect of this interface, particularly the gingival margin. That being said, why should we ever want any adhesive interface to be less than it possibly could be? Outside of a situation where we use provisional cement or fill, I can’t think of a time in which we’d benefit by having a less-than-ideal or maximal adhesive interface.

There are so many dentin bonding agents on the market today that it can be overwhelming for many dentists to sort it out. Fortunately, there are credible studies that demonstrate the function of a few high-quality bonding agents available today. Many of you know me as the owner of Ultradent Products, Inc. (I actually describe the relationship more as “I’m the guy Ultradent owns.”). I know that Ultradent offers bonding agents that are considered “top of the heap” in terms of strength and ease of use (i.e. PQ1 or Peak by Ultradent), but no matter what company you decide to go with, I urge you to select your bonding agents from the best. A few of the finer products on the market are Solo by Kerr and Clearfil SE by Kuraray. Regardless of whichever bonding agent you select, please don’t compromise. Strive to “mimic the natural.”

Quality composites come closer to mimicking dentin in both compressive strength and flex modulus than any other dental material. When placed and adapted directly to a quality high-strength adhesive, which is bonded to a substrate of mineralized tissue, it’s hard to beat. Nothing we can create intraorally or as an indirect can more closely mimic the strength of the DEJ and dentin than these two. In terms of mimicking enamel, the closest material we have to the physical properties of enamel is ceramic. Since all of our patients can’t afford ceramic, I recommend using quality, low-abrading composite to replace both the enamel and dentin. Experience has shown us that the dentin can continue to serve in a quality sense even when significant occlusal enamel has worn away. And, composite can be repaired and added to if needed.

Over time, dentists will continue to hear about the importance of mimicking the natural. Some like Bertollotti, Magne and Allmen have even come up with a nice sounding name for it – “Biomimetics,” which means “mimicking the natural.” Amalgam has served us relatively well in its time, but its time has gone. Amalgam doesn’t have the ability to mimic the natural and is very different than dentin or enamel in regard to thermal conductivity. Additionally, the flex modulus and flexural strength is far different than dentin or enamel. Add to this the fact that it can’t be bonded at a high strength to dentin or enamel. By today’s standards, this is not acceptable.

We cannot underestimate the importance of aesthetics to humans. It is actually a compliment to any society when aesthetics rises in terms of human priority. We should feel fortunate that we live in an era in which aesthetics is paramount to our patients. When it comes to mimicking aesthetics, it is important that we remind ourselves why this is so meaningful to humans. For example, humans are the only living life form which posses the ability to simply “smile.” Yes, other mammals can generate powerful body language via fierce growls and the like, but only humans have the ability to generate the marvelous expression of well being or happiness through a smile or a laugh. It stands to reason that dentistry must pay attention to human needs, particularly in mimicking the most pleasing of attributes – a beautiful smile. The expectation of the 21st century is that we restore to “aesthetic function” not only “masticatory function.”

Fortunately, the majority of dentists have moved away from amalgam. Sadly, the majority of our schools still teach it as the material of choice for the posterior. This wastes precious school time, causes confusion in the minds of students even with regard to technique and forces graduates to have to learn the sensitive procedures of adhesives and composites on their own or via expensive post-graduation courses.

I learned some time ago in my dental practice that the one human health more important than any other health is mental health. Facilitating self-confidence via a “smile” must be an important consideration for modern dentistry. Minimally invasive dentistry must be at the forefront. We must embrace preventive techniques and other forms of low invasiveness such as bleaching. When tooth preparation is required, we must operate with an understanding of minimal invasiveness and the valuable consideration such imparts. I’ve said this before, “the more you cut a tooth, the more you weaken the tooth. The more times you cut, the sooner you kill the tooth. Trauma to a tooth is additive.”

Clinicians will continue to see more and more researchers, lecturers and authors teaching the importance of mimicking nature or “biomimetics.” It is appropriate that we learn from nature. It is paramount that we develop and maintain the skills to “restore,” and as my alma mater (Loma Linda University) taught me, “To Make Man Whole” in ways that approximate nature, complete with aesthetics while keeping economics and ethics in mind. The overriding lesson is to avoid compromise. Use the strongest adhesive you can find; the practice of adhesive dentistry is for real. Don’t be complacent, our patients deserve the best. You must learn the science behind quality high-strength adhesives and other resin materials and then apply them. Use bonded quality ceramics where indicated for those who can afford it, but don’t turn your back on those who can’t. Quality composites continue to advance. Listen to the needs of those you serve. Listen to the needs of the tooth, be “patient” and “tooth-centered” and keep driving towards mimicking the natural to the best of your ability.

Certainly the high-strength of non-compromising adhesives today have contributed most importantly to the biomimetic equation. Bonding with non-compromising adhesives that closely mimic the inherent strength of dentin, followed by a material that closely mimics dentin, enables dentists to soar like eagles into the 21st century. As Dr. Magne instructs, the “post-amalgam” era is now.

References
1) Composite Resin and Bonded Porcelain: the Post-Amalgam Era? Pascal Magne DMD, February 2006, Volume 34, No. 2, CDA Journal
2) Reconstruction of devital teeth using direct composite resins: A clinical study, Simone Deliperi, DDS – Postgraduate Esthetic Dentistry, Adjunct Assistant Professor-Tufts University School of Dental Medicine-Boston (USA) and private practice, Cagliari (Italy)
3) Clinical Evaluation of Direct Cuspal Coverage with Posterior Composites, Deliperi S, Bardwell D. J Esthetic Restorative Dentistry 18: 2256-267, 2006
4) Dentin Shear Strength: Effect of Depth and Location. N. Jessop, G.E. Denehy, M.A. Vargas (The University of Iowa, College of Dentistry, Iowa City, IA. 52242, USA).

Author’s Bio
Dr. Dan E. Fischer, founder of Ultradent Products, is a 1974 graduate of Loma Linda University. He lectures around the world on the subject of Minimal Invasive dentistry and reaching more social economic groups via maximizing the possibilities of simplistic modern dental technologies. He still practices part time.
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