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Dentistry Must Move Beyond the Age of Amalgam by Dr. David Clark

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by David Clark, DDS

Sadly, outcome studies support amalgam as a superior choice when compared to posterior composite restorations. However, with a modern approach taken to composite dentistry, I have found that not only can outcomes be better, but quality of life for the patient and the health of the tooth and tissue can also be superior. The issue is that if this argument is framed with the current G.V. Black model of cavity preparations, then the most honest response is to concede to the amalgam standpoint.

The Prep – Not the Restorative Material – is the Issue
I view this not as an argument, but rather as an enlightenment process. My esteemed colleague is absolutely correct when he states that amalgam does not contribute to cusp fractures. Studies done on Class I and II composites versus Class I and II amalgams cut with G.V. Black preparations have found the cuspal fracture rate to be about the same for both groups. If we are going to stay mired in the old system of retentive G.V. Black cavity preparations, composite has no advantages over amalgam in protecting the tooth from fracturing. The truthful answer is that it is not amalgam or composite that leads to cusp fracturing – it is G.V. Black preparations. Cracking and fracturing combined are the third leading cause of tooth loss in industrialized nations. Dentists have the responsibility to stop weakening teeth, and that can only be accomplished by the elimination of archaic retentive preparations.

If we redesign the cavity prep, then we can eliminate fracturing by creating cavity preparations that, first, do not weaken the tooth, and second, allow the composite to wrap around the tooth. Initial studies have shown that new cavity preparations actually allow the composite to strengthen the tooth.

Changing Principles
The case shown here illustrates all the advantages we can realize with composite. But in order to place composite restorations that will outlast amalgam, a number of factors in dentists’ approach to the restoration must change. First and foremost, a pre-wedge is necessary to place these posterior composites (Fig. 2). The soft wooden wedge (Bioclear) used in this step, prior to creating the preparation, retracts the tissue so we have better visualization and allows us to control bleeding and achieve tight contacts.

The second step that is critical to the success of the composite restoration is to move away from a retentive preparation. The creation of mechanical retention in a preparation increases the risk of exposing pulp. In the era of modern dentistry there are no more pulp exposures, as one of the advantages of using direct composite is that with a very aggressive surface prep and better vision, the clinician can be more careful to avoid running into the pulp. Total access and visualization for final caries removal allowed me to simply scrub away the final caries near the pulp horn with sodium hypochlorite and a microbrush (Fig. 3).

Restorations that Enable Healthy Tissue and Strong Teeth
A careful examination of the tissue in the interproximal area of the case shown displays two very excellent amalgam restorations with perfect margins, but tissue that is chronically inflamed. This is common around Class II amalgams, due to the fact that it is impossible to polish this area effectively and the tarnish can lead to mild inflammation. This highlights an additional advantage of the incredible shine of Filtek Supreme Ultra restorative and its ability to retain that shine. The clinician can expect better tissue response over the long term.

An additional advantage of composite versus amalgam – and one that this case demonstrates – is its ability to create a good contact. Using amalgam in this particular case would have made it very difficult to get a good contact, with difficulties in trying to place, tack and carve amalgam to get a nice rounded contact. However, with an injection-molding technique utilizing Filtek Supreme Ultra restorative and a Bioclear matrix, we were able to achieve a nicely rounded post-op contour.

As shown by all of the points mentioned herein, we must enter the modern era of dentistry. While there might be arguments in favor of amalgam, my stance is that traditional preparations deprive composite of its superior assets. I will not argue as to whether amalgam is toxic or non-toxic, or many of the other oft touted advantages of amalgam versus composite. This is because I believe the more urgent reason we need to step away from amalgam is that it doesn’t create tissue outcomes as healthy as a well-done composite, and because it requires unnecessary mutilation of the teeth.
Author's Bio
Dr. David Clark founded the Academy of Microscope Enhanced Dentistry, an international association formed to advance the science and practice of microendodontics, microperiodontics, microprosthodontics and microdentistry. He is a course director at the Newport Coast Oral Facial Institute in Newport Beach, California. He is co-director of Precision Aesthetics Northwest in Tacoma, Washington, and an associate member of the American Association of Endodontists. He lectures and gives hands-on seminars internationally on a variety of topics related to microscope-enhanced dentistry. He has developed numerous innovations in the fields of micro dental instrumentation, imaging, and dental operatory design. Dr. Clark has authored several landmark articles about microscope dentistry including Aesthetic Dentistry, Sealants, The Role of Ultrasonics in Three Dimensional Shaping and Restoration of Non Vital Teeth, Micro-Imaging and Practice Management, and Crack Diagnosis. Dr. Clark is a 1986 graduate of the University of Washington School of Dentistry. He maintains a microscope centered restorative practice in Tacoma, Washington. He can be reached at drclark@microscopedentistry.com, drclark@bioclearmatrix.com matrix.com or www.bioclearmatrix.com.
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