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A Quarterly Publication for Dentists Jan 2003 A newsletter that Keeps you abreast with the very latest in Dentistry

1. Very Old Issues of YPB clic here to see very old issues !so"e very #ood articles. $ealthcare %rust and I&D' are playin# a vital role in continuin# education. In near future we plan to brin# you a course on (fficient Be## %echni)ue* with this techni)ue as we will teach you will be able to #et results al"ost as #ood as strai#ht wire. %o #et "ore infor"ation on this e "ail to be##+health"antra.co" In this issue we brin# you lot of interestin# articles to i"prove your clinical practice. ,riends please spare a "inute and send us your feedbac at ypb+health"antra.co" and tell us "ore about you and what you would li e to see at our website. %hat will help us serve you better. W at are !io"ers W at are t e Benefits of Pre #rocedural "out rinsin$% &o Bond Or not to Bond A"al$a" 'lo(able )o"#osites

-hat are .io"ers

Giomers are a relatively new type of restorative material. The name "giomer" is a hybrid of the words "glass ionomer" and "composite", which pretty well describes what a giomer is claimed to be. Although glass-ionomer restorative materials such as Ketac-Fil !" #$%#& and Fu'i Type (( G) America& have some very important properties, such as fluoride release, fluoride rechargeability, and chemical bonding to tooth structure, they also have well-*nown shortcomings. Their esthetics, for e+ample, are less than ideal and ma*e them a poor second choice to resin composites for restoring esthetically-demanding areas. Also, they are sensitive to moisture contamination and desiccation, which can present the clinician with challenges during their placement. (n the ,--.s manufacturers improved these shortcomings by adding resins to glass ionomers to produce resin-modified glass ionomers. These products e.g., Fu'i (( /), G) America0 1itremer, !" #$%#0 %hotac-Fil 2uic*, !" #$%#& have much better esthetics and

handling characteristics than glass ionomers. (mportantly, they also retain many of the glass ionomer3s beneficial properties, such as long-term fluoride release and the ability to be recharged with topically-applied fluoride. They tend, however, to discolor over time. (n another attempt to "better" the glass ionomer restorative materials, compomers were also developed. They were touted as being similar to glass ionomers but having much better esthetics and being easier to place and polish. 4nfortunately, some of the manufacturer3s claims were not confirmed by published research. Although they handled better than G()s, they released much less fluoride and could not be recharged. (n the continuing 5uest for improved glass ionomer-li*e restoratives, manufacturers have developed and introduced a new class of materials called "giomers." As noted earlier, the term implies they are combinations of glass ionomers and composites. Their manufacturers claim they have properties of both glass ionomers fluoride release, fluoride recharge& and resin composites e+cellent esthetics, easy polishability, biocompatibility&. Giomers are distinguished by the fact that, while they are resin-based, they contain prereacted glass-ionomer %6G& particles. The particles are made of fluorosilicate glass that has been reacted with polyacrylic acid prior to being incorporated into the resin. The pre-reaction can involve only the surface of the glass particles called surface pre-reacted glass ionomer or $-%6G& or almost the entire particle termed fully pre-reacted glass ionomer or F-%6G&. Giomers are similar to compomers and resin composites in being light activated and re5uiring the use of a bonding agent to adhere to tooth structure. 7nly one giomer is commercially available at the time of this writing, $hofu3s 8eautiful, see at right& which uses the $-%6G technology. According to $hofu, 8eautiful is indicated for restoring )lass ( through 1 lesions as well as for treating cervical erosion lesions and root caries. (t is available in ,! shades and is supplied in syringes. /ittle published research is available on the properties or performance of giomers. 7ne recently published study compared the fluoride release of a glass ionomer, a resin-modified glass ionomer, a giomer, and a compomer. (t found that while the giomer released fluoride, it did not have an initial "burst" type of release li*e glass ionomers, and its long-term i.e., 9:-day& release was lower than that of the other materials., Another study found that a giomer, after polishing with $of-/e+ dis*s, had a smoother surface than a glass ionomer, and one that was comparable to that of a compomer and a resin composite. 9 A threeyear clinical study comparing the performance of a giomer with that of a microfill resin composite in )lass 1 erosion;abrasion;abfraction lesions has also been done. After measuring eight performance characteristics, no significant differences between the two materials were found. ! Almost assuredly, many other giomer products will become available in the future.

6eferences ,. <ap A4=, Tham $<, >hu /<, /ee ?K. $hort-term fluoride release from various aesthetic restorative materials. 7per @ent 9..909AB9C--9DC. 9. <ap A4=, "o* 8<<. $urface finish of a new hybrid aesthetic restorative material. 7per @ent 9..909AB,D,-,DD. !. "atis 8A, )ochran "A, )arlson T=, #c*ert G=, Kulapongs K=. Giomer composite and microfilled composite in clinical double blind study EAbstractF. = @ent 6es 9..90:,BA-:.. What are the Benefits of Pre procedural mouth rinsing? %re-procedural mouth rinsing is the use of an antimicrobial mouth rinse by the patient before a dental procedure. (ts ob'ective is to reduce the number of oral microorganisms that may be released as an aerosol or spatter from a patient3s mouth during dental care that subse5uently contaminate e5uipment, operatory surfaces, and dental healthcare personnel. A visible spray is created during the use of rotary dental and surgical instruments e.g., handpieces, ultrasonic scalers& and air-water syringes. This spray contains, primarily, large-particle spatter of water, saliva, blood, microorganisms, and other debris. $patter travels only a short distance and settles out 5uic*ly, landing either on the floor, nearby e5uipment and operatory surfaces, the dental healthcare personnel providing care, or the patient. The spray may also contain some aerosol. Aerosols ta*e considerable energy to generate, consist of particles less than ,. microns in diameter, and are not typically visible to the na*ed eye. Aerosols can remain airborne for e+tended periods of time and may be inhaled0 they should not be confused with the large-particle spatter that ma*es up the bul* of the spray from handpieces and ultrasonic scalers. Appropriate use of dental dams, high-velocity air evacuation, and proper patient positioning should minimiGe the formation of droplets, spatter, and aerosols during patient treatment. To date, no scientific evidence supports the claim that pre-procedural mouth rinsing actually prevents disease transmission in the dental operatory, but studies have shown that a pre-procedural rinse with a product containing an antimicrobial agent e.g., chlorhe+idine gluconate, essential oils, povidone iodine& can reduce the level of oral microorganisms generated when performing routine dental procedures with rotary instruments. %re-procedural mouth rinses may be most beneficial before a prophyla+is using a prophyla+is cup or ultrasonic scaler since rubber dams cannot be used to minimiGe aerosol and spatter generation, and unless the provider has an assistant, high-volume evacuation is not commonly used.

&o Bond Or not to Bond A"al$a"

"ultiple laboratory studies have found definite advantages for bonded amalgam restorations including increased retention,, fracture resistance,9,! and marginal seal.H $taninec found that the use of adhesives provided greater retention than grooves or dovetails., 7liveira and others found improved fracture resistance in large "7@ preparations when bonding amalgam compared to the use of )opalite alone.9 A study by 8urgess and others found no difference in the strength of comple+ amalgam restorations using four T"$ pins or bonding, but the combination of the two significantly increased the forces necessary for fracture.! $tudies have also shown increased retention of amalgam when bonding with resins containing filler particles.C The more viscous bonding agent may improve penetration into the amalgam during condensation. D Also, research has shown a reinforcement of remaining tooth structure with bonded amalgam restorations.A ?owever, the ability to maintain this reinforcement over time remains e5uivocal with some studies showing no increase in fracture resistance after aging and thermocycling.:,- The use of an adhesive agent under amalgam has been shown in laboratory studies to decrease microlea*age. H Again, the long-term significance of this decrease is un*nown. "ost of the clinical studies have found no decrease in post-operative sensitivity,.,,, and no difference in the performance of bonded amalgam restorations compared with traditional mechanically-retained restorations. D,,9 )ontrary to popular belief, the preponderance of clinical investigations has demonstrated no difference in sensitivity reported by patients receiving amalgam restorations with or without resin adhesives. ,.,,, $ummitt and others published a clinical study comparing the performance of bonded versus pin-retained comple+ amalgam restorations and found no difference after five years between the two techni5ues. They concluded that bonding with a filled bonding resin Amalgabond %lus, %ar*ell (nc., Farmingdale, I<& was a satisfactory method of retaining large amalgam restorations replacing entire cusps. D $o, should you place an adhesive agent under all of your amalgam restorationsJ Given the added cost, time and techni5ue sensitivity of using adhesive liners, there appears to be no clinicallydemonstrated benefit in bonding conventional preparations which contain customary retentive features.,! ?owever, given the advantages of increased retention, strength and marginal seal found in laboratory studies, the bonding of amalgam may be 'ustified ad'unctively with traditional mechanical retention in large restorations replacing a cusp, when tooth structure may need some reinforcement, and for crown foundations.,! 6eferences ,. $taninec ". 6etention of amalgam restorationsB undercuts versus bonding. 2uintessence (nt ,-:-09.B!HA-!C,. 9. 7liveira =%, )ochran "A, "oore 8K. (nfluence of bonded amalgam restorations on the fracture strength of teeth. 7per @ent ,--D09,B,,.-,,C. !. 8urgess =7, AlvareG A, $ummitt =8. Fracture resistance of comple+ amalgam restorations. 7per @ent ,--A099B,9:-,!9. H. "eiers =), Turner #K. "icrolea*age of dentin;amalgam alloy bonding agentsB

results after , year. 7per @ent ,--:09!B!.-!C. C. @iefenderfer K#, 6einhardt =K. $hear bond strengths of ,. adhesive resin;amalgam combinations. 7per @ent ,--A099BC.-CD. D. $ummitt =8, 8urgess =7, 8erry TG, 6obbins =K, 7sborne =K, ?aveman )K. The performance of bonded vs. pin-retained comple+ amalgam restorationsB a five-year clinical evaluation. = Am @ent Assoc 9..,0,!9B-9!--!,. A. el-8adrawy KA. )uspal deflection of ma+illary premolars restored with bonded amalgam. 7per @ent ,---09HB!!A-!H!. :. $antos A), "eiers =). Fracture resistance of premolars with "7@ amalgam restorations lined with Amalgabond. 7per @ent ,--H0,-B9-D. -. 8onilla #, Khite $I. Fatigue of resin-bonded amalgam restorations. 7per @ent ,--D09,B,99-,9D. ,.. "ahler @8, #ngle =?, $imms /#, Ter*la /G. 7ne-year clinical evaluation of bonded amalgam restorations. = Am @ent Assoc ,--D0,9AB!HC-!H-. ,,. $males 6=, Ketherell =@. 6eview of bonded amalgam restorations and assessment in general practice over C years. 7per @ent 9...09CB!AH-!:,. ,9. 8rowning K@, =ohnson KK, Gregory %I. )linical performance of bonded amalgam restorations at H9 months. = Am @ent Assoc 9...0,!,BD.A-D,,. ,!. $etcos =), $taninec ", Kilson I?F. 8onding of amalgam restorationsB e+isting *nowledge and future prospects. 7per @ent 9...09CB,9,-,9-.

Flowable Composites
(t has become popular to routinely place a flowable composite e.g., Filte* Flow, Flow-(t A/), Tetric Flow, 6evolution Formula 9& on the pulpal floor and a+ial wall of a )lass (( preparation prior to restoring the tooth with a pac*able resin composite e.g., %yramid, $ureFil, $olitaire 9, %rodigy )ondensable&. , (n fact, some manufacturers of pac*able and flowable composites include recommendations in their instructions to do so. )linicians usually place a flowable liner because it reduces the bul* of pac*able composite that has to be placed. This ma*es it easier and less time consuming to restore the tooth. 7thers believe it helps reduce lea*age at the tooth;resin interface because the liner is fle+ible and absorbs some of the pac*able composite3s shrin*age as it cures. This, at least theoretically, may result in a better bond between the resin and tooth with little or no gap being formed. There is some evidence supporting this theory.9,! Finally, some users place a flowable because it contains fluoride, and they believe that the fluoride release will have a anti-cariogenic effect. (f you routinely place a flowable composite as a liner before restoring a tooth with a resin composite, be it a microhybrid or pac*able, you should be aware of some precautions to ta*e. First, the flowables are essentially "thinned down" composite resins, which accounts for their appealing characteristic of easy placement. The thinning down process is accomplished, at least in part, by incorporating fewer filler particles into the resin. As a result, physical properties such as strength and resistance to fracture are lower. $o we should be mindful of the need to place a flowable in a relatively thin layer. Also, a study published a few years ago found

that a number of then currently-available flowable composites lac*ed a sufficient degree of radiopacity. H This means that on radiograph the flowable would appear as a thin, radiolucent line e+tending from the margin to the a+ial wall. Kithout a well-documented record, a clinician could misinterpret this as caries, possibly secondary to microlea*age. 4nfortunately, cases have been reported where the otherwise acceptable resin composite restoration has been removed only to find that the radiolucent "line" was a non-radiopa5ue flowable resin. %erhaps the best reason for using a flowable resin as a liner beneath a pac*able composite is to ma*e it easier to pac* the composite into the preparation. %ac*ables are thic*, and it can be difficult to place them in a preparation especially one that is irregular with undercuts& without producing voids. 8y placing a flowable resin liner into areas of the preparation that are difficult to access, the potential for producing voids is reduced. The bottom line is not that we shouldn3t use flowable resins as liners, but that we need to be aware of their limitations, so that we choose the right flowable product and use it sparingly so that its lesser physical properties do not compromise the clinical success of the pac*able resin restoration. 6eferences ,. Fortin @, 1argas ". The spectrum of compositesB new materials and techni5ues. = Am @ent Assoc 9...0,!,B9D$-!.$. 9. %ayne =? (1. The marginal seal of )lass (( restorationsB flowable composite resin compared to in'ectable glass ionomer. = )lin %ediatr @ent ,---09!B,9!,!.. !. Ferdiana*is K. "icrolea*age reduction from newer esthetic restorative materials in permanent molars. = )lin %ediatr @ent ,--:099B99,-99-. H. "urchison @F, )harlton @G, "oore K$. )omparative radiopacity of flowable resin composites. 2uintessence (nt ,---0!.B,A--,:H. BA&K