Wednesday, August 1, 2012

Hey all,

Sorry about Friday. I had half the thing written and then just left the office. And when I leave the office, I really leave the office. I don't bring my computer home and really don't think about work much when I am gone.

My son comes home from Mexico today. He seems to have had a great time, but at home, we have not been ourselves. We are all just looking forward to having him home. We have gotten emails from a couple of friends that went, and some sent us some photos. Here he is. (He is a good looking kid, isn't he?)

Anyway, I saw a lecture a couple of months ago and I have been reviewing the notes. I think I talked about it before. The guy was Alan Atlas, a dentist out of UPenn. Very good lecture on adhesives. He began the lecture talking about composites versus amalgam. We all agreed that amalgam was the better material for longevity, but if we were getting a restoration, most of us will choose composite (as will our patients). So, we need to make composite better.

We talked about the negative of composites. He showed a study on composite that claims 30% have to be replaced within the first 6 years, and he talked more about failure. The number one reason for failure within the first five years is technique, fracture or sensitivity. Between 6 and 17 years, the number one reason for failure is secondary caries.

He went on to say that responsibility of the failure rests first the patient, second on the dentist, and third on the material. He said that the caries risk patient is that way for two reasons: diet and genetics. According to the lecture, for patients at low risk of caries, COMPOSITE did better than amalgam in a 12-year study. Hmmm.

This study is from the Journal of Dental Research from 2010. I still don't know about this. I have always said that you can find research to say whatever you want. There is an article for everything. For every article that says amalgam is a great product, you have two that say that is causes Lupus. Use a rubber dam; don't use a rubber dam. Bleach in a canal for an RCT; bleach is poison. Ceramic versus gold. You can find an article that will back anything you want.

In this case, we find an article that says that composite is holding up better than the gold standard. I know composite is getting better. The more we place, the better we get at it. The more research we do, the better the products become. I don't know about you, but I have not seen a 45-year-old composite filling that looks like the day it was put in.

I think composite is awesome. I have spent my life trying to make teeth with restorations look like natural teeth. I have 19-year-old composite fillings in my mouth. I have pictures of 16-year-old composite fillings that I did. But do I believe that, in a 12-year study, composite has a higher success rate than amalgam? I just have a hard time believing this.

Am I the only one that has a hard time with this? Do you just read this and then move on, and not really think anything of it? It is not going to change the way you practice… is it?

BUT, we are almost there. It is like last week’s blog: 22 years of success. Every day, I am more and more convinced (especially after all the reading I am doing) that we are on the right track. We are saving teeth and we are doing it better and for longer. Okay, that is going to be my last composite blog for awhile. Sorry about all that.

I have to go now. I have to get back to watching my 16-hour-a-day obsession with the Olympics. I can't stop watching. GO USA!!!

Have a great rest of the week.



Bdraht said...

Thanks for your comments on composite fillings. It seems to me that they are the future-BUT the longevity is the issue. I love the fact they strengthen the teeth, they look good, but how long will they last is my biggest question. Please continuing sharing what you find!! said...

These days, it really seems to me that an amalgam "the poor man's filling". Most mid-high tier dental offices that I know of do not even place them anymore. Amalgam is incredibly efficient in terms of placing a quick filling, and yes, a MOD amalgam will likely outlast an MOD composite, but people will only tolerate them if they have absolutely no other choice.
ANother thing I have noticed is many older dentists that have been practicing for 30+ years do not know much about adhesion, and all the new advances that have been made in resin bonding. They may have many composite failures turing up from years ago when materials were not at the level they are now, and they prefer to stick with what has worked for them. I want to say that amalgam will die out when the dentists that use it most retire, but from a public health perspective, it is one of the few options to provide quick and affordable dental care to those in need.


Anonymous said...

i just tell patients the truth. Amalgam will last longer, hands down. There is no 20 year composite period particularly if its a deep dentin bounded box. Dentin bonding is weak at best and it will always be so regardless of your FAGD or MAGD. The more CE a dentist takes, the more he likes composite, but it doesnt change facts. It's like Tide detergent. Since I was a kid Tide has always been New and Improved. It's a marketing thing. The dentist, against his knowledge, places a more pricey material on the hedge that it is new and improved and that things are so good that it will last forever. Composite in enamel works well and if you keep to that, it's great. Like any building material, a good contractor knows what to place where and justifies it to his clients. Practices that forbid amalgam based in reality on it's low price are fooling patients and not providing quality care where it is often served best with amalgam. To say amalgams are cheap and quick is also not true. In my practice I tell people how the world works and let them decide what they want. Sometimes if a patient wants an amalgam MOD on a bicuspid based on the lower fee, and once in the prep it is bound in enamel in the box, I'll often "upgrade" them to composite as it is most times quicker for me to place and then charge the amalgam fee while justifying my choice of materials for them. Class II composites will always fail first at the bottom of a deep dentin bounded box, God or not. I don't acquiesce to patient pressure or cont ed points. When diagnosing a condition I make recommendations based on what material will work best for the job and then ask patients what they want me to do for them. Most times they'll agree to what I recommend. Sometimes placing a lower priced and more time consuming filling based on science , not cost, is the right thing to do.

That's my legacy.


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