Terri Lively

You use composite to fix cavities and restore function. But do you ever consider the ways dental composite resins can enhance a patient’s smile? From chips to stains to closing diastemas, cosmetic treatments with dental composite resins can help your patient be ready for their close-ups.

Part of what makes these cosmetic treatments minor is the dental composite resin materials themselves. Sculptable and polishable, today’s composite resins can shape and mold the patients’ dentition and retain a high gloss and natural look after finishing. Here are a few cosmetic procedures you can do with composite:

Fixing chips in the teeth is an everyday use for bonding in the anterior. In repairing chips, Sarah Jebreil, DDS, AAACD chooses her composite based on several factors. Does it polish well? Is the shade matching simple? Can it layer easily?

Dr Jebreil says she finds that using cosmetic bonding after an Invisalign treatment gets the teeth ready for their close-ups.

“I get the teeth in the right position, and then I’ll just zhuzh it up with some bonding and make it look nice,” Dr Jebreil says.

 Another quick anterior treatment Dr Jebreil thinks composite makes easier is fixing hypocalcifications. She takes them out and then bonds those areas. She says even this quick and easy anterior fix makes a significant difference to patients.

“It’s just a tiny little spot, but fixing it makes a huge difference to somebody’s life, and it’s pretty easy,” Dr Jebreil says.

 Diastema closures are another way you can use composite in the anterior esthetic zone. First, the clinician chooses the shade and opacity needed to close the gap. Then, after isolating with a rubber dam, the dentist prepares any misalignments in the teeth, if required, followed by etching on the enamel surface of both teeth. Next, the material is applied simultaneously and contoured to the facial half of the preparations for both teeth and light-cured. Following that, dentists can use a matrix to layer the lingual half of the diastema and cure it. Last, the dentist finishes and polishes it.

closing a diastema with composite is an excellent way to improve a patient’s smile in a minimally invasive way. Researchers suggest that the direct composite veneer provides proper esthetics and costs less than other options, like a full crown. Also, clinicians can do it in a single appointment.

Dr Jebreil doesn’t like diastema closures, preferring bonding for smaller areas, although she has done her fair share of diastema closures with composite when patients ask. The challenge with bonding for a large area in the anterior is that it expands over time and collects stain. Dr Jebreil prefers to do a super-thin contact lens veneer for a diastema closure using a porcelain prosthetic because the porcelain doesn’t stain, remains smooth, and looks prettier in the midline of the mouth.

“I will do a diastema closure with composite if someone asks, but I always say it’s a temporary, not a permanent, solution,” Dr Jebreil says.

Dr Jebreil uses composite bonding to fix a tooth-size discrepancy for patients with narrow teeth. When placing veneers on the laterals or 4 veneers on the front, Dr Jebreil says that clinicians sometimes have too much space and need to work on balance of teeth proportions for the patient.

“If you feel like you don’t want to make the laterals too wide to close the space, you can do a proportional lateral. Then, add composite from the mesial lingual of the canine in the contact area. It gives you nice proportions, and from the mesial lingual angle, the composite doesn’t get as much stain,” Dr Jebreil explains. “That is one of my favorite ways to use composite.”

Essential Considerations for Composite in the Anterior

Having a tooth shade match the surrounding dentition is essential for using composite cosmetically in the anterior. As a result, many composites today have optimized their blending and shade matching.

Studies suggest that layering composite is an excellent way to create esthetic restorations that have the characteristics of dental structures. Researchers in the 

International Journal of Esthetic Dentistry

 recommend employing a natural stratification of the anterior teeth using a dentine hue, and a predefined thickness of enamel or by implementing a single layer of composite enhanced with the placement of pigment and opacities will achieve predictable esthetic results.

In the anterior, shade matching is only part of the cosmetic concern. Polishing is another crucial area. Dr Jebreil says that having a broad bevel is essential because that helps blend a composite into the natural dentition.

Per Spear Education, the bevel is a crucial area for beautiful anterior composite. First, create a facial feather using a round-end cylinder diamond to make a 2mm bevel on the facial that “feathers out” from dentin to enamel. Then create a facial starburst to make different depths and widths to the bevel, which enable the composite to blend effortlessly. Finally, Spear recommends a lingual 1 mm chamfer for strength.

“A wide, broad bevel helps,” Dr Jebreil says. “Then I like to use the whole sequence of disks, and when I get to the finer ones, I use water with it to hydrate the composite.”

However, the best composites in the world don’t help a dentist who is uncomfortable with their technical performance in the esthetic zone. Studies have shown that while the composites have reached a point in their development where their performance is about the same across the board for mechanical and esthetic properties, the treatment environment and the clinician’s placement technique significantly influence the success of therapeutic outcomes.

With so much riding on a dentist’s ability to use materials properly, it is essential to continue to train in new techniques. To get more comfortable with cosmetic procedures, Dr Jebreil recommends going to American Academy of Cosmetic Dentistry (AACD) conferences to get more experience. Dr Jebreil says the hands-on courses are great because you can use the different kinds of composite and learn various techniques to see what works for you and what does not. She also thinks accreditation from the AACD is essential too.

“The process is great because it gives you a lot of practice,” Dr Jebreil says of the AACD accreditation. “And it truly trains your eyes to evaluate the esthetics and what is the proper treatment for each patient.”


Six Steps to Consider When Closing Diastemas. Aacd.com. Published 2010. https://aacd.com/proxy/files/Students%20and%20Faculty/AACD_6_steps.pdf.

Mai Abdulgani. Closing Diastemas With Resin Composite Restorations; A Case Report. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), 18. 30-33. Published 2019. Retrieved from https://www.researchgate.net/profile/Abu-Hussein-Muhamad/publication/331589564_Closing_Diastemas_with_Resin_Composite_Restorations_a_Case_Report/links/5ccf3028458515712e9547f4/Closing-Diastemas-with-Resin-Composite-Restorations-a-Case-Report.pdf.

Varvară, Elena & Mesaros, Anca & Culic, Bogdan & Adrian Mihai, Varvara & Dudea, Diana. (2018). Resin composite layering technique for direct anterior teeth restorations. Palestrica Of The Third Millennium - Civilization And Sport. 19. 234-238. 10.26659/pm3.2018.19.4.234.

Wehking D. Simple Process for Making Beautiful Anterior Composites - Spear Education. Speareducation.com. Published 2018. https://www.speareducation.com/spear-review/2018/08/a-simple-process-for-making-beautiful-anterior-composites-the-dentin-samich-technique.

Dietschi, D., Shahidi, C., & Krejci, I. (2019). Clinical performance of direct anterior composite restorations: A systematic literature review and critical appraisal. The International Journal of Esthetic Dentistry, 14(3), 252-270. Retrieved from https://archive-ouverte.unige.ch/unige:121627

Articles

From chips to stains to tooth-size discrepancies, cosmetic treatments with dental composite resins can help your patient be ready for their close-ups. 

Cosmetic Procedures: Making Patients Ready for Their Close-ups with Composite

Over the past 20 years, dental services organizations (DSOs) and large group practice models have been increasing in dental practice types. Meanwhile, over in medical, large medical groups and medical management services organizations (MSOs) have preceded DSOs in growth by at least a decade or more. We can explore the changing growth rates in dental practice types and what the dental industry can learn from the medical industry regarding the development of these practice models.

How dentists like to practice has changed over the past 2 decades. Just before the Millennium, the majority of dentists were solo practitioners. Per the Health Policy Institute of the American Dental Association, 65% of dentists in 1999 were solo practitioners. Twenty years later, that number has decreased to 50% in 2019, a proportion of 1 in 2. In other words, these days dentists are just as likely to be solo practitioners as they aren't.

Also, the age of the dentist affects their probability of skipping the solo practice type. Amongst dentists under 35, the proportion of solo practitioners drops to 1 in 4.

Moreover, these numbers and trends do not include the curveball that COVID-19 threw many dental practices in 2020. Based on what dentists learned about what can happen when you are a solo practitioner without anyone in the chair for several weeks to months, these percentages could have changed even more.

So, how do dentists want to practice today? Many of them are working in groups; others are joining DSOs. In the DSO model, dental practices join the DSO, which then supports the dental practice for their non-clinical operations. Per the Association of Dental Support Organizations (ADSO), DSOs allow dentists to focus on delivering patient care with the support DSOs provide in professional office management.

Dentists like it too. In 2019, 10.4% of dentists in the U.S. were affiliated with DSOs, up from 7.4% in 2017. Also, the ages of these DSO dentists are skewing younger; 34% were under 49. Female dentists like them too; 13.3% of dentists in DSOs were women.

DSOs are offering an attractive option for dental professionals, although they are not where most dentists practice. The idea of "corporate dentistry" still has a long way to go in the dental community to become like the medical community where large groups and managed care organizations are nothing new to medical doctors. MSOs have been a part of medical practices for years, growing in popularity with the adoption of a managed care approach to medical care that prevailed in the 1980s and 90s.

 Unlike dental, medical has already navigated many problems and pitfalls of this change in practice type—and dental practices should take note.

Learning Vicariously from Medical Software Development

There are a few things that large medical groups can teach the burgeoning DSO organizations in dental. One of the most significant is implementing the software functionality medical uses in dental software programs.

Mike Uretz, Executive Director of Dental Group Partners and founder and editorial director of DentalSoftwareAdvisor.com, works with many group practices in the DSO space. He also worked in medical software for 12 years before moving into dental, where he saw the potential for improvement. He thinks DSOs can learn a few things from large medical groups regarding the technology they use:

 Medical groups have embraced cloud-based software systems. Uretz says that dental software and practice management systems have been moving toward cloud-based systems, but there is some resistance to them from practices still tied to their physical servers.

: Uretz says DSO and multi-location groups need to put everything they need in a single integrated database, from financial to patient care to operational information. While he says that many dental software vendors have integrated databases, it is not to the extent that Uretz would like to see.

: Although operations and claims management are key to a DSO’s success, it is also critical to focus on having good clinical and electronic health record (EHR) software. Software evolved in the medical industry and moved from concentrating on practice management functionality to including more powerful clinical care management and EHR tools in their software. Uretz would like to see dental do the same. He says that one of the criticisms of large DSOs and groups is that they can't deliver a good level of personal patient care, but by showing that you can with state-of-the art clinical and EHR software you can defend against that bias.

Take advantage of analytics and business intelligence tools

: Medical groups and MSOs have used analytics and business intelligence (BI) to manage their practices' key performance indicators (KPIs) for years, Uretz says. He would like to see DSOs use these tools more consistently.

: Medical has many different software systems that can talk to each other, which has been essential with the EHR following patients through their medical path. Uretz thinks dental practices must communicate with their medical counterparts and other dental systems, but dentistry has a long way to go in this area.

Embrace the Cloud and Prioritize Integration

Before becoming Director of Marketing for Planet DDS, David Means also worked in a healthcare technology company, specifically an ephemeral messaging app company tasked with helping medical professionals communicate more effectively. Like Uretz, Means also thinks a critical priority for DSOs is to use a cloud-based system rather than a server-based. Not only is it more remotely accessible and less vulnerable to theft or destruction, but cloud-based practice management systems are also less prone to in-house maintenance and obsolescence. Plus, your data is more secure in the cloud than it is physically in the practice.

"Unfortunately, dentists are becoming more of a target for ransomware attacks because a lot of practices do not have sophisticated security in place on their systems, but instead have rudimentary passwords or encryption on their servers," Means says. "But if they have a practice management solution in the cloud, then there's physical security, but also additional layers of security behind firewalls that are going to make it much more difficult for somebody to be able to access the patient data inappropriately."

Means also agrees with Uretz that DSOs should prioritize integration. For example, when Planet DDS works with large DSOs, many of them centralize their back-office operations first thing. However, that team still needs access to the data from all the individual locations to assess the opportunities for improvement. Means says having an integrated product like Denticon is an excellent way for growing DSOs to have a common place for everything. Moreover, the technology optimizes the patient experience to ensure patients receive a consistent delivery of care each visit, a metric that investors—and dentists— like to see.

"They are putting in a process that enables the staff to ensure that they're giving great quality service and everything that patients need every time," Means says.

Bridge the Communication Gap Between the Different Practices for Patient’s Benefit

Dental and medical sciences have operated independently from each other for over a hundred years. However, research shows a connection exists between patients' overall health and oral health. In addition, more medical professionals see dental as a specialty for oral health, like a cardiologist is for heart health. As a result, Uretz thinks the future of financial and clinical success of all dental practices—solo, group, or DSO—will be enhanced by electronic communications with patients' medical counterparts.

Unfortunately, most dental software vendors haven't embraced this concept or prioritized it in development. Uretz would like to change that.

"Most people who read the studies can see where this relationship between medical and dental is going, but we don't have enough tools and software to make that relationship work," Uretz says.

Sam Ahani, DDS, CEO of Refera, an online referral platform for G.P.s and specialists, agrees that medical is doing better than dental for investing a lot in technology that supports the more effortless transfer of patient records. Investing in technology that can centralize recordkeeping and facilitate sending the patients' EHRs to other practices, medical or dental, is essential to large dental organizations.

However, dental practice management systems are not as compatible or ubiquitous as the large practice management systems for medical. Moreover, it is difficult for app developers to work with dental systems. For example, in the development of Refera, an app that connects general practitioners and specialists for patient referrals, Dr Ahani says one of the biggest obstacles was communicating with the practice management software. However, software developers are connecting multiple practices and getting the systems to talk to each other.

"But it feels like we're a long way from consolidating the platform," Dr Ahani says.

Finding Ways to Focus on Practicing Dentistry, Not Running a Business

Means says that the solo-practitioner is like a one-man band because they have to manage everything. From staff to payroll to human resources to administrative headaches, the solo-practitioner handles it all while also trying to deliver exceptional patient care.

Post-COVID, Means thinks the growth of DSOs will accelerate. Many dentists experienced first-hand the dangers of going it alone last year during the pandemic when most dental practices, especially smaller, older general practices, were shuttered.

"It was like, 'Well, why should I do this when I can have a partner help me manage this risk moving forward?" Means says.

Dr Ahani says that DSOs got off to a rough start. DSOs learned that focusing on delivering exemplary care was the recipe for success, a lesson he thinks medical had already learned. Large medical practices allow doctors to be "in the zone."

From the doctors' perspective, Dr Ahani thinks that DSOs and selling to a corporate dentistry organization appeal to dentists. Many dentists feel like artists and want to practice dentistry, not run a small business and all the details that entails. Dr Ahani thinks medical group practices are heading in the right direction.

"They're doing what they are supposed to do by building a lot of infrastructure and technology to improve the patient experience," Dr Ahani says of the medical group practices. "I also like the technology coming out, like the My Health online app, which is all about keeping patients in the loop and in control of their healthcare."

DSO's rough start was in part because of pushing productivity and profit improvements. From a business standpoint, boosting production is suitable for a dental practice. However, as a solo practitioner, Dr Ahani says it is difficult to put into place the marketing tools and staff you need to boost production while managing the patient schedule. So the DSO takes on those business marketing tasks, enabling dentists to focus on patient care, which will increase output inherently.

"You're producing more because you are doing what the patient needs," Dr Ahani says. "I don't see anything wrong with that."

"Becoming a part of a group practice or DSO helps free up some of those administrative, overhead management tasks, and allows practitioners to focus on patient care," Means agrees.

Use Technology to Give Patients the Experience They Want

Means also thinks that something dental can learn from medicine is how to use technology to practice better dentistry. Implementing technology helps dental professionals efficiently manage the practice and allows them to pinpoint what they could be doing to ensure they deliver the best care. For example, functionality like secure patient messaging built into the patient communication technology ensures that patients follow the treatment plan and return for prescribed periodic screenings and recommended checkups.

Also, technology gives patients more of what they experience in the other parts of their lives, like secure payments on their phones. However, technology applications can take you even further than that regarding patient experience, per Means.

"In our post-COVID world, people want to spend less time in a waiting room. They want to get through the process as quickly as possible, so having touchless options that you can provide to patients is going to help with patient experience," Means explains. "They want that touchless experience in other areas of their life, and they are expecting that same type of experience when they go to the dentist."

Providing these types of technology integrations in the patient experience is an area where the larger practices on the dental side are excelling. Solo guys, he says, aren’t necessarily there yet. However, if dentists want to remain competitive, Means says, solo practitioners will need to start.

"They need to have practice management solutions to enable that," Means says.

However, dentists do have some legs up on the medical side when it comes to imaging integrated directly in the practice management software. Uretz says that dental software also does a much better job using technology to manage imaging models within the software itself. Naturally dental practice management and clinical software needs to have imaging “baked in”

"Therefore, what I found, is that the idea of integrating images in very creative and user-friendly ways is doing well in dentistry," Uretz says. "There is a lot of exciting work being done with imaging and software in dentistry."

Uretz says that dental software programs have made it possible to pull images from the cloud. So, if an extensive practice has 20 locations or even 100 locations, any office has access to images, even 3D images, in the cloud.

Managing digital imaging isn't the only thing dental does better than medical. Means thinks that dentists' relationship with their patients is more emotionally engaging than the ones patients have with their medical doctors.

"The quality of their chairside manner is better when I go to the dentist versus when I go to see my medical doctor," Means says.

DSOs have been improving over the past 10 to 15 years, too, Dr Ahani says. DSOs’ original approach was to consolidate individual practices to deliver a consistent experience, like a McDonald's or a Starbucks. Now, DSOs support the unique culture of the dental practice and focus on optimizing it. In addition, these "invisible" DSOs produce excellent results by buying a majority interest in the practice but keeping the dentist as part-owner and managing the dental practice behind the scenes.

"They give then economies of scale for supply purchases to get better pricing. They help them with their human resources, which is a huge problem for dentists right now," Dr Ahani says. "This version lets dentists do the things that they want but helps them a bit in the background."

 https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIGraphic_0121_1.pdf?la=en. Published 2021. Accessed July 1, 2021.

Association of Dental Support Organizations || TheADSO.org.

 https://www.theadso.org/about-dsos/. Accessed July 15, 2021.

How Big are Dental Service Organizations. 

. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIGraphic_0720_1.pdf?la=en. Published 2020. Accessed July 1, 2021.

 Managed care | health insurance and system

. Encyclopedia Britannica. https://www.britannica.com/topic/managed-care. Accessed July 15, 2021.

The establishment of corporate and group practice models is increasing in dental. We explore what the dental industry can learn from the medical industry regarding the growth of these practice models.

Corporate and Group Practice Models: What Dental Can Learn from Medical

Etching a tooth's surface to prepare for bonding is a dental procedure that changed restorative dentistry. Since the 1960s, creating a simple mechanical bond with teeth by etching the surface paved the way for today's adhesive dentistry, making bonding, porcelain veneers, dental sealants, and placing orthodontic brackets possible.

However, many variables affect etching, from the tooth surface you need to etch, the type of etchant you choose, and how many bottles are included in the etching system. Today we take a look at some of these differences and why you should know about them.

The Difference Between Etching Enamel vs. Etching Dentin


Perhaps one of the most significant variables for etching's effectiveness is the tooth surface the dentist needs to prepare for bonding. Enamel, made of compact crystalline structure-hydroxyapatite, has a distinct composition from dentin, made of hydroxyapatite and collagen-infused together. Enamel has robust intermolecular forces and a high-energy surface, while dentin has weak intermolecular forces and a low-energy surface. Each requires a different type of etching to create a successful bond.

Moreover, the dentin composition varies from the surface to the interior depths, which affects the bond you can achieve. Unlike enamel, dentin has a smear layer, organic contents, and fluid in the dentinal tubules. These tubules' density varies as you go deeper into the dentin, and the water content increases. The ability of the restorative material and adhesive system to permeate the intratubular dentin is what creates the bond. When the dentin suffers decay, it tends to mineralize and reduce permeability. Moreover, dentin thickens as it ages, reducing its permeability, even when "healthy."

Since the 2 types of tooth structures are so different, the substrate you want to bond to dictates your protocol. Per Nathaniel Lawson, DMD, Ph.D., Assistant Professor and Director of the Division of Biomaterials for the UAB School of Dentistry, etching dentin and etching enamel are different tasks.

When etching enamel, Dr Lawson creates some surface roughness to achieve micromechanical retention of his cured bonding agent. In this case, he needs something acidic enough to dissolve the mineral content of enamel partially.

"Phosphoric acid is very capable of etching enamel. Some self-etch adhesives/primers can also create surface texture on enamel. However, some of the universal adhesives are not sufficiently acidic to create surface texture on enamel. With these materials, I etch the enamel separately with phosphoric acid," Dr Lawson says.

Etching dentin is a different story, Dr Lawson explains. Etching dentin with phosphoric acid partially demineralizes it and exposes collagen. The adhesive can then penetrate the exposed collagen and form a hybrid layer. This hybrid layer can be several microns thick and allows a solid bond to dentin.

"Self-etch adhesives can also partially demineralize dentin, but not to the same extent as phosphoric acid," he says. "But the monomers in many new universal adhesives are capable of binding to calcium in the mineral content of dentin. So even though they form thinner hybrid layers (about half a micron), they can form a chemical bond with some of the remaining minerals in the dentin."

Dr Lawson says that one of the technique-sensitive aspects of etching is over-etching dentin. If too much collagen is exposed, then the adhesive cannot completely infiltrate the collagen.

"This exposed collagen may be hydrolytically or enzymatically degraded," Dr Lawson says. "Therefore, the development of a self-limiting etchant would be beneficial. "

The Differences Between the Types of Etching Protocols


To respond to the etching needs of the tooth's surfaces, dental products manufacturers have released different products and protocols over the past few decades. There are 3 clinical routines associated with etching products: total-etch, self-etch, and selective-etch. Each has a different protocol, with advantages and disadvantages

In this protocol, the clinician puts etching gel on the entire tooth preparation, which can include enamel and dentin in some cases. While the total-etch advantage ensures the etching pattern on the preparation, the disadvantage is that the mixture of tooth surfaces requires different timing to achieve ideal conditions for bonding. In addition, if there is a problem with the total-etch technique on the dentin layer, patients can experience postoperative sensitivity. 

This protocol involves using a single-step product that combines the etchant and the bonding agent, including a primer for the dentin layer, in one step. The advantage is that it is time-efficient and creates more predictable outcomes for dentin etching, but the disadvantage is that it doesn't do as well etching enamel.

In this third etching protocol, the etching gel is placed on the enamel only, and the dentin surfaces are sealed instead of etched. The advantage is that it reduces the potential from postoperative sensitivity generated from problems in the dentin layer. Still, the disadvantage is that it could fail to etch some enamel surfaces enough to achieve a proper bond.

Selective-etch, the newest of the protocols, is an option for working surfaces composed of enamel and dentin. Also called universal adhesive systems, these are known as multi-purpose adhesives and take the 1-bottle approach to the different types of substrates. These newest versions of universal adhesives have different monomers incorporated into them than the previous versions to simplify the etching process to dentin. An example is Methacryloyloxydecyl Dihydrogen Phosphate (MDP), which is a hydrophilic monomer with mild-etching properties. MDP enables universal adhesives to be used with any etching technique. These new adhesive systems reduce microleakage, enhance the flow of resin into fissures, and decrease or eliminate postoperative sensitivity.


Like many things in restorative dental care, the answer to which type of protocol to choose is answered with an unsatisfying version of, it depends. Per the 

Compendium of Continuing Education in Dentistry

, it comes down to personal preference. However, the authors did go on to suggest that etch-and-rinse bonding systems (total-etch) were preferred for indirect restorations where a lot of enamel was still present, and self-etch adhesives were better than total-etch for direct composite restorations, mainly when there was a lot of dentin in the preparation surface.

In other words, there are some indications where a total-etch will be more effective than a self-etch and vice versa. However, the literature suggests that selective etch and improved monomers that can create chemical bonds in the dentin layer are heading in the right direction.

1. Sofan E, Soufan A, Palaia G, Tenore G, Romeo U, Migliau G. Classification review of dental adhesive systems: from the IV generation to the universal type. 

. 2017;8(1):1-17. Published 2017 Jul 3. doi:10.11138/ads/2017.8.1.001

2. Sofan E, Soufan A, Palaia G, Tenore G, Romeo U, Migliau G. Classification review of dental adhesive systems: from the IV generation to the universal type. 

3. Paul C. The science of tooth bonding (acid-etch technique) – Etching | How a bond is formed. | Dental composite composition. Animated-teeth.com. https://www.animated-teeth.com/tooth-bonding/a13-tooth-bonding-enamel.htm. Published 2019. Accessed July 3, 2021.

4. Sofan E, Soufan A, Palaia G, Tenore G, Romeo U, Migliau G. Classification review of dental adhesive systems: from the IV generation to the universal type. 

5. Ozer F, Blatz MB. Self-etch and etch-and-rinse adhesive systems in clinical dentistry. 

6.  Sofan E, Soufan A, Palaia G, Tenore G, Romeo U, Migliau G. Classification review of dental adhesive systems: from the IV generation to the universal type. 

Different ways to etch teeth for adhesive dentistry create different outcomes. We explain each and the benefits so you can make the best decisions possible for your restorations.  

Etching: What's the Difference and Why You Should Know

Bulk-fill composites help clinicians simplify the restoration process for direct restorations by allowing for placement up to 4 to 5 mm. However, by reducing the layers, bulk fills require extra attention to other areas of the restorative technique process. Let’s take a closer look at the benefits of bulk fills over conventional composite resins for direct restorations, what the literature says about their performance, and areas identified in the literature to keep in mind as differences when placing bulk fills.

As composite resin materials improved over the past few decades, the prevailing wisdom determined that a layering technique in 2mm increments was the best way to overcome the complications caused by polymerization shrinkage in restorations with composite resin. However, it was also time-consuming and increased the risk of bubbles between the layers, which created tension on the cured material. To counteract this complication and simplify the placement process, manufacturers developed a new composite type for direct restorations, known as bulk-fill resin composites.

Bulk-fill composites have a few benefits over conventional incremental composites, including the following:

Bulk fills have lower volumetric post-gel shrinkage after curing.

Their increased translucency means they have more light penetration and depth of cure during polymerization.

The 4-5mm layers used to place bulk fills facilitate improved handling and quicker placement of the materials.

How Do Bulk Fills Perform vs. Conventional?

In terms of performance comparison, research suggests that bulk-fills seem to perform as well as conventional composite clinically. Based on the review for 

, the authors suggest that the clinical performance of bulk-fill composites for direct restorations is similar to that of conventional composites, with the caveat that more unbiased studies were necessary.

Odovtos International Journal of Dental Sciences

, these sentiments were echoed by the contributing authors. They said that various studies reported satisfactory bulk-fill restorations in posterior teeth with results similar to conventionally layered composites.

 went even further to say that when it came to adaptability and gap formations on the pulpal floor, bulk-fills did even better than conventional composites.

 suggests that bulk-fill performance depends on the cavity configuration. In the 2018 study, incremental composites had higher bond strength than bulk-fills in high C-factor cavities, aka cavities with more bond surface. In low C-factor cavities, there was not a difference in performance between the 2 types of composite.

However, there also exists a feeling that more study of bulk-fills is needed. Like the authors in 

 also suggest more clinical studies that focus on using the bulk-fill technique on deep and large restorations to understand the clinical benefits of the materials.

Differences in Technique When Placing Bulk Fills for Direct Restorations

There are differences in the technique necessary when placing bulk-fills. The most obvious difference is in the ability to place in up to 4-5 mm increments. However, there are a few more nuanced differences that we found when using them for direct restorations.

 resin composites.The flowable bulk fills have a lower viscosity that makes them excellent for adaptation to deep preparations. However, flowable bulk-fill composites have fewer fillers which decreases their wearability.

The 2-step bulk technique can address this drawback. Clinicians should use a flowable bulk-fill composite to fill the cavity preparation for all but the last 2mm (provided it isn’t deeper than 4-5 mm). Then, on top of the cured flowable bulk-fill material, clinicians should place a 2mm layer of conventional composite, cure, and then proceed with the finishing process. By contrast, full-body composites have a higher filler content than the base types and do not need the extra layer of conventional composite.

One of the significant benefits of using bulk-fill resin composites is that they do not require layering, which runs a higher risk for voids. However, the risk of voids is not nonexistent with bulk-fill composites; there could be voids hiding in the mass of the material. A 2017 study published in the 

 revealed that randomly chosen samples of different bulk-fill composite ampules had voids. The authors suggested materials manufacturers fill the syringes of bulk-fill flowable composites under vacuum to eliminate these voids' risk.

However, it is not just the manufacturers that can cause voids in bulk-fill materials. Clinicians can, too. To reduce the risk of clinician-originating gaps, it is essential to exercise care in placement techniques. The 

Journal of the Dental Association of Thailand

 published a study in 2018 suggesting that injectable resin composites reduced the voids present in the material.

 Moreover, with flowable composites, the tip should remain embedded in the material during placement. Also, clinicians can use the tip to get back in the corners of the preparation.

As the layers of the bulk-fill composite are thicker, achieving the proper depth of cure might require more curing time of the material, depending on the output of the light, the light’s angle, the light’s tip size, and curing area, among other factors. However, longer curing times can generate heat, which increases the risk of thermal damage to the tooth’s pulp.

To counteract the heat generated from the light curing units, clinicians can try a couple of different things. Reducing the thickness of the composite layer would also reduce the need for longer curing time.

 However, that does negate the main benefit of the bulk-fill composite. You can also use flowable composite as a “pulpal insulator” for the light curing unit’s irradiance.

 From a technique standpoint, another way to reduce the heat is to break the curing time into shorter increments to give the tooth’s pulp a chance to cool. In addition, you can reduce the heat by dissipating it with an air stream during curing.

Bulk-fill composites have many benefits for direct restorative dentistry, not the least of which is the ability to fill a preparation with a thicker layer of material than conventional composites. With performance metrics that mimic their conventional counterparts, these composites can produce excellent-looking and long-lasting restorations.

However, like all things in composite restorations, they have technique-specific nuances that make them produce better outcomes. Using a 2-step bulk technique, avoiding voids during placement of the material by using injectables when you can and keeping the tip in the material during extrusion, and protecting the pulp from thermal damage caused by the curing light, you provide bulk-fill materials the best possible chance to produce successful outcomes

Arbildo-Vega HI, Lapinska B, Panda S, Lamas-Lara C, Khan AS, Lukomska-Szymanska M. Clinical Effectiveness of Bulk-Fill and Conventional Resin Composite Restorations: Systematic Review and Meta-Analysis. 

. 2020;12(8):1786. Published 2020 Aug 10. doi:10.3390/polym12081786

Vasconcelos-Monteiro R, Cavalcanti-Taguchi C, Gondo-Machado R et al. Bulk-Fill Composite Restorations Step-by-Step Description of Clinical Restorative Techniques Case Reports. Scielo.sa.cr. https://www.scielo.sa.cr/scielo.php?script=sci_arttext&pid=S2215-34112019000200023. Published 2019. Accessed July 4, 2021.

Kapoor N, Bahuguna N, Anand S. Influence of composite insertion technique on gap formation. 

. 2016;19(1):77-81. doi:10.4103/0972-0707.173205

Han SH, Park SH. Incremental and Bulk-fill Techniques With Bulk-fill Resin Composite in Different Cavity Configurations. 

. 2018;43(6):631-641. doi:10.2341/17-279-LR

Van Ende A, De Munck J, Lise DP, Van Meerbeek B. Bulk-Fill Composites: A Review of the Current Literature. 

. 2017;19(2):95-109. doi:10.3290/j.jad.a38141

Mulder, BChD, MSc R, Mohamed, BChD, BSCHons, Mac, PhD N, du Plessis, MSc, PhD A, Le Roux, MSc S. A pilot study investigating the presence of voids in bulk fill flowable composite. Scielo.org.za. http://www.scielo.org.za/pdf/sadj/v72n10/05.pdf. Published 2017. Accessed July 4, 2021.

 Leevalloj C, Chaldarun S. Evaluation of Voids in Class II Restorations Restored with Bulk-fill and Conventional Nanohybrid Resin Composite. ResearchGate. https://www.researchgate.net/publication/327631259_Evaluation_of_Voids_in_Class_II_Restorations_Restored_with_Bulk-fill_and_Conventional_Nanohybrid_Resin_Composite. Published 2018. Accessed July 4, 2021.

"Advantages and Challenges of Bulk-Fill Resins." Cliniciansreport.org. https://www.cliniciansreport.org/uploads/files/19/201201.pdf. Published 2012. Accessed July 4, 2021.

Janeczek, M, Herman, K,Fita, K,Dudek, K., Kowalczyk-Zając, M,Czajczyńska-Waszkiewicz, A, Piesiak-Pańczyszyn, D, Kosior, P, Dobrzyński, M. Assessment of Heat Hazard during the Polymerization of Selected Light-Sensitive Dental Materials ,BioMed Research International, vol. 2016, Article ID 4158376, 7 pages, 2016.https://doi.org/10.1155/2016/4158376. Published 2016. Accessed July 4, 2021.

Nilsen BW, Mouhat M, Haukland T, Örtengren UT, Mercer JB. Heat Development in the Pulp Chamber During Curing Process of Resin-Based Composite Using Multi-Wave LED Light Curing Unit. 

. 2020;12:271-280
https://doi.org/10.2147/CCIDE.S257450

"Advantages and Challenges of Bulk-Fill Resins." Cliniciansreport.org. https://www.cliniciansreport.org/uploads/files/19/201201.pdf. Published 2012. Accessed July 4, 2021

We take a closer look at the benefits of bulk fills over conventional composite resins for direct restorations, what the literature says about their performance, and areas identified in the literature to bear in mind as differences when placing bulk fills. 

3 Important Differences in Technique When Placing Bulk Fills in Direct Restorations

Technology is always an essential enhancement for dental hygiene. But how has our aerosol-focused world changed the innovation in dental hygiene technology? We spoke to dental hygiene experts to get their take on the necessity of technology, the current state-of-the-art hygiene technology they like, and advice for how to get the practice to invest in it.

Katrina Sanders, RDH, is a dental hygiene educator, a practicing dental hygienist, and an international speaker. Sanders says the expectations for what hygienists can do in an hour are much higher today than they were 20 years ago. To integrate all that patient care efficiently, technology is essential. Sanders also feels dentistry as an industry is reticent to incorporate technology because practitioners worry about how patients would react to new things introduced into their care, a worry she thinks is unnecessary.

“The reality is, patients want it,” Sanders says. “Our fears are simply fears, not a reality for the majority of our patient population.”

In addition to new demands on hygienists’ time in the operatory, Sanders says the pandemic accelerated the incorporation of high-volume evacuation (HVE) for aerosol mitigation and personal protective equipment in the dental practice. She describes the pace of the change as uncomfortable, disruptive, and expensive for the whole industry. Sanders says she doesn’t want to wait for the next crisis to move the industry forward.

Moreover, she sees technology enhancing the hygienist’s role as a preventive specialist. Technology can help hygienists be the change agents in their patients’ lives through objective diagnoses and patient education on preventive care. This role might require hygienists to be technology advocates in the practice. However, it requires getting outside the usual routine, Sanders says, which can be challenging.

“There is a comfort in routine, and it happens in all relationships. Every 3, 4, or 6 months we put instruments into the same teeth, catch up with the same patients,” Sanders says. “The challenge for dentistry now is to figure out, how do we step out of that comfort zone and create the change that our patients need and deserve?”

Tina Clarke, RDH, professional speaker, consultant, and dental hygiene faculty member at Lane Community College, has a technology perspective influenced as both a practicing clinician and a dental hygiene educator. By taking a proactive approach to seeing what is out there to make their jobs easier, hygienists can elevate the level of patient care they deliver. Clarke suggests reviewing what is new every 6 months.

“When we get to do trade shows again, go through it and look at the technology, and talk with other people that are using them,” Clarke says. “Talk with your rep that comes in and ask if they have any suggestions for insights into what technologies could benefit your practice.”

Lynne Slim, RDH, MS, is a writer and speaker for dental hygiene and has practiced for 40 years. As a self-described “passionate, evidence-based hygienist,” Slim always looks for scientific evidence to support a product or technique claim. Before she invests in any new products, she investigates whether the company’s claims are backed by research. She says it is essential to be objective when looking at potential technology and products to determine efficacy. She also steers away from sources like internet chats and relies instead on unbiased online sources and clinical trials.

“I also look at cost because right now, during our second COVID-19 year, we are definitely being challenged to keep overhead way down,” Slim says.

Aurelia Byrne, founder and CEO of A-flexX Assist Arm, has been a hygienist for 5 years and working in dentistry for 27. She is a firm believer in incorporating new technology to the practice flow, having been part of a practice at the beginning of her career that was an early adopter for technology. Seeing how technology can enhance a dental practice and patient care shaped Byrne’s philosophy.

“It saves time,” Byrne says about dental technology. “The key is learning it and getting out of your comfort zone. And, once you do, it’s better for the patient.”

The State-of-the-Art Hygiene Technology Experts Love

This passion for technology in the operatory helped Byrne conceive the A-flexX Assist Arm. When COVID-19 hit, Byrne knew aerosols were going to be an issue. The A-flexX Assist Arm was designed to free up the hygienists’ hands and suck up the aerosols in the operatory. With a light, ergonomic hose hooked up to the HVE, the A-flexX Assist Arm attaches to the back of the chair then curves around to the front of the patient to aim down toward the patient’s oral cavity at a comfortable distance.

Byrne says the A-flexX Assist Arm has several benefits for the hygienist. It helps with indirect vision and repetitive motion disorders. The A-flexX Assist Arm’s small, compact design doesn’t take up much space in the room. The A-flexX Assist Arm is also reusable. The infection control protocols for the arm are to spray and wipe the arm and HVE hose and autoclave the HVE tip, valves, funnel adapter, and funnel. In May, Byrne’s company released new, autoclavable tips. Byrne says the goal is to send less waste to the landfill and save customers money in the long-term.

“We are moving to more sustainable products as a company," Byrne explains.

Clarke thinks the A-flexX Assist Arm, which provides additional suction of ambient aerosols in the operatory, can do a lot to help solo practitioners. Clarke likes how the arm leaves the hygienists’ hands free to deliver care and comes in low- and high-vac speeds.

“They have a lightweight tube, which makes it a lot easier for a clinician doing it solo to have reduced weight and drag,” Clarke explains. “So that’s wonderful.”

In addition, Clarke thinks face shields are making a difference in the operatory for hygienists. While face shields have been the standard for a while, the pandemic has hastened their adoption rate by clinicians. Clarke says that face shields boost the efficacy of the filtration of the hygienists’ masks. However, Clarke says she can’t recommend one face shield over another because it depends on the clinician’s loupes or the protective eyewear they are using.

“How far the light sticks out or how deep the magnification is can impact the face shield that they are working with,” Clarke says.

Clarke has been a longtime advocate for aerosol evacuation systems in the operatory. She likes the Isolite line by Zyris. It not only props the patient’s mouth open, Clarke says, but it also reduces the aerosol splatters and the fluid in the patient’s mouth. Clarke also likes the Purevac® HVE system with mirror tips by Dentsply Sirona, particularly when using a Cavitron and aerosols are fogging up your view of the lingual surface of the teeth.

“It’s a nice adjunct for your high-vac because it has the mirror on there, and it will take care of the aerosol generation but also keep that mirror clear so you can see,” Clarke says.

Slim is a fan of the stannous fluoride dentifrices for adult patients that address conditions like dry mouth, gum detoxification, and sensitivity. She admits that part of it is that she likes the packaging, but its effectiveness made her a user.

“I put it in my occlusal guard at night because I like the taste of these dentifrices so much,” Slim says.

Slim also likes Hu-Friedy’s AIRFLOW® therapy as a technology for the operatory. AIRFLOW delivers polishing through a mixture of air, specially processed powders, and water pressure. The hygienist controls the stream directly on the teeth to remove surface stains, plaque, and other material. However, for now, Slim says she has only read about it.

“Hu-Friedy’s AIRFLOW therapy really appeals to me, but I don’t have one to use right now,” Slim says.

Sanders is excited about the enhancements in some of the products she uses in the operatory. For example, she likes her Designs for Vision Aerosol Protection Loupes, which she says is something good that came from the pandemic.

Technology is essential to dental hygiene, perhaps even more now in our aerosol-focused world. We spoke to dental hygiene experts to get their take on the current state of the art in hygiene technology. 