Terri Lively

		A significant part of the population is aging. The Baby Boomers, the second-largest generation in our society today, are getting older. They are hitting retirement age at the rate of 10,000 every day until 2030.

The oldest baby boomers, born in 1946, are around 73 years old, and the youngest, born in 1964, are 55.

		Per the American College of Prosthodontists (ACP), the geriatric population has a ratio of 2:1 for edentulous patients.

 With over 76 million people in the Baby Boomer generation, you may have many conversations with older patients about tooth replacement therapies in the coming years.

		Since edentulism tends to be highest in the geriatric population, understanding the effects of age on implant success is significant to a dentist’s ability to treatment plan in these conversations with their patients. Particularly, when talking with the fully edentulous patient, it begs the question of how old is too old for overdentures?

Related reading: Baby Boomers and oral irrigation

		Your patients might expect you to discuss a conventional, removable partial or complete dentures. Conventional dentures are prevalent with edentulous patients regardless of age. The ACP says 15 percent of the edentulous population have dentures made for their tooth replacement each year and 90 percent of all edentulous patients have dentures.

		However, it might be because they do not know about or understand the benefits of an implant-retained overdenture. When compared with removable dentures, patients prefer implant-retained overdentures. The 

International Journal of Oral Maxillofacial Implants 

published a study where 20 edentulous patients received implant-supported mandibular and maxillary dentures to replace their former prosthesis, and a significant increase in patient satisfaction occurred.

5                                                                          

		So, are your older Baby Boomer patients too old for this preferred tooth replacement treatment? The answer is, maybe, maybe not. It all depends on the Baby Boomer. 

What research says about age and implant survival

		There are many considerations when you use implants with older edentulous patients, but age is not a significant factor by itself when you are considering whether to go with a removable or fixed prosthesis for fully or partially edentulous patient. Per 

, a systematic literature review of 17 studies on survival rates of mandibular implant overdentures supported by two implants showed a survival rate of 93 to 100 percent at ten years.

 Furthermore, the literature shows elderly patients were just as successful, and in some cases, more successful, with implant treatment than younger patients.

The International Journal of Oral Maxillofacial Implants 

confirms this fact. Researchers compared two groups of patients, one with a mean age of 46 and another with a mean age of 68. Their results showed the implant-retained overdenture in the mandible was equally successful in both groups.

		It is important to note the researchers in both reviews said there should be more research on this specific question. Many times, in the research reviewed, age was not isolated as a causative factor for failure.

 Furthermore, the general health conditions accompany aging could affect survival rates, and they also were not isolated as a causative factor for implant failure.

However, for the literature that does exist at this time, age alone is not a factor.

So, what is an essential consideration for the older edentulous patient?

		If chronological age is not an indicator of whether a patient is a proper candidate for an implant-retained overdenture, what is? It turns out, many things, and some of them are age-related.

		For example, as we age, we begin to experience endocrine, metabolic and physical changes, referred to as physiologic changes. An example here would be menopause. However, we also have specific medical conditions that occur with age and change our health, called pathologic changes. Some examples are diabetes, heart disease, pulmonary disease and arthritis, to name a few. While not linked to increased implant failure in the current literature, we know these changes affect a patient’s overall health, as well as their state of mind.

Related reading: soft food for thought: Why explaining soft food to your patients is crucial for compliance

		When speaking with mature or elderly patients about implant-retained overdentures, it is essential to consider their overall health condition, oral health and economic constraints.  Per 

, age is a consideration, but not a determining factor by itself, nor should age be a contraindication.

 Instead, dentists should consider the specific disease that has led to the present condition (e.g., diabetes, osteoporosis, etc.) and the bone and soft tissue capacity available at the site of the implant when determining whether or not implants would be an option for treatment.

		Therefore, it isn’t a simple question or a simple answer for how old is too old for an overdenture. Treatment planning is individualized and based on the following considerations for an elderly patient:

, meaning how much they want it, whether they think it’s worth hassling with and paying for, and whether they can afford it

Individual assessment of maintenance requirements

, which addresses whether they can take care of the restoration once it is delivered

 which takes into account their other health conditions

, which considers whether they can accustom to the prosthesis chosen

		Also, it is crucial to identify these pathologic systemic conditions in the elderly before suggesting implant surgery for the edentulous patient:

iew recommends having an awareness of how aging affects the body physically, metabolically and hormonally.

An example is the effects of hormone changes seen in post-menopausal women’s bone resorption rates, which increase after menopause and exceeds the bone resorption rates for men. However, both men and women lose the ability to heal bone as they age and bone density for both sexes decreases steadily after age 30.

Read more: Study finds obstructive sleep apnea causes complications in dental implants

The Journal of the American Dental Association (JADA)

 recommends a comprehensive diagnosis of geriatric patients before treatment planning to provide for predictable esthetic and functional outcomes.

In addition to the areas already mentioned by the previous journals, 

 recommends assessing the patient’s history of:

recommends having a conversation with the patient and his or her significant others to explain the details of the treatment plan, as well as obtaining a written and oral informed consent from the patient. Also, they recommend making the prosthesis during the diagnostic phase, whether the plan is for removable or fixed or a combination thereof. Clinicians should also assess the hard and soft tissue changes and set reasonable patient expectations.

Overdentures benefits and drawbacks for seniors

	Once you decide to move forward with a treatment plan that includes an implant-retained overdenture, it is incumbent on you to communicate the benefits to those patients. The two most commonly cited benefits are the retention aid they have for maxillary dentures and the reduction in covering the palate. Also, the ability to remove and clean the overdenture thoroughly is a significant benefit.

	It would also be crucial to include the drawbacks that occur with this solution. The survival rates of maxillary overdentures range from the low 70

 percentiles, with the time ranging from five to seven years.

Some studies indicate there are higher maintenance costs with this option, too, which is a significant consideration for patients and their families.

	That said, one study showed patients preferred maxillary overdentures over fixed prostheses. In the study, participants had a mandibular overdenture and alternated between a maxillary overdenture and a fixed maxillary prosthesis. The participants said they liked the removable maxillary overdenture in general better than the fixed, and liked it better for talking and cleaning, as well.

Related reading: How to simplify overdenture treatment for today's patients

So…how old is too old for overdentures?

	Our research revealed our question, “How old is too old for overdentures?” is flawed. Chronological age alone is not the indicator to use. The health of your elderly patient is. The health of your older patient is affected by age in ways a younger patient is not. Ultimately, when it comes to age and the edentulous patient, the answers are found in the individual and not general guidelines.

	We would amend our question to say, “How healthy is my patient and is their bone ready for overdentures?” The answers to that question point you to the most predictable outcomes for your elderly patients with overdentures.

To read the resources used for this article in full, please click below:

Dental Implants: A Role in Geriatric Dentistry for the General Practice?

Is old age a risk factor for dental implants?

https://www.seniorliving.org/life/baby-boomers/

.“Patient preference and satisfaction with implant-supported mandibular overdentures retained with ball or locator attachments: a crossover clinical trial.” 

. 2012 Nov-Dec;27(6):1560-8. Accessed via web: 18 June 2019. < 

https://www.ncbi.nlm.nih.gov/pubmed/23189311

 Dudley, J. “Implants for the ageing population. 

. 2015:60 1 Suppl): 28-43 Accessed via web. 13 July 2019. < 

https://onlinelibrary.wiley.com/doi/pdf/10.1111/adj.12282

 Clark, Stanford. M. “Dental Implants.” 

The Journal of the American Dental Association

.  :138;  34-40; Accessed via web. 17 July 2019. <

https://jada.ada.org/article/S0002-8177(14)62741-0/fulltext

Articles

Age alone is not a contraindication for implant-retained overdentures, but age-related health conditions can be.

How old is too old for overdentures?

	You tell your new denture patients to eat a soft diet and send them on their way. But do they know what that means and which foods are the best for their new prosthesis? Here’s what you need to know about setting the proper expectations about what foods to eat while they adapt to their new dentures.

	Marc Wagenseil, CDT, DD, a denturist in Alberta, Canada, and an international lecturer for VITA North America says there is often a misperception in dentistry that once you deliver the dentures, the patient is good to go and they don’t need to be careful.

	However, Wagenseil reminds clinicians the central nervous system is not ready to go back to business as usual as far as chewing and eating foods. It needs time to adapt to the change presented by the dentures in the mouth.

	“A marathon runner does not buy a new pair of shoes and run a marathon on them immediately. They know to break them in,” Wagenseil says. “Yet we don’t do that in dentistry or with dentures, and then the patient becomes upset or irritated wondering why it hurts.”

	Wagenseil explains the central nervous system had a pattern before it had the dentures, and now it will have a new one with the dentures. It will develop a habit with repetition and practice.

Related reading: How to set proper denture expectations

	To facilitate this process, Wagenseil wants patients not to eat without consideration. He tells them he wants them to intervene, exercise caution with the pressure with which they bite and reduce the size of their bites. In short, he tells them to take it easy.

	However, “taking it easy” means different things to different people, Wagenseil says. It can come down to how a patient interprets “easy” if they are going to have a successful adaptation to the denture.

	You should define a soft diet for patients. 

, the term soft diet describes foods that are easy to chew and swallow and does not include foods whose texture is hard.

 However, this definition leaves a lot to interpretation. Wagenseil says it is essential to take a deeper dive on defining patient expectations for what you mean by “soft diet.”                                                                                  

	“Some of the things we know we'd like to say is you want to stay away from the real chewy or more difficult hard things such as nuts,” Wagenseil says, adding for his nut-loving patients, he recommends breaking the nuts with a mallet before they eat them.

	Wagenseil also cautions his patients to be careful with bread. Bread has wheat gluten, and when mixed with saliva, it sticks together. The gelatinous mass that results requires more bite power to get through.

	“Thus, the higher the risk of damaging the new appliance or damaging your tissues or bruising them,” Wagenseil says.

	Wagenseil knows people are going to eat what they eat, no matter what he says. While he does not get granular with the food on the soft diet, he does want people to go slow and eat smaller pieces.

	He also talks with patients to come up with workarounds. For example, if a patient likes raw vegetables, he encourages them to mash them first with a meat tenderizer. If they love Indian food, he explains they need to cut it into smaller pieces.

	“You have to give the muscle time to heal and build again, so these are the things to keep in mind when we instruct our denture patients on this,” Wagenseil says.

	One of the most important things to do when discussing the soft diet, Wagenseil says, is to see it from the patient’s perspective. Compare it to a time when you received instructions from a healthcare professional for a test or lab work and remember what worked for you.

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	“You have to think of yourself as a patient and what did they tell you to do?,” Wagenseil says.

	Dr. Shirin Khoynezhad, director of second-year pre-clinical dentistry at the University of Alabama, is a prosthodontist that lectures on denture materials and CAD/CAM dentures. She agrees getting detailed about food is crucial for the new denture patients.

	She compares getting dentures to traveling to a new country where everything is new and unpredictable, and when you get there, you are hungry. There is no restaurant you recognize, and no one there speaks your language. If no one told you what to do, you would have to go to every building looking for food and hope there is something appropriate. She says it can feel like being thrown into the ocean without knowing how to swim.

	However, if someone familiar with the area told you to go to a particular store (and explained how to get there), and get a certain dish because it their favorite, you’d be prepared. Dr. Khoynezhad says if you get tips ahead of time, you know where to go, and what to do and perhaps most importantly, what to expect.

	She does the same with her patients regarding the soft diet. She takes the time to explain and recommend a specific list of foods to help the new denture patient have a better experience transitioning to their new teeth.

	“The more you know, the transition and the adaptation will be easier for you because you know what will happen,” Dr. Khoynezhad says. “You are prepared mentally as well as knowing what the proper foods are.”

	She tells patients to expect to take some time to adjust to chewing with the dentures and keeping them in balance. To do that, she recommends graduation of soft foods from the most basic the first week and then building up from there. She recommends mushy vegetables, meats that are tender and moist and pudding. Then, the next week, add in some more advanced soft foods, like lentils, and go from there.

	“It’s like practicing. You start at the first level and then go to the second level, and build from there,” Dr. Khoynezhad says. “Give the body time to adapt and eventually add more texture to foods.”

	Raymond Choi, DDS, a mini-implant dentist and educator for Glidewell Laboratories, agrees a soft diet is crucial to adapting to a new denture. He defines it as anything you can cut with your fork. He also explains to patients how a denture will not perform the same way as their teeth, they need to slow down, and they need time to learn how to use it before they dive into a regular diet again.

	With patients, he uses analogies, comparing the acclimation process for the denture to a person who just lost a leg and has a new prosthesis. The patient with the new leg is not going to sprint on the artificial limb (at least not right away). However, given time, they can run a marathon.

	“With a denture, it’s a similar thing. It’s not the same as natural teeth anymore,” Dr. Choi says

	Dr. Choi does not have a specific time period he recommends for the soft diet. Instead, he likes to explain to patients that soft food is giving the denture time to settle into the gums and working out any sore spots. As far as when that time is over, Dr. Choi tells patients they will know.

	“I will usually say, ‘When the time comes to step it up, you’ll know, and you’ll be more comfortable,’” Dr. Choi explains.

Read more: Improving accessibility with 3D-printed dentures

	Dr. Choi also likes to explain to patients how to learn to chew in detail with their new prosthesis. He tells patients to put the food into tubules, then chew on the left and right of the back teeth to stabilize the dentures.

	For patients with upper dentures, he tells them not to chew with their upper front teeth. He explains the compression in the soft bone of the premaxilla can accelerate the patient’s bone loss, which will compromise their denture-wearing capacity long-term.

	“It took me 20 years to be able to say that because when I was younger, I was afraid patients would say, ‘What do you mean? I pay for this denture, and I can’t even eat?’” Dr. Choi says, laughing. “But now I’m older, I have some gray in my hair, and I can say whatever I want, and they listen.”

	Dr. Choi also recommends clinicians assess the alveolar ridge of the oral cavity before dispensing advice. Patients with a tall wide ridge can chew things much differently than patients whose ridge has flattened out. He also recommends with the latter group clinicians use flatter teeth in the denture, so they don’t catch as much.

	
	VeryWellHealth.com has some additional tips for you to cover for patients eating with dentures:

Have patients use their lips to test the temperature of foods.

 The insulating quality of dentures might not give patients an accurate read of temperature at first.

Set their expectations about discomfort. 

At first, the tongue and other muscles in the mouth might be sore from the new ways they are chewing. Remind them it’s normal and will decrease with time. However, advise patients to call if they find the denture is causing sores that don’t heal or if the muscle pain continues past the first week or so.

Remind patients to drink water with their meals. It will not only wash away sugars that can damage the denture, but it will also keep grains from sticking to their teeth, which can cause problems.

	Adapting to dentures is a process. Wagenseil compares the soft diet phase of eating with dentures to physical therapy. You go slow in physical therapy, and you do not overdo it because that will set you back in the healing process.

	Wagenseil wants people to err on the side of caution when they’re first getting accustomed to dentures, and the clinician should instill that caution. He wants the patient to understand they are slowly building their eating up again with the new appliance.

	“You must learn to crawl to learn to walk to learn to run,” Wagenseil says.

 Olsen, RD, LD, ACSM, EP-C, Natalie. “What are the soft foods and mechanical soft food diets?” 

https://www.medicalnewstoday.com/articles/321331.php

 Lehman, Shereen. “Tips for Eating With New Dentures.” Verywellhealth.com. 5 July 2019. Web. 11 July 2019. < 

https://www.verywellhealth.com/tips-for-eating-with-new-dentures-2507129

 How to educate your patients about transitioning into their new dentures.

Soft food for thought: Why explaining soft diet to your patients is crucial for compliance

	Composite-resin materials require light curing to achieve the physical properties necessary to restore function to the tooth and durability for restorations. The technical aspect of light curing composite is an area every clinician should remain diligent about to ensure the success of their composite restorations.

	Tim Bizga, DDS, FAGD, a private practice general dentist in Cleveland, OH says all the steps of setting up a composite resin restoration are interconnected, like a web. When one step is handled poorly, then it causes problems to the entire restoration.

	For example, composite direct restoration success starts with adequate isolation. Then, after you have sufficient isolation, Dr. Bizga says curing the materials in the tooth are reliant upon receiving precise amounts of light energy for a specific period of time.

	“Everything hinges on that curing light and how well it works,” Dr. Bizga says.

	We researched light curing and spoke to experts about how they successfully cure their composite restorations. Here are a few tips they had for curing.

Related reading: How to avoid restorative Class II blues

	The University of Iowa’s College of Dentistry and Dental Clinics published a list of 

Operative Best Practices for Clinical Care

Invest in quality equipment and keep up on maintenance.

	The Operative Best Practices for Clinical Care included a consensus statement from the 2014 Symposium on Light Curing in Dentistry. The experts agreed that all curing lights are not the same quality and do not deliver the same results. The article recommends only using lights from a manufacturer that includes:  

		Contact information                                                                               

		User manuals for the curing light                                         

	Dr. Ed Kusek, a private-practice dentist in Sioux Falls, SD, agrees clinicians would be wise not to buy cheap lights. He uses the VALO™ curing light from Ultadent, an LED curing light with a broad-spectrum LED pack and a wavelength range of 385 to 515nm. Dr. Kusek chose it because of the wide width of its output and he says the depth of penetration is better than other lights on the market.

	Dr. Kusek and the team also check to ensure the VALO rechargeable batteries are fully charged before use. A full charge ensures the most efficient use of the curing light.

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	“It’s  not very conducive to getting a good cure if all of the sudden the batteries burn out midstream, Dr. Kusek says.

	The Operative Best Practices for Clinical Care guidelines also recommend that you know the key performance parameters of your curing light out of the box. These include the light output (mW/cm

), the beam uniformity and output across the light tip and the diameter of the light beam.

	Dr. Bizga says regular maintenance of the light is essential to ensure your light is functioning correctly. Manufacturers also recommend periodic evaluation of the light output using a radiometer. Dr. Bizga recommends checking once a week with the same measurement device to ensure your light is still functioning correctly, especially if you are using an inexpensive light.

	“Some of these lights may not cure the material or may require longer than you think,” Dr. Bizga says. “That’s why testing is important.”

	At Dr. Kusek’s practice, they have five curing lights in rotation. They send each of them in annually to the manufacturer for maintenance and recalibration.

	“We keep track of when it was last sent in and then send them into the company one at a time,” Dr. Kusek says.

	Skipping curing light maintenance is not a good idea. Dr. Bizga compares it to buying a new car and then never changing the oil.

	“To keep your car running, you need to make sure your oil is changed regularly and your fluids are topped off,” Dr. Bizga says. “With your light, you buy it, and you know it should perform great. However, like anything, you have to check it and make sure the bulbs are still putting out the same intensity.”

	Operative Best Practices for Clinical Care provides guidelines for practitioners regarding light curing. The light tip should deliver a uniform output covering as much of the surface of the material as possible. You should also cure each surface of the restoration independently. 

	The guidelines also say to position the light as close and as stable as possible over the surface and parallel to it. Also, when curing, avoid positioning the light in ways that decrease the amount of light delivered to the resincomposite. Some examples of poor positions are:

			Having the light tip several millimeters away from the area

			Positioning the light at an angle to the surface you are curing

	However, Dr. Bizga says dentists are often not curing the composite themselves; instead, the assistant is curing the material. He recommends proper education for the assistant to ensure they cure the material in the right direction. 

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	Dr. Kusek also says the attention to detail from your assistant is vital to your curing success. He advises dentists to ensure t their assistant is taking care to have the light in the right area. If the assistant does not know where to aim the light for the cure, spots in the material might remain uncured.

	“It doesn't work by osmosis,” Dr. Kusek says.” You have to place it into the area.”

	“You want to have your light directed straight down, perpendicular to the material at a 90-degree angle, preferably,” Dr. Bizga says. “It's a good idea to cure from multiple directions on the tooth and spread the light energy to make sure you're curing it evenly.”

	Operative Best Practices for Clinical Care dictates the curing light should not have anything inhibiting the beam delivery and encourages inspecting and cleaning the light unit before using it. Shielding the lens during use keeps the light clear of debris. It ensures the proper amount of light will cure the material, Dr. Kusek says.

	“We always use a clear sleeve over the light so we won’t damage the illuminating part,” Dr. Kusek says.

	Protecting the lens of the curing light is essential, but so is protecting your eyes. Operative Best Practices for Clinical Care indicates you should wear “blue-blocking” glasses or other eye protection when using a curing light. Also, never shine the curing light into the eyes and avoid looking into the reflected light when you are not wearing eye protection.

Related reading: Why dentists should take a fresh look at new restorative innovations

Time your cure based on the depth of the restoration

	Every curing light and composite resin material has light exposure times that are recommended by the manufacturer. However, it would be best to extend those times if the distance is further or the shade of the composite is on the darker end of the spectrum or if the material is opaque.

	If you are mixing and matching materials and curing lights, Operative Best Practices for Clinical Care recommends allowing for the differences between the two as necessary. Also, you should ensure the curing light’s settings are on the correct mode and time for the resin composite type and shade.

	Dr. Bizga also wants dentists to allow for enough time to cure the material based on the depth of the restoration. Assuming you know the light is performing up to its specifications, cure the material for the time indicated by the thickness of the composite layer.

	Usually, when your isolation is excellent, timing isn’t a problem. Dr. Bizga says he sees dentists getting into trouble when they rush their cure because they have not isolated the area well enough.

	“They are trying to rush through it so they may cut a few seconds here and there off their cure times,” Dr. Bizga explains. “Incrementally, they’re undermining the material because it is not curing to the full physical property that is required, and that leads to microleakage and other problems.”

Remember, you can’t over cure composite material

	You should always follow the manufacturer’s instructions for exposure times related to incremental material thickness amounts. However, Dr. Bizga always reminds himself and others you can never over cure the materials, but you can under cure them. Therefore, if you feel like extending the curing time for whatever reason, he says you should do so.

	“Before you send the patient out the door, you can throw one more good pulse of energy at it. You can't over cure, so cure away,” Dr. Bizga says.

	Operative Best Practices for Clinical Care also advises clinicians to consider additional light exposure when the area has limited access to light. Examples could be interceding tooth structures or restorative material, or shadows cast over the curing surface from the matrix bands. 

Related reading: Solve my problem: Covering a large area in one cure

	Another factor to consider with longer or additional curing times is some high-intensity curing lights will put out a little bit of heat. Curing for long periods could be hazardous to the pulp or soft tissues in those cases. Operative Best Practices for Clinical Care suggests air cooling the tooth during this process to prevent any thermal damage. Also, Dr. Bizga says many manufacturers that make these lights have a time-delay feature which allows the tooth to recover so you cannot damage the pulp.  

	“A lot of the manufacturers have built in these fail-safes to try to help that,” Dr. Bizga says.

	Composite restorations do not last as long as amalgam fillings. Furthermore, composite restorations in real life sometimes fail much sooner than they did in testing.  Dr. Bizga says it all comes down to the technique of the clinician.

	“If you read what these materials are capable of doing in lab testing, you wonder why we see more failures and so much sooner,” Dr. Bizga says. “What it comes back to is the technicians and their understanding of what's important. With each of the steps, they need to make sure they do everything as perfectly as they can."

https://www.dentistry.uiowa.edu/operative-light-curing

				Light Curing (last modified February 19, 2017)

				Dalhousie Light Curing Symposium May 2014 comments published in  Journal of Adhesive Dentistry, Dental Materials, Operative Dentistry, and the Journal of the Canadian Dental Association.  Blanket copyright license is given for the table and figures below to be freely used, in whole or in part, for all derivative works without permission from the copyright holder. 

We share what experts recommend to enhance the curing step of the restorative process with composite-resin materials.

Light curing: What you can't afford to be in the dark about

	Resin bonding does not work well in moisture-rich environments. The composite resin materials dentistry presently uses are hydrophobic and require a dry field to be successful, making isolation crucial to prevent bond failure and other problems with composite restorations.

	“We want to try to keep it as pristine and as clear a field as we can. These adhesives need it; they require it,” Tim Bizga, DDS, FAGD, a private practice general dentist in Cleveland, OH says. “Nothing good happens if you don’t control the fluid.”

	In addition to bond failure, poor isolation leads to sensitivity, contamination, and microleakage. Dr. Bizga compared microleakage to a break in a medieval city wall. If there is a gap in the wall or it is broken down in one area, the city’s enemies can get in. Microleakage follows the same principle on your restoration, but with bacteria.

	“If I'm doing a filling and 95 percent of it is clean and dry but there's one little spot that's getting blood on it, well, that's an area that potentially could leak and can undermine the whole thing. That's why it's so critical to isolate,” Dr. Bizga explains. “It's an all-or-nothing-type thing.”

	Effective isolation affects the permanency of a restoration as well. When you look at longevity studies around composite in the U.S., Dr. Goodchild says the results are not impressive.      

	Amalgam restorations last much longer because the material is not as technique sensitive. In his lectures on posterior composite restorations in the U.S., Dr. Goodchild quotes an average longevity of 5.7 years, which he describes as “pretty bad.” T

 suggested in 2011 that only 60 percent of resin composite restorations will last more than ten years.

	Dr. Goodchild thinks on the clinician’s part, mastering the technique for placing resin composites and all the procedural steps that go into the process are essential to improve the survival rate of your composite restorations. It starts with good isolation-and in his case, a rubber dam.

	“What can we do on our side to give that composite restoration its best chance for survival? We can place it in ideal conditions, and, in most cases, that is a well-isolated environment and a rubber dam fits the bill.”

	In dental school, students receive instruction on rubber dam isolation. However, as they practice on their own, they begin to branch out to other methods of isolation. These systems have different features that range from mouth props to providing a light to suctioning systems and are designed to be easier-to-use than a rubber dam. They also purport to be as effective as rubber dams, and many clinicians use them to great effect for composite restorations.

	We spoke to three experts with differing views on rubber dams. Here’s what they say about isolation and the rubber dam.

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	Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company is also an associate clinical professor at Creighton University School of Dentistry so he uses the rubber dam often in his restorative work. He says it not only helps to ensure good clinical outcomes, but it also helps with the pictures he takes to demonstrate the concepts about the treatment he is presenting to his students.

	“From an educator standpoint, there's no better way to get a great picture of a restoration than to isolate it from the cheeks and gums and the tongue and saliva than to use a rubber dam. It’s a wonderful way to highlight it,” Dr. Goodchild says. “From a clinician standpoint, which is much more important, good isolation means you can do better dentistry and when I say better dentistry, I mean you can use materials better.”	 

	Rubber dams are the standard of care for endodontic treatments and have been for many years. So, for root canals, all clinicians should use a rubber dam. If there was ever an issue with the treatment and the case was reviewed to reveal the doctor used something other than a rubber dam for isolation, that could be looked at unfavorably.

	“When it comes to endodontics, it’s always been the standard of care,” Dr. Goodchild says. “But from a resin standpoint and as a restorative dentist, I am just a big fan.”

	Dr. Goodchild says using rubber dams has become a lost art . However, in recent years he has seen more people returning to rubber dam isolation.

	“It's tried and true and we get wonderful results when we do it that way,” Dr. Goodchild says.

	Per Dr. Goodchild, there are many techniques to place a rubber dam if you are experienced with them. He says you don’t have to always punch a series of holes so each tooth comes through each hole. He sometimes uses a slit-dam technique, which is two holes with a slit cut between them making it possible to expose a few teeth at once. Then, he would secure the rubber dam down between teeth using floss or Wedjets Dental Dam elastic stabilizing cord. 

	“So, there's lots of easy ways to place a rubber dam,” Dr. Goodchild says.

	Rubber dams are versatile and useful with almost any dental procedure. Dr. Goodchild says they are especially effective with anxious or fearful patients that need sedation.

We spoke to experts with differing views on rubber dams and isolation for composite restorations.