Reducing Incidences of Secondary Decay With Bioactivity

In 2016, one of my patients—a frustrated mom who was about the same age as myself—humorlessly asked me, “Isn’t there, like, a magic coating you can put on my teeth so I don’t get any more cavities?”

Her husband, who never flossed, snacked on Twizzlers, and would only brush for a minute with a manual toothbrush, just received the good news: He had no cavities. In contrast, his wife, who was in the operatory room just next door to him, had 3 cavities. What’s worse, 1 of these 3 cavities was recurrent decay at the margins of a filling I had done only a few years prior. She has excellent at-home habits; she meticulously and properly uses all the tools when she wakes up and before she goes to sleep, yet she continues to receive bad news at her dental visits while her less-responsible husband is delighted to receive the news that he would be granted another 6-month reprieve from any visits to our office.

As any dentist who has practiced for any length of time would agree, sometimes meticulous home care is not enough. Some people just have unlucky oral environments. Some people, like the dear patient described above, have a less-than-optimal oral pH, or a poorly balanced diversity of oral microbiota, or even an inability to produce certain enzymes in their saliva.

Figure 1

A 21-year-old woman presents with a large cavitated lesion extending well into the dentin. Because of the patient’s age and associated radiograph, it was clear that her pulp anatomy and pulp horn prominence would put her at risk of either short-term or long-term pulpal sensitivity upon complete decay removal.

Figure 2

After decay removal. Notice the discoloration at the deepest portion of the prep.

Figure 3

Beautifil Flow Plus X was used as a liner.

Figure 4

Its handling properties are nearly identical to any other high-level bonded flowable composite.

Beautifil II packable composite was used as the finished restoration at the cavosurface margin. There was no need to re-etch, prime, or bond between the liner and final restorations.

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I knew that my approach to her fillings had to be different. Without a doubt, I knew that however thorough and conscientious I intended to be when restoring her teeth with traditional class I, class II, and class V bonded restorations, she would inevitably return to my office with ugly discolorations at the margins, and I would inevitably question my own clinical expertise.

Fortunately, around that same time, I had attended a continuing education (CE) course in Chicago, Illinois, in which some of the most incredible minds in general dentistry shared innovative and not-so-well-known techniques and products with the audience. It was at that course where I learned about bioactivity. By now, you have probably heard the word, but I would like to describe bioactivity the way I understand it best.

Our enamel is a bunch of rods held together by a highly mineralized cement substance. This is like holding a bunch of Nerf bullets together in your hand, and then squirting superglue all over the bullets. Demineralization, which is caused by acid from bacteria, sugar, and bad luck, weakens the superglue. If the glue weakens enough, you lose some of the Nerf bullets, or you then have enamel cavitation. Dentin is made of similar hydroxyapatite crystals but is arranged in a much more porous grouping, such as a really hard block of Swiss cheese, allowing for branches of the pulp to occupy the tubes within the cheese.

Certain minerals act on the dentin, the enamel, and those branches of the pulp in a really convenient way. Fluoride is like superglue to the hydroxyapatite rods in the enamel and hydroxyapatite crystals in the dentin, holding them together and inhibiting demineralization and eventual cavitation. Additional ions, such as strontium, silicate, aluminum, borate, and sodium, all act either independently or in combination with one another to neutralize the demineralization of acid and inhibit plaque formation. Moreover, they work together to elicit the growth of new hydroxyapatite. They don’t allow bacteria to grow; instead, they remineralize enamel and dentin that have been subject to acid and elicit growth of new solid healthy tooth structure. If only there was a product that constantly released these ions.

It was at this same CE course that I had the opportunity to try Beautifil composites from Shofu in both packable and flowable options. These are restorative solutions that have bioactive Giomer as its filler particles. What was incredible for me, though, was the fact that this product behaves just like all the other packable and flowable restorative products that I was already using. It isn’t too hard, flaky, sticky, or any of the other negative characteristics that make me shy away from certain composites. Beautifil II is a pleasure to work with clinically, and the outcome after curing and polishing is almost always fabulous.

Inspired by the taste tests that I remember from my childhood—blindly pitting Coca-Cola vs Pepsi, or a Whopper vs a Big Mac—I decided to take all the composites I had in my office and ask an assistant to cover any identifying features. Every composite that I used in this test was highly rated and had been used with satisfaction at one time or another in my own office. I then ordered a bunch of typodont teeth and prepped simple class I’s in each tooth. Myself and 2 other dentists all were tasked with restoring the fake cavities, evaluating each composite on its handling. The unbiased winner was Beautifil II.

Recently, this product was given to several members of the Catapult Education product review board. This is a group of general dentists coming from a diversity of clinical environments. The group was asked to use the product during everyday clinical scenarios, including anterior and posterior restorations.

Most respondents said that they most appreciated Giomer bioactive products’ ability to reduce/eliminate the incidence of secondary decay, whereas several others cited its ability to reduce/eliminate postoperative sensitivity. They appreciated its natural-looking esthetic, ease of use and handleability, predictable shade stability, and, of course, its Giomer bioactive features. “This is a no-brainer,” one respondent said.

It is incredibly rare for a product that is tested among the Catapult Education board to acquire a 100% positive response rate when asked, “Do you intend to continue using this product?” and “Would you recommend this product to a colleague?” Beautifil II is just such a rare product.

So, now I have a composite product that is a pleasure to work with, and it happens to be bioactive. I think I found my magical restorative product