The Supporting Cast of Adhesive Dentistry

Every successful indirect restoration needs a star. A world-class universal adhesive or a recognition-worthy bonding agent that ensures best-in-class clinical success. And while adhesive materials rightfully steal the show in adhesive procedures, they can’t do it alone. It takes a whole crew of supporting instruments, tools, and supplies for an award-winning procedural performance.

But to be victoriously efficient, what tools and supplies should be cast in these supporting roles? A few rise above the rest to promote efficiency and streamline adhesive undertakings.

“My definition of efficiency in dentistry is working quickly and also getting it right the first time,” says Jason Goodchild, DMD, director of clinical affairs at Premier Dental Products Co, “To accomplish this, providers must follow the steps and directions every time, and having the right tools can make this simpler.”

Dr Goodchild recommends finding products that work for you—and sticking with them. “If the office has a lot of material or tool choices and lots of different team members, then it’s hard to ensure that things are being done correctly when adhesive products and procedures have unique directions and steps,” he says.

When it comes to the most critical tools for success, several categories can make the prize-winning difference, including curing lights, isolation materials, and a toolbox of procedure-expediting tools. The key is to find the right one for you.

Curing Light

Supporting cast member number one is a curing light. When choosing a curing light, there are a many factors to consider, including functionality, access, light intensity, cost—the list goes on. Narrowing down what you want is a matter of personal preference, but it’s important to consider the type of light and if it will create adequate polymerization.

Heat generation is another concern. Despite a high light output (1,400-2,700 mW/cm²), plasma arc and laser curing lights are less popular because they generate a lot of heat. Now, many dentists are experiencing the same problem with halogen lights. However, LED lights generate less heat than the blue-light halogen curing lights and provide flexibility with a broad range of wavelengths for curing various materials. Although they have a more limited wavelength spectrum than halogen lamps, they use less energy and are smaller and lighter than their predecessors, which Dr Goodchild finds invaluable.

Ergonomics, he says, is one of the most important things to consider when selecting a curing light. While he believes factors such as output and price are important, he feels that unless he can easily position the light close to the tooth, he’d probably reach for something else.

“The most important consideration for me is the ergonomics of the curing light,” he says. “This includes the weight of the unit and comfort of the grip, as well as the ability to position it inside the mouth to reach all areas. Personally, I like the SmartLite Focus by Dentsply Sirona because of its simple operation, its lighter weight, and ease of access to areas in the mouth. It doesn’t have the highest output compared to something like the VALO™ [by Ultradent] but I reach for the SmartLite because of the weight, more secure grip, and easier access to the back of the mouth.”

Another factor to take into account are the multiple settings offered by the light.

“I have the VALO from Ultradent, and I love it,” says Sarah Jebreil, DDS, a cosmetic dentist practicing in Newport Beach, CA “I love that it has different settings so I can use it to tack indirect restorations, then clean up my cement, and then change the setting to do a full cure.”

According to a 2014 study conducted by the ADA Professional Product Review, VALO is also one of 3 curing lights that ranked as having irradiance above the gold standard. Additionally, the VALO Grand offers increased optics size for improved curing on larger restorations.¹

In addition to selecting a high-quality light, practitioners can’t forgo technique.

“Having a good quality LED curing light with sufficient output is critical,” says Dr Goodchild. “However, proper positioning and angulation of the light as close as possible to the material being cured is critical. You also have to deliver sufficient curing times, based on factors such as output, distance to the material, and the shade of the material. It’s important to cure for enough time to properly cure the intended material.”

Isolation Devices

If your curing light is doing its job effectively, you can turn your attention to other issues that can make the difference between a successful restoration and an adhesive disaster. And the biggest one, says Dr Jebreil is isolation. “The 3 most important things to take into consideration when light-curing are isolation, isolation, isolation,” she says.

There are many ways to achieve good isolation, though each case may call for a different approach. “Each patient and clinical situation is unique and the only way we get things done is by being adaptable,” says Dr Goodchild. “Generally, I prefer rubber dam isolation. There are always times when it is not possible for a variety of reasons, but when I can use it, I do.”

But, remember that adaptability is key, says Dr Goodchild. “When I cannot use a rubber dam, I use several techniques to achieve the best possible environment for adhesive dentistry,” he explains. “Sometimes this is a careful retraction and cotton-roll isolation, and sometimes it is with devices such as Isolite and Isodry® [by Zyris™].”

Dr Jebreil agrees that different cases call for different measures. “Depending on the circumstance, I like to use a rubber dam, OptraGate [by Ivoclar Vivadent] or Isolite,” she says.

Each system has its advantages. OptraGate, a latex-free cheek and lip retractor, helps make the treatment field easily accessible and is easy to position thanks to three-dimensional flexibility. This allows the dentist to focus on the procedure, instead of worrying about a visible, dry field. On the other hand, Isolite has the bonus of providing suction in addition to retraction and isolation.

Suction has become increasingly important in the face of the COVID-19 pandemic, as it reduces the number of aerosols created by dental practices. The Centers for Disease Control and Prevention (CDC) reports that while there is currently no data to assess the risk of SARS-CoV-2 (the virus that causes COVID-19) transmission during dental procedures, it can survive for hours in aerosols like those created by the use of instruments such as ultrasonic scalers, air-water syringes, and handpieces. The CDC recommends that “if aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high-evacuation suction, and dental dams to minimize droplet spatter and aerosols.”² The high-evacuation suction provided by Isolite has been reported by Henry Schein Dental® to reduce aerosols by up to 90% before they leave the patient’s mouth.³

Tools for Efficiency

In addition to curing lights and isolation systems, a toolbox of time-saving instruments can turn a cumbersome procedure into an efficient success. While many everyday tools may seem mundane, they are often a practitioner’s most important assets. “I always have 5 things for an adhesive procedure,” says Dr Jebreil. “My loupes, a rubber dam, a MicroEtcher™ [by Zest Dental Solutions®] and QwikStrip™. With these, I can ensure a good view of the field, isolate properly, and prep the area, and easily remove cement after cementation—simplifying every step of the procedure.”

Dr Goodchild also recommends that practitioners add a sectional matrix ring system to their arsenal. “A sectional matrix ring system like Palodent Plus [by Dentsply Sirona] or the Garrison [Dental Solutions] system can make things a lot more efficient and streamline the process,” he adds. “I always like to have those on hand.”

And sectional matrix systems are important for good reason—many clinicians have reported that contact creation is the most challenging part of a Class II restoration. Sectional matrix systems provide separation between teeth and isolate the composite material, forming good interproximal contacts and shaping restorations—and saving a lot of cleanup time.

The Leading Man ​

Of course, Dr Goodchild can’t help but mention the star of the show: The adhesive itself. “All the tools mean nothing if your adhesive is ineffective. A universal adhesive like Prime&Bond elect [also by Dentsply Sirona] or Scotchbond™ Universal [by 3M] is something I turn to,” Dr Goodchild says. “This allows me to select how and when I want to use phosphoric acid.”

But, you don’t need an overflowing armamentarium to get the job done. Sometimes, less is more when it comes to adhesive success. “I’m old fashioned,” says Dr Goodchild. “I believe efficiency in dentistry involves finding a solution that works for more clinical situations and following it carefully. This way, everyone on the team [multiple doctors and multiple assistants] knows exactly what is needed and how to use the materials.

“This is the key—adhesive dentistry is tedious and demands attention to detail,” he continues. “Different products will have unique directions and best outcomes depend on following them. If we try to be consistent with what we use, then we only have to learn one—or a few—sets of directions, which will help us get it right.”

References

1. Megremis S, Ong V, Lukic H, Shepelak H.An ADA laboratory evaluation of light emitting diode curing lights. The ADA Professional Product Review. Published November 2014. Access September 14, 2020. http://www.ada.org/en/publications/ada-professional-product-review-ppr/archives/2014​ ​

2.Guidance for dental settings. Centers for Disease Control and Prevention. Updated August 28, 2020. Accessed September 14, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html​ ​

3.Isolate dental isolation system. Henry Schein Dental. Accessed September 14, 2020.

https://www.henryschein.com/us-en/dental/supplies/isolite-dental-isolation-system.aspx​

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