Episode 53: Preventing Composite Failure

Transcript for Episode 53

Dr. Seibert: Why is it so necessary to implement stress-reducing protocols?

Dr. Deliperi: It is very important to implement stress-reducing protocols as it helps to avoid problems in the short term and the long term. Also, it helps to avoid a problem regarding post-op sensitivity which is one of the main problems that people are having when they are placed in a direct composite restoration. Especially, if these restorations are placed in ice effect or cavity configurations.

Dr. Seibert: Why would that stress lead to post-operative sensitivity?

Dr. Deliperi: Because if you do not stress-reduce all of your raising, all the chemistry is going to shrink following the curing protocol. Therefore, a gap is going to be created between a bond if you do not have a good bond and a composite. That means the tooth structure and the restorative material will not work as just a tooth restoration complex, but they will work as two different parts of a system. This is why you may have post-op sensitivity. It is also the main reason.

Dr. Seibert: You have dedicated an immense part of your career toward developing stress-reducing protocols. Would you give us an overview of some of those protocols?

Dr. Deliperi: I have started the stress-reducing protocols since I was a student at tufts university. I was trying to research this area because post-operative sensitivity was a big issue 20 years ago, and it is still an issue today. The main reason is that materials have improved a lot while the chemistry is still alike. So, we are going to still have a shrinkage in the composite. The residual stress may be transmitted either to the hyper layer or residual structure. This stress may be responsible for creating a gap between the composite and the tooth if the bond is not good enough. Especially for the bonding to dentin which is a little bit more challenging to achieve something compared to it. If the bond is still good all of its prices are going to be transmitted to the residual cavity walls Moreover, different side effects may be developed including the cuspal deflection. Sometimes we may also have some cracks on the surface of the enamel because of the residual strain in the restoration. This is why it is crucial to reduce all of these phenomena related to stress, because microleakage may occur. This, meaning bacteria may penetrate the restoration interface and may be responsible for secondary decay in the long term. However, if a gap is created right away once the patient leaves the dental chair, then some dental tubules may be exposed and post-op sensitivity may occur. This is terrible for the patient as we are not restoring the tooth ceiling interface and a lot of damage may occur. I had many patients come into my office, on a number of occasions, to complain about post-op sensitivity in the direct composite restorations. Even in the indirect composite restoration that was placed a few weeks ago, a few months ago, or perhaps a year earlier. As a result, this would be a huge discomfort for a patient who paid for the treatment and was not able to solve the problem. This would defeat their entire purpose of going to the dentist.

People are suffering from post-op sensitivity. This causes them to turn to Amalgam as it helps people resolve this problem. Although, amalgam restoration may create other problems over the years. We all know the side effects of amalgam: cracking of both enamel and dentin, fracture of a portion of the tooth (which may be cuspal), or maybe a complete fracture of the tooth wall- which may sometimes be catastrophic. It may also be responsible for the tooth extraction which is its velocity. So, this is an enormous issue that we need to address. This is why it is so important to know all the ABCs of the stress-reducing protocols to avoid this problem. I had people that came to me and had the problem of sensitivity with a composite. Indeed, I had a tough time pushing them to try again to place direct composite restorations. Sometimes the pain (especially on the chewing side) is so bad for patients who prefer to keep the old restoration and avoid the replacement of the direct composite restoration. The issue of sensitivity and all are related to the issue of stress. Our stress is going to create a strain on the tooth restoration complex.

Dr. Seibert: So, you touched on an essential point. What is it about amalgam that can ultimately lead to cracks and in the worst-case scenario catastrophic failure of the tooth?

Dr. Deliperi: Amalgam and tooth structure are not bonded together- we do work as two different entities in the tour restoration complex. In other words, amalgam is worked as a filling material- it is just filling a cavity. The way amalgam fills the cavities creates the foundation for future problems such as cracks restoration for many years. Besides, this is still happening while I am trying to change this trend. All the dentists in the world are thinking of the corporeal and if it is strong enough for restoration. The tooth is structurally compromised. Thinking of the corporeal first is important of course, but it is not the precedence to consider. The truth is that we do structure, so this is what makes the restoration work. When prepping a tooth for an amalgam restoration, the tooth may be destroyed regardless. Moreover, this is the same thing that happens when we are trying to create a retention form using a strong material to make it struck. However, the tooth then suffers from a different modulus of elasticity between the rigid restoration and v2 structure. The mismatch in the modulus of elasticity is going to create some micro-movement in the tooth restoration interface. Moreover, this is going to create leakage, which triggers the bacteria’s intuitive structure- this is going to lead to a lot of problems. Of course, it is time to think differently and this is typical.  Using the composite protocol is not just about stress-reducing and restoration, but you end up prioritizing the tooth. Therefore, the v24 is the priority and the material is just a means to replace via compliant. What has been lost due to disease and due to endothermic treatment may be due to trauma or it may be secondary carries due to the failing restoration. Or it could be a composite amalgam or ceramic. The main point for the clinicians is not just selecting the material but looking at the tooth at all times. This is mandatory to me when I place my composite restoration. My priority is to save as much structure as possible because this is what works and what mother nature creates cannot be replaced by any material, not even ceramic or hybrid material. We need to respect our nature and over the years I learned that even if we must compromise a tooth, it is so important to preserve the weak thin walls. This is what makes the restoration work reliably in the long term. However, the only problem is that we are missing protocols that can protect these thin walls that I am trying to defend.

Dr. Seibert: Yeah, tell us about the protocols that you have developed.

Dr. Deliperi: Well, once again we needed to be known for the innovation. I used to say we have to be minimally invasive. Now I’ve got changed and I am switching from minimally invasive to non-invasive. In other words, I love the additive restorations both in the anterior and posterior areas because we are saving 100 percent of the residual structure even in the most structurally compromised clinical scenario. Once you decide to save these remains on to the structure, you need to be able to preserve, protect and reinforce this residual structure and protect it from the stress coming from above the restorative material. For example, composite and the occlusion functions; we need to think about these in the long term so when we design composite stress-reducing composite restoration, we are just not doing a regular filling. Our goal is not to backfill the restoration, but just to make sure that we do not have a cavity anymore. So, it is not like in the old days that you drill and fill then send the patient home. It is different. We needed to spend more time in an attempt to treat the tooth the right way. I am not calling it a filling; I am calling it a restoration. Restoration refers to something that takes some more time. You develop brick by brick that each brick is a 1-to-1.5-millimeter shape increment of a composite that you place in a 2v cavity to reduce the stress coming from polymerization. So, by using this layering technique- layer after layer increment after incremental is also known as a daily basis in our community Vidalia. This application allows you to reduce stress and if you couple the layering protocol with a pulse urine technique, you are allowing the composite material to delay vital points. In other words, you can give some more time to the composite for strength and stress relief. Also, it is very important because you aren’t just allowing it to stress-reduce, but you are also allowing more time for the composite molecules to create more interpret trading and cross-link in a chain in the polymer that will also improve the mechanical properties of the material. This is just a brief review of the stress-reducing protocol regarding the composite material. We needed to think of the function so you need to create a design restoration in a way that is able to withstand the stress, so this is also very important.

Dr. Seibert: So, you mentioned adelebit, would you please explain to us how to place that in the technique involved?

Dr. Deliperi: The idea is to place these small increments for it to be bonded to its triangular shape. The increment is bonded to only two bundle surfaces. For example, in a class one or class two restorations. As you are bonding to only two bundle surfaces by placing these daily beads, you are creating a layering protocol where each increment is similar to that of a class 4 restoration. The ratio of a bond to unbound surfaces is very favorable. The stress is automatically reduced. This means it is very important you pulse cure each increment and you do not try to connect the opposing cavity walls right away with a single increment. This is true for both of the approximate enamel replacement which is the first step in a class to direct composite restoration. Since we build up according to this stress-reducing protocol of the proximal surface first, in the meantime we are giving time for the bumps denting to mature because bonding to dentin takes some more time than bonding into an ambulance so I usually build up the proximal surface first with multiple deli beads and then I place a very thin layer of global composite just on the floor. This is a recommendation that is coming from my first paper where I introduced, for the first time, this protocol back in 2002. It is also true for the occlusal enamel buildup. We are trying to build up each cuspal separately without connecting them to others to avoid cast deflection. This is related to post-op sensitivity and this way you are also protecting the hybrid layer from stress so that is very important. You need to give time for the hybrid layer to mature for it to be stronger and you need to try to stress-reduce this area to avoid the formation of the gap at the interface.

Dr. Seibert: You’ve brought up a pretty crucial point, and there is a belief in dentistry that the bond to enamel is always stronger than the bond to dentin. Dr. Deliperi, with all of your background, would you please correct that statement? And explain why the bond to dentin is stronger?

Dr. Deliperi: It is stronger if you give time for the bond to dentin to mature. If you bond to dentin immediately in a high c factor configuration then it is true that the bond to dentin is weaker but we learned that we do not have to do that. We need to give time for this bond to mature and we cannot rush. That is why we cannot just place a regular filling. We cannot bulk fill a restoration because we are not giving time for this bond to mature beyond all of the other problems. Also, remember that the more structurally compromised tooth, the more difficult it will be for the dentist to create a long-lasting restoration of being a conservative. This is very important if you wanted to be conservative or if you wanted to perform almost additive restorations. You need to master the stress-reducing protocol because it is not easy to do that so it requires a learning curve that will then bring you to do more and more complex restorations. It took almost 20 years for me to achieve this level of dentistry but now we can teach it right away so people can learn this protocol and start the learning curve that will last not 20 years as it happened to be by developing every protocol, but it will take less time training is very important if you wanted to perform stressful using restoration. 100 preservation of the residual structure going back to your questions regarding the dentin enamel bond. If you bonded to enamel immediately at time zero, of course, the bond to enamel is stronger. That is why we start the building out of the proximal surface first which is just a replacement of the missing enamel so it is going to be a very thin layer of the composite up to 0.5 in the cervical and up to one 1.5 into the occlusal. This is completed depending on the size of the effect or the restoration with different delegates.

Dr. Seibert: You’ve also developed a curing protocol. Would you tell us what it is?

Dr. Deliperi: I didn’t develop it. I just reviewed the literature and I tried to take the information that was coming from the literature. There was evidence that delaying the gel point means giving time to the composite to move into the degradation of the cavity walls. This is happening in the pre-gel phase. When you start the polymerization process, once the gel point is achieved, that means the molecules are locked and cannot move anymore. All these threads and all the residual stress are concentrated into the composite and transmitted into the cavity walls via the hybrid layer. So, by delaying individual points, it means a pulse curing for one second to another second, depending on the location of the increment we are placing, we are just delaying visual points. We are giving more time for the composite to move and by moving and releasing stress at the same time, you are giving more time for the connection of the polymer to form. It cross-links to inter-penetrating the different chains and is very helpful in improving the mechanical properties of the composite. We have studied from both Japan, Europe, and the US demonstrating that the stress is going to interfere with the mechanical properties of the composite.

Dr. Seibert: I’ve also had some input from colleagues in the biomedical community who recommended that I ask you about your opinion of Everex. Do you have a special stance on it or any commentary?

Dr. Deliperi: I believe it is a very promising material and we are missing clinical trials so we don’t have a long-term clinical trial on the material. I know that the community is very focused on this material and it has very interesting chemistry to it, but we do not know enough to be including both for the Everex and the Everex flow. We do not know enough regarding the long-term result of the material but I am coming back to the same question that I asked the youth and all the people that are listening to us. It is more important to have a strong material because the material Everex has an increased fraction toughness. This material is stronger compared to regular composite refraction. Toughness is defined by the ability of a material to resist crack propagation. For this reason, the material is pretty interesting. We have some contradiction in the literature and I am referring to Vitro studies only. I am not talking about the clinical ones, because since I know we do not have any clinical study on this material in the long term it also means we have a contradiction. Even in the literature regarding the Vitro study. If this material should be applied in layers or maybe bulk film (as the company is recommending), it is going to shrink away. This material has an increase in fraction toughness, but it is not going to be a miracle material. I am a little bit worried that the dentists are expecting too much from this material. This material probably is going to work pretty if you work with it in layers. I would recommend using delegates and once again, you should think 2v2 first, so if the cavity is not big enough, almost any material is going to work well in the short term. If the shielding effect of a tooth is enough, in other words, if the tooth can protect itself from the drawbacks that come in the front of the material, the problem is when the cavity is becoming bigger and bigger and the cavity walls are becoming thinner. So, the shielding effect of the tooth is dramatically reduced. It is now time for us to create the condition for that residual to structure it to keep working by reinforcing it and protecting it from stress coming from both the material. So, I believe the material is going to work pretty well if we use it in layers in daily beasts and if the shielding effect of the tooth is good enough. If we are going to have a very cognitive wall of the era, then we need to use perhaps a continuous fiber, like the wallpaper protocol that we didn’t develop, instead of a chop the fiber or maybe a combination of continuous fibers close to the residual cavity. This could be a good combination of materials. These are the things I would recommend to use- as long as you use it in thin layers.

Dr. Seibert: So now, you have an upcoming webinar with the academy of biomedical dentistry and there is a lot of hype about it in our community, would you give us an overview of what you are going to talk about? because we had the honor of getting a brief sneak peek into your expertise in this interview but you are going to go way more in-depth in your webinar.

Dr. Deliperi: We’ll try to give a more detailed introduction to the stress-reducing direct composite protocol for restoration medium to large size restoration including the direct cuspal replacement. This is from the original stress reduce direct composite protocol published in 2002 and implemented a step-by-step protocol that includes six main steps and we are going to go through all of these steps and people will have a chance to be introduced to this protocol for them to be maybe more curious about it. They may even investigate more about that and maybe learn even more about it. The plan is for me to give a lecture on stress reduce direct composite restoration. Only then, David Olemaun and I are going to complete the dual webinar for the app where we are going to review our 2017 paper publishing the operative dentistry journal about wallpapering. We are dealing with this second webinar with more structurally compromised teeth but the foundation of everything is stress reduce drug composite protocol. You cannot skip the stress-reduce direct composite protocol if you wanted to use the word paper in the right way. 

Dr. Seibert: If a clinician were to fail to implement these protocols, what are some of the shortcomings? What might they find about what we’ve talked about (post-operative sensitivity)? And what are some of the other shortcomings? 

Dr. Deliperi: Shortcomings could be a fracture of a restoration. Fracture of the tooth restoration complex or maybe a catastrophic failure of the tooth meaning a fracture that is going to go below the gingival level and to be cemented into the root so that unfortunately sometimes the tooth may be required some more invasive therapy. Or maybe the extraction which we wanted to avoid. We wanted to stop the cycle of death for the tooth.

Dr. Seibert: Well, thank you so much. Do you have any closing remarks to leave for us?

Dr. Deliperi: I would encourage all the people to follow us to maybe on Instagram. Please be aware that I am also giving a three-day a three-day course on the stress-reducing direct composite protocol from a to z where you can implement and understand. First of all, this is the philosophy of tooth preservation, first followed by stress-reducing from both the composite and envy function so we usually like to say to get bonded and to stay bonded. This is something coming from my buddy. David Holloman and I would like to add this sentence via stress-reducing- proper courses which is the key to achieve long-term success. On the other hand, I am also going to launch soon a three-day webinar on additive direct composite restoration in the anterior area so this is another topic that I am going to cover pretty soon. So, for all of those who are interested not only in anterior but also in posterior restoration, with 100 percent of the tooth preservation even when you get the tooth discoloration, these are the ways to go so just follow me.

Dr. Seibert: Well, thank you so much for joining us.

Dr. Deliperi: Thank you for your time, patience, listening to me, and your questions. I appreciate you.