“How long should I tell my patients their posterior composites will last?” – what a great question from dental student Emma Hutchison!

As part of our new Protrusive Students segment we’ll be bringing you monthly episodes packed with valuable insights, tips, and tricks specifically tailored to dental students like Emma.

Whether you’re navigating clinical rotations, honing your skills in phantom head, or gearing up for those daunting exams, we’re here to support you every step of the way. And kicking off this segment, we’re diving headfirst into the topic of adhesive dentistry!

Link for further reading regarding the longevity of direct restorations – A retrospective clinical study on longevity of posterior composite and amalgam restorations – PubMed (nih.gov)

The Art of Treatment Planning – The Art of Treatment Planning: Dental and Medical Approaches to the Face and Smile: Amazon.co.uk: Romano, Rafi: 9781850971979: Books

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:
00:00 Adhesive dentistry
03:41 Bonding systems
07:00 Self-etch vs. total-etch vs. selective-etch
14:38 Post-operative sensitivity
16:10 Communicating risk with patients
17:42 Polymerisation shrinkage
19:38 The snowplow technique
21:13 Instruments
23:19 Consent
25:30 Longevity
28:05 Risk factors
37:37 The next episode

If you liked this episode, you will also like PDP077 I Can’t Believe This Sticks

Jaz's Introduction: So welcome to Protrusive Students Episode 2. In Episode 1, we introduce you to Emma Hutchison, who's the Protrusive Student. I'll be releasing one episode with her every month to answer questions from a dental student's perspective. And every month, we will release some of her revision notes, which are absolutely epic.

Jaz’s Introduction:
I’ll check them myself on the Team Brandsim. All of these notes are going to go in the Crush Your Exam section of Protrusive Guidance. Protrusive Guidance, if you’re brand new through a podcast is our little family. It’s our little home on the internet via the web browser, or even it’s native app via Android, iOS.

All dentists and students can join it, but if you want to verify yourself as student, you have to email student@protrusive.co uk. So when you apply to join the network, which is on protrusive.App. Once you apply, you fill in some details, you explain that I’m a student, and then you should email student at protrusive. co. uk with some proof that you’re a student.

That way we will add you to our secret space called Protrusive Vault. So as part of your benefit of being a student on Protrusive Network. You had access to a paid space. There’s also student clinical videos, which we’ll be adding soon, as well as more episodes, just like this one.

Hello, Protruserati. I’m Jaz Gulati. Protrusive Students is part of the Protrusive Dental Podcast. If you are a dental student, don’t hoard this, share it with your colleagues. Eventually they’re going to find out anyway. So you might as well be the person who shared it with them. I’m hoping that on Protrusive Guidance, we can help you on your journey.

Look, there’s almost a thousand dentists so far on Protrusive Guidance, and these are the nicest and geekiest dentists in the world. And by being someone who is a keen learner, who listens to this podcast, right? Not everyone does, right? Only those who self select themselves as a keen learner listens to stuff like this.

And so it’s time for you to meet your tribe and start learning and growing together. Now in this episode, which was supposed to be released in February, but life got busy with kids. It’s actually Adhesive Dentistry. Questions from Emma Hutchison all around the topic of adhesive dentistry. Like for example, some of the things we’re going to cover is the longevity of composites.

This is such a fundamental thing. And actually what I love about doing these series now with Emma is everything she’s asking is so foundational that even the dentist listening and watching, I think will gain from this. So let’s go ahead and join the main interview with Emma, all about adhesive dentistry from a student’s perspective, and I’ll catch you on Protrusive Guidance.

So Emma, have you started on the clinics yet? So we’re talking about adhesive dentistry today, you’ve got some questions for me. Have you done your first composite on a patient yet?

[Emma]
I have, yes, I’ve actually been quite lucky. I’ve had quite quite a few patients. So I’ve done maybe about 10 composites so far. I know some of my friends have had zero, so I’ve actually been very lucky at the start of my third year, had some good patients.

[Jaz]
Very good. Well, you, you’ve done 10, but you’ve seen thousands, right? From your experience in nursing, which is great. So you get even more from that. So you would have seen different bonding systems being used and whichever one you’re using at the end of school. Just curious thing here, this wasn’t scripted, but when you’re doing your bonding stages, like you’re etching, bonding, everything, what’s going through your mind? What are you thinking about?

[Emma]
What I’m thinking about is just, I’m a nervous hummer. So you know that I’m concentrating, I’m going to be, I’m just so in the zone. You just need to especially early on, I’m just concentrating so hard. I come out, I’ve got a sore jaw after. But honestly, it’s just etch, prime and bond, etch, prime and bond, just repeating that in my head over and over, but just total concentration mode. I forget it after, I was concentrating so hard.

[Jaz] Bonding systems
I remember working on the clinics as a student and this is like our first year in the clinic and the dental student in the bay behind me, I won’t name and shame him, I don’t want to embarrass him, but the patient left, he was like, oh no! I forgot. I forgot to bond. I etched and I put my composite, but I forgot to put the bond.

So I’ll never forget that. So I see what you mean. You etch prime bond. Don’t forget the stages because when you’re so new. Exactly. But the reason I asked you that, Emma, is because what goes through my mind is a bit funny. Interesting. I think scientifically, I just wondered, are there any other dentists out there?

Maybe if you guys are watching on the new platform, just comment below whether this is you or not. I am imagining, the scanning electron Microsoft images of dentine and stuff, right? I’ve got these tubules on mine. And then as I’m doing the etching, I’m seeing these enamel, like etched enamel, like the sort of scanning electron Microsoft part of it. Then when I’m putting my primer, I’m seeing that hybrid layer being formed. So that’s what I’m visualizing. I don’t know if I’m the only one who does that.

[Emma]
I’m just trying not to cry at this point, but I cannot, I cannot.

[Jaz]
I love it.

[Emma]
I just need to just etch, prime, and bond, etch, prime, and bones, because if you miss that, then, your patient will be back in next week.

[Jaz]
Look, when you start endo, your head will explode.

[Emma]
Yeah. No, definitely. Yeah, we’ve been doing endo down on the phantom heads and things and it’s just so I’m dreaded. No, I won’t say I’m dreading it. I’m looking forward to the first endo patient, but it’s a lot. It’s a lot.

[Jaz]
It is. What this chat reminds me of is I remember being a third year student and I was living with fifth year students at the time. So it’s pretty great. I was like constantly getting advice and stuff. So you finished your morning lectures. I’d come home and I literally lived in a flat, like two minutes walk from the dental school, right in Sheffield. It was amazing. And there we are standard, you get a bit sandwich and you start playing FIFA as you do.

So I’m playing FIFA with a fifth year dentist. And I say to him, when do you get to a stage where you don’t have to like do a step by step memory of exactly what you have to do next and endo? Yeah. And he said, I’m still not there yet, but I’m almost there. And then when you speak to, when I used to speak to dentists, when I was a dentist, he would say, hey, endo, yeah, you don’t have to memorize it.

It just comes instinctively. It’s like something that just gets etched into your brain and it does happen eventually. And now you can, when I’m doing a composite, you don’t have to think about the different steps. It’s just part of the procedure. You’ve done it thousands of times. So don’t worry. It will normalize. It’s like driving. You get, you don’t think about it anymore.

[Emma]
Yeah, yeah, no, eventually, eventually it’ll all fall into place.

[Jaz]
It certainly will. Now, Emma, you’ve got some questions for me, depending on time. You’ve got some questions for me that are going to make this topic tangible. I’m actually excited to cover these because I think this will generally make a really good educational episode in dentistry in general. So, it’ll be nice to serve students and dentists together in this episode. So come at me.

[Emma]
Okay. So my first question sort of spawns from, it was our first day or our first lecture of second year. And bearing in mind, this was the first time we had been in the dental hospital because in the first year it was COVID.

So I didn’t get into the dental school until second year. And then we had a year out. So that was technically my third year of university. And I remember our first ever lecture was on boarding systems. And I’m sitting there in the lecture theater and I’m like, what is going on? I’ve had no introduction to composite.

Self-etch vs. total-etch vs. selective-etch
No introduction to anything. And everyone was just sort of like, I remember thinking, it was just a bit, a bit mind boggling. And then, obviously I understand we need to know all these different protocols, etch, prime, bond protocols, but there’s just so many different, different things that we’ve covered. You’ve got like, your total etch, your self etch, selective etching, different steps, two, three steps, etch and rinse bonding systems. So I just wanted to know, would you use different protocols in different situations? Like, what are the basic, what are the most common protocols? What do you do yourself, your day to day?

[Jaz]
Great question. Really real world questions. And I think where I’m going to start to answer this is in the real world, believe it or not. I mean, it’s really good to know all this stuff, by the way. I think Dental Materials is like that one textbook that you still keep because it’s really nice to connect with it. And we’re using dental materials every day, which are ever improving. And it’s great. But to have the foundational science behind it is good.

What you’ll find is that wherever you get a job, when you start practicing, start working as an associate, you’re kind of at the mercy to whoever made a decision at one point in that practice, be it a group of associates or being a principal about which dental bonding system that they’re going to adapt in that practice.

So every surgery is stocked up with that same one usually, right? It just for think about stock, like when you were nursing, like if there was five different types of bond, I mean, they’d expire, there’d be a ordering issue. Did you ever work in a practice that had different types of bonds or was it just usually one or two bonds?

[Emma]
I’ve mostly worked in mixed NHS private practices and usually there’s one for private patients and there’s one for NHS patients. That’s about it really. That’s about it. That’s all that I can remember.

[Jaz]
So yeah, so there was like one or two basically and generally that’s usually how it is. And so you are at the mercy of whichever supplier had that buy three bonds, get two free offer. And then the practice said, okay, let’s go for it. Let’s buy a year supply of bond. And so the most important thing is, figure out which bond it is you’re using, okay, the actual name of it and download the DFUs, the directions for use, right? The most important thing I think is whichever system you’re using, please use it in the way that the manufacturer intended it to get those bond strengths, okay?

The biggest sin you can do is like, for example, we were saying earlier, etch prime bond, etch prime bond, that kind of stuff. But imagine you are using a, what I’m using, like I’m using a G-Premio Bond I think it’s like a sixth or seventh generation, right? It’s like a newer generation. I don’t even know exactly which generation it is, but I know exactly how to use it, right? That’s more important for me. It is a self etch. Okay. And so the worst thing you could do is use your phosphoric acid etch on the dentine.

[Emma]
Right.

[Jaz]
Wait 15 seconds, wash it away and then use this bond. You’ve dramatically reduced the bond strength. Big time.

[Emma]
Okay.

[Jaz]
Because the directions are, you do not etch the dentine here. That’s specifically the direction, you do not etch the dentine. You actually weaken your bond strengths that way. The self etching primer, it does all that kind of stuff for you with the dentine.

And so what I’m using at the moment is G-Premio Bond, because that’s what we decided as a practice that we’d like GC products. Okay. And it served us well. And so what I would do typically is once it’s all clean, what I mean by clean is personally, I’m using air abrasion. Are you familiar with what air abrasion is?

[Emma]
Yeah, I’ve worked with dentists that use air abrasion a lot, yeah.

[Jaz]
So I’m using like 27 micron or 50 micron aluminium oxide particles blasted. What that does is it, most important thing, is it gets things clean, right? You get rid of the biofilm. That’s the most important thing. And supposedly gets a nicer structure of dentine to bond to. That’s actually debated, but you definitely remove the biofilm, which I think is the most important thing.

So I’ve got a nice clean surface. I’ve got rubber dam isolation. I’m a big believer in rubber dam isolation only because like you look away and if you don’t have rubber dam isolation, that’s when I’m stressed. Like the patient’s tongue goes there. It feels a saliva. The gingiva starts to bleed into the cavity.

It’s just a stressful. It’s more about stress. My mental health and stress will benefit from having rubber dam on. So I’ve got my rubber dam on. I’ve got my abrasion on. And so what I would do is I would use my etch first on the enamel only because of system that I’m using. So whichever system using follow that the system I’m using, I will do a selective etch technique.

I. e. I’m selecting, I’m choosing to etch the enamel only. Then I will wash it. So I would typically wait 20 seconds to 30 seconds. Okay. I’ll wash it and observe that frosty enamel. Okay. I want to see that frosty enamel. Okay. Not overly frosty, but you just want to see some degree of frost frost there. Then I will get my G-Premio Bond.

Post-operative sensitivity
Okay. So I don’t, there’s not a separate priming stage in a separate bonding stage. Like a fourth generation one will be OptiBond FL, which is supposedly the gold standard. Have you heard of OptiBond FL? Have you heard of it?

[Emma]
I’ve heard of Octobond, but not OptiBond. It might be the same thing that I’ve heard of, yeah.

[Jaz]
Probably. I mean, they have OptiBond Solo, and they have a few different varieties of stuff, but one of the ones that a lot of pedantic dentists like to use is OptiBond FL, because the initial research in the 90s and 2000s was like, wow, this is amazing. And people, once you have a system that you can trust and things work.

It’d be silly to deviate away from it. And so the way that one works is that you do a total etch. Total etch is when you etch the enamel and you etch the dentine. And typically what you do is you etch the enamel first. Then by the time you get to etching the dentine and then you wash it, that means the enamel had more time than dentine. Is that what you do at the moment?

[Emma]
Yes. That’s what we’ve been taught at class school. Yeah.

[Jaz]
Do you know what bond you’re using at the moment in the

[Emma]
No. I should, I should, but I know it’s got the pink or purple color. That’s all I know.

[Jaz]
That’s totally cool. Emma, that’s totally cool. I don’t remember the bond I use at dental school. If you ask me when I’ve done 10 composites in, listen, as long as I remember to use a damn thing, I’m happy. Right? So these are the things whichever one that be in the real world, when you get there, it will be so different to what you use in dental school that you must take a moment to pause and look at the directions for use.

So back to the OptiBond FL, you do the total etch, which is the etching, the enamel, then the dentine, then you do the primer stage. Separate. Okay. Get nice and dry. Another coat get nice and dry. Okay. You don’t wash that that way, then you put the separate bond adhesive. So the primer goes into the tubules, okay?

Okay. And then it links to the adhesive that you put next, and then that hybrid layer is formed. Then you put the composite on top. Whereas what I’m doing, back on the newer generation, is everything is in that one bottle. So after I have selective etched the enamel only, we’ve put the G-Premio Bond, which has got the prime and the bond, everything inside there, and it’s got the etching ability to self etch the dentine.

[Emma]
Okay. Yeah.

[Jaz]
Then I will dry and it, this stuff goes to like four microns thin. So super thin, we will cure it and then we’ll go proceed with our composite restoration. So the real world lesson here is to make sure whichever system you’re using, you make sure that you follow the directions.

And if for those of you who want to really get deeper into this, but in a really tangible episode, there’s an episode that I did with a guy called David Gerdolle. So the episode we call it, I can’t Believe This Sticks Extreme Bonding. It was PDP 077. I would encourage anyone listening to this right now.

And you’re interested in learning more about what are the most important things to do? And what Dr. Gerdolle said was that as long as you get the tooth, clean and rough. Out of the six different things that you’re trying to do when you’re bonding something, the two most important is clean, no biofilm.

And what you meant by rough is get that nice etch pattern, like optimize your surface to bond to. And if you can do that, things will stick. So we talk about air abrasion, we talk about etching protocols and that kind of stuff. And so the whole bonding thing, whichever one you’re using nowadays, they’re newer, they’re supposedly better.

The issue, Emma, with using the more gold standard fourth generation earlier bonding is it’s technique sensitive, right? You have to get the whole what we call wet bonding where you have to make sure you don’t over dry the dentine and the risk of over drying the dentine increases when you’ve etched it.

If you’ve etched it and now you have to wash it and then you have to dry it, how do you know you haven’t overdried it and whatnot? That’s why it’s supposedly technique sensitive. So the new ones actually make it a lot easier for me.

[Emma]
Yeah, okay. That makes total sense. That’s good to know, actually, because I’ve never seen anyone do the separate prime, the separate bonds. I had never even heard of that. And then when they’re talking about it in this, maybe that’s the drawback of doing dental nursing, actually. I’ve never seen that before. So putting that into context for me was really, really difficult, actually. So no, that’s good to know, just follow your manufacturer’s guidance and don’t just take any random bond and use it willy nilly.

[Jaz]
And if you could do this for me, Emma, for homework for the next monthly episode is, I want you to find out exactly which bond you’re using. Let’s look at the directions for use together for that one. Okay. And let’s evaluate what you were doing well and what you weren’t doing on your first two composites so we can actually learn together. If you don’t mind, that could be a nice reflective thing, right?

[Emma]
Yeah. Yeah. Perfect.

[Jaz]
You know what? You asked a good question, which I didn’t answer. Would I use something different in different scenarios? Personally, I don’t, because we just, that’s what we have, right? Like the real world answer. That’s what we have.

Communicating risk with patients
That’s what we use. And some of my biomimetic dentists are like, oh, Jaz, you shouldn’t be using that bond. You don’t get as high as bond strength is like clear fill or that kind of stuff, which I get. But I have heard this thing on some webinars that I went on whereby. If you have got some caries, which is not close to the pulp, which is not close to the pulp, then in those scenarios, you should consider using a gold standard total etch.

So we’re etching the enamel and the dentine. If you are in a scenario where you’ve got deep caries close to the pulp, then the theory is perhaps we don’t want to put that 37 percent phosphoric acid etch right next to the pulp, right? So that makes sense to me. And then for those, you might decide to use a self etch, which actually when I heard that, like, five, six years ago, it made a lot of sense to me. But in the real world, do people do that? I’m not sure.

[Emma]
Yeah. No, I mean, I’ve just never had the conversation. I just sort of pass what I’m supposed to pass. So no, that’s good to know. Very interesting. Very interesting. The next question I had for you, Jaz, was we’ve talked a lot about like post op sensitivity can last for quite a few weeks. Do you think, do you notice that there’s any certain patient populations or specifically situations where post op sensitivity is more likely and how do you address this?

[Jaz]
Again, fantastic question. The only thing that comes to mind to me is people with cheese molars. M I H. Have you heard of M I H?

[Emma]
Yeah.

[Jaz]
So molar incisor hypomineralization, and these molars, which for those dentists who might be not familiar with this, this is when at the point of development, when the enamel is developing on the sixes and the centrals and whatnot, is hypomineralized.

Polymerisation shrinkage
There’s not enough mineral content. These teeth are weaker, and there’s different sort of degrees of it. It’s mild, moderate, severe kind of stuff. And if it’s severe, as the tooth erupts, the enamel is just breaking away and that tooth’s got to come out. Whereas if it’s mild, they have like these yellow patches and white patches on it and the yellow patches is why they’re called cheese molars.

Typically, these teeth can be a bit more difficult to numb and what I have found and what I’ve read is that they will be a bit more prone to post op sensitivity. So that’s the first thing that comes to mind. The other one that comes to mind for me, I don’t know if this is evidence based or not, is people with pre existing cracks in their teeth.

If you’ve got a crack in the tooth, especially if it’s a wide one or deep one, then that nerve is already upset, especially if they’ve already got symptoms of crack tooth syndrome. Every time they chew something hard, they feel like some sensitivity. That pulp might already be upset. Deep caries.

Especially if they’re already symptomatic whenever I look at a tooth and I think what risk level should I inform my patient, right? So should I tell my patient that you are low risk of needing a root canal? Are you a high risk of needing root canal? Number one thing I look at is how deep is the caries and if it’s close really close to the nerve, then not only is their risk of root canal treatment going to be higher, pulp necrosis, but also it just makes sense that the settling period might be longer.

And I think generally speaking, Emma, my patients don’t thankfully experience post op sensitivity very much. And I think the reason for that is is I got anything just like damage a dollar to us, get everything clean and rough. So I’m using rubber dam isolation. I’m not allowing that saliva or blood to touch my cavity, super, super clean, following my bonding protocols rigidly.

I’m doing the air abrasion, so I’m trying to do everything really gold standard here and I’m not rushing it. It easily will take me 45 minutes plus to do these restorations. And so my experience of post op sensitivity, because I do like to ask my patients when they come back has been pretty good over the last 11 years dentistry, especially even more that as I’ve developed as a dentist.

The snowplow technique
But people with deep caries, I would expect it. This is just a given and perhaps people with cracks, that’s the only ones I can think of. But thankfully, when you follow good bonding principles, it’s not normal. If someone’s saying that, oh, post op sensitivity is normal and every single patient will get it.

Then I think I would look at the protocols. Are they using their bonding agent properly? Are they perhaps etching the dentine where they’re using a self etch bonding agent and that would then help lead to the sensitivity problems. The other thing I do, Emma is when you’re placing composite, if you don’t mind me asking, what have you been taught in terms of the exact way to do it? So you don’t remove, but you’ve reduced the impact of that polymerization shrinkage or the polymerization stress.

[Emma]
Very small increments. Your depth of cure around about two millimeters, definitely not any more than that when you’re not trying to like connect the walls together.

[Jaz]
Okay. Yeah, yeah. Makes sense. You’re not doing like, for example, you wouldn’t join the buccal in the lingual wall straight off the bat and cause that shrinkage stress. And that’s, that’s correct. I would agree with that. So also depends on how you’re placing it. Anything else?

[Emma]
Make sure you’re doing your full cures. Don’t ever, I know some people do the 10 seconds and then build up the other cusp. Do that 10 seconds so that your first increment gets 20 seconds. Fine, but sort of just making sure that everything’s fully cured. You don’t want that. I don’t know in Glasgow we call it a soggy bottom. I don’t know where to start. Yeah, there you go. No soggy bottoms, thanks. Yeah, very small increments. Just taking your time with it and building it up nice and slowly.

[Jaz] Instruments
Great principles there. So yeah, don’t join the walls together. Smaller increments. It all makes sense. What I found is that when you look at radiographs of your work some years later, you find these little air voids and air bubbles in there, right? Because like I imagine as a dental student, you’re not heating your composite, right? You’re just using normal cold composite, right?

[Emma]
Yeah.

[Jaz]
If you work on like a tooth model, that’s clear and uses clear bands and you start doing these increments and if you can see the actual composite in place, you’ll notice that when you add one increment and then you add another increment and when you, whatever instrument you use and then you retract it, sometimes the composite gets pulled away a bit or that to two increments, they don’t meet together beautifully, that wettability isn’t there.

And so you get little voids, right? Which is not ideal. And if that void happens at that sort of where the hybrid layer area is, you might get more sensitivity, right? It just makes sense if you haven’t been able to do that. So what I’ve been doing for the last seven years is something called Snowplow Technique. Have you heard of this?

[Emma]
No, I haven’t. No.

[Jaz]
So, a dentist called David Winkler taught me to do this when I used to work for him in Windsor, and he used to teach a lot on composites and fantastic dentists. And then I started to read the literature behind it. A lot of great dentists do this, whereby before so, you’ve done your whole etch bond, it’s ready to now put your composite in.

Before I put my composite in, which, by the way, I am using heated composite. In practice, again, to get more wettability, right? Something that’s hard and stiff and cold compared to something that’s warm. It’s just going to get in all the nooks and crannies, right? So that’s also helping to reduce this void issue.

I will put a tiny, tiny, teeny, weeny drop of flowable first. Then I will put my composite increment. Okay. And then I will adapt it and cure. And then before the next increment, again, a tiny little bit of a flowable composite. And so that’s called a snowplow Technique, basically. And so, that’s-

[Emma]
I think, I’ve seen people doing that.

[Jaz]
You’ve seen that in practice. Yeah?

[Emma]
Yeah, I’ve seen people do that, yeah.

[Jaz]
It just makes sense to me. And so I’ve been doing this for years and I feel as though maybe that may or may not be relevant. I don’t know if the study’s been done where there’s a snow plow technique versus no snow plow where that actually really makes a difference. But in terms of my radiographs, I’ve seen that issue where you used to have these little random voids. That’s definitely been eliminated.

[Emma]
Okay, cool. So is that something that you would only really use with heated composite?

[Jaz] Consent
You can use that snow plow technique even without heated composite. In fact, I think the need for it probably gets even higher when you don’t have the benefit of the heated composite, right? But I just like this, the way it all seamlessly mixes together so nicely, which actually takes me to my next point. What are you using as a dental student to adapt your composite? So you put increment, what instruments are you using now to actually get the composite where you wanted to go in the cavity?

[Emma]
So, I am actually, not just saying this, I’m a big fan of a flat plastic. But then also I’ve found just a dry microbrush. I quite like a dry microbrush. One of the dentists I work with he’s a huge Protruserati, actually he was the person who said to me, you should definitely go for this job, you should do it. He’s a huge nerd.

[Jaz]
Give a shout out, give a name.

[Emma]
Oh, his name’s Pearse Hannigan.

[Jaz]
Of course it is, hello Pearse, good to see you.

[Emma]
He’s a huge Protruserati, so he is just a huge fan of just using a dry microbrush, and I’ve been trying it and it’s just getting into all these wee bits and bobs. I’m still sort of, I’m definitely still in that realm of figuring out what works for me, but a flat plastic and a micro brush are my sort of holy grails at the moment.

[Jaz]
I’m the same. So I’m using a micro brush. So I knew when you said that you use a micro brush, that I knew that’s not something that you would picked up from dental school. I knew someone in the real world would have taught you that. And so shout out to Pearse for this great advice. Something that Jason Smithson taught me years ago.

So yes, when you’re adapting the composite, when you use a micro brush, some of the reported benefits of this is you don’t get that. It doesn’t stick to the micro brush, so it doesn’t sort of pull up. And also if you look at it like you use something like something spiky on the composite and it makes this like a roughness even within the composite ready for the next increment.

Now, just so we know a reported disadvantage of using a microbrush is when you look at those scanning electron microscopes, you have these, your composites are a bit hairy, like the microfibers are actually breaking off into the composite. So what we know is try and use a more expensive, higher quality microbrushes rather than the cheap ones, because that might be more of an issue with the cheap ones. So just in case everyone starts to switch, make sure using a nice microbrush that’s going to be strong enough.

[Emma]
Okay, no, that makes sense. Yeah, I suppose you don’t want hairy composite.

[Jaz] Longevity
That’s right. And so I think all these things together are what reduce your post op sensitivity.

[Emma]
Okay. Okay. Perfect. Is that something that you would ever, I know you’re saying it doesn’t happen to you that much, but is that something that you would put in a consent form? Is it just something you generally mention at the end of an appointment? When do you address that?

[Jaz]
Every time. So there’s always a pre chat, right? There’s always like a debrief before we start the restoration. So usually I’ve got the photo of their tooth because at the checkup, I would have taken a photo of the tooth, showing the caries, showing the issue.

So I’ve got the photo on the big screen already as they walk in and I say, Mr. Smith, do you remember what we’re doing today? And usually my patients are like, I have no idea what you’re doing today. They don’t remember. They’ve got memories like fish. So they come in and say, have a look at his tooth, right?

I describe them. Can you see that there’s a bit of discoloration? There’s an issue over here. Oh yes. Yeah. Oh, now I remember. Yes. We’re doing a filling. So yes. And then I showed them the radiograph saying, okay, based on, the fact that you’re not in pain at the moment and you’re not having sensitivity and it’s not super close to the nerve, the chance of your nerve dying after this and needing something called a root canal is thankfully low.

It’s not zero, but it’s low. And then obviously I do the reverse and I really exaggerate it in terms of, okay, this decay is really close to your nerve. This is really bad news. We are doing CPR for the tooth here. We’re going to give it the best shot we can, but if the tooth dies, don’t worry.

There’s a solution. We can still help you. But here’s the things that we should watch out for afterwards kind of thing. And then I’ll remind him at the end as well that, okay, Mr. Smith is totally normal to have a bit of sensitivity to hot and cold for a couple of weeks. It will settle. The bite will feel a bit funny initially.

It will settle. Be careful not to bite your lip when you have food today. The usual stuff that you will always, always, always say. And so there was another podcast we did actually consent is like an onion. Right? Consent is like an onion. I don’t know if you listened to that one. And Sean said this amazing thing in terms of what patients remember from the appointment.

And what they remember is peak end. There’s two things that patients remember from any dental appointment is the peak, the highlight of the appointment. Was it a funny joke? Was it something bad that happened? Like they can remember the peak of that appointment and the end. So it’s really important to utilize the end and end on high to make sure that they remember and end with the most important bits.

[Emma]
Okay. Yeah, that’s helpful. Yeah. Save it all till the end. But that sort of overlaps with my next question talking about how do you assess, suppose predict the longevity of your adhesive restorations in your patients like are there specific maintenance or follow up protocols that you recommend just to make enhance the durability of your restorations over time?

[Jaz] Risk factors
That’s an interesting question in terms of, I think we’re coming to is that, okay, when we see the patients again, checkup after checkup, what should we be watching out for? Is there any way that we can intervene to help these patients get the most? I think there are a few things actually that we can talk about here, but let’s take a step back.

How long, when I’m placing a posterior composite, how long do I expect it to last? And I think this figure in my mind has changed a lot over the years as I’ve gained more experience and read more things. In terms of what you’ve been taught, I don’t know if you’ve been taught this or seen this in terms of the research or in terms of what the lecturers have taught you at dental school, how long should these fillings last?

[Emma]
I still don’t think I could tell you. I don’t think I could tell you to five years. I don’t know.

[Jaz]
And so let’s start with that. So some of the key literature that I was looking up for in preparation for this episode was a guy called Nick Opdam, who’s done lots of great work on longevity of restorations and composites and whatnot.

In fact, funny story, when I was a DCT, like one or two years out of dental school, there was this conference at King’s, and Nick Opdam was there. And I came up with him. And I was like you’re a total celeb. Can I get a selfie with you? And it must have been the first ever selfie a dentist has ever taken with him, right?

Because he was completely taken aback. He’s like, what? Someone wants a selfie with me? Like, how do you know who I am? My face is never on all these papers that I write. But I recognized, I saw his name and I saw the lecture. I was like, oh my God, this is Nick Opdam’s a legend, right? So I’ll see if I can dig out that photo.

Go to my Google photos from like 2014 and see if I can dig out this photo actually. So anyway, absolute legend. And I think 2007 he did this retrospective study where they looked at almost 3, 000 restorations done by two dentists and they followed it up. And I’m just going to see if I can get numbers. I don’t want to say anything wrong here in terms of their good work.

But it was 82 percent longevity. Okay, of composite at 10 years. Okay, so 82 percent at 10 years. And for amalgam, interestingly, it was 79%. Okay. And I think what counts as a failure is, caries, fracture, and sometimes with an amalgam, the tooth fractures rather than the amalgam, right? So that would be a failure.

And so 82 percent at 10 years, we can make what we can of it. But what are the things to consider was the annual failure rate of 1 to 3 percent is generally what’s said in the literature. So every year, 1 to 3 percent of composites will fail. But the most important thing I think to come to directly answer what you’re saying is when the restorations perform the worst, is patients with high caries risk and on cases whereby you had to do more than one surface, every additional surface that you had to do.

So if it’s just an occlusal, great. If it’s an MO, okay, still okay. If it’s an MOB, okay, that’s stretching If it’s an MOBL, right, it’s an MODBL, like the more surfaces that are involved in a composite, the more complex it becomes. Trying to get a good contact point. I don’t know if you’ve found this on your restorations. Have you done like class twos already?

[Emma]
We don’t actually, is that black’s classification? We don’t use Black’s classification.

[Jaz]
Really? My God, what do you use?

[Emma]
We don’t. Just whatever surfaces it is.

[Jaz]
MODO.

[Emma]
Yeah, yeah, yeah. We don’t use Black’s classification anymore.

[Jaz]
That’s mad.

[Emma]
I’m always Googling, when I’m editing your episodes, I’m always Googling what’s what.

[Jaz]
That’s alien to me, that’s crazy, I wouldn’t even expect that. Okay, fine. So, MO or DO, have you done the interproximal on posterior teeth?

[Emma]
I believe. Yes, yeah, I have, yeah.

[Jaz]
I think one day we can talk about matrix selection and that kind of stuff. I think that maybe would be really good, connecting the real world. But you probably have one or two matrices available in dental school to use for posterior, right? Do you know which ones and the names of them?

[Emma]
We’ve only got one, actually. What are they called? It begins with an O.

[Jaz]
Omni-Matrix.

[Emma]
Yeah, we’ve got Omni-Matrix, I think. Yeah, just the standard Omni-Matrix. And then your clear cellular strips and that’s about it really.

[Jaz]
When you’ve done your restorations, have you done some MOs or DOs yet?

[Emma]
I’ve done one.

[Jaz]
Okay.

[Emma]
All the others have actually been anteriors. So, yeah.

[Jaz]
Nice.

[Emma]
So no, just one.

[Jaz]
One thing that I would struggle with, even struggle now, I’m much better now and I’ve got some videos I even recorded yesterday actually, which I’ll upload to the portal of just getting a lovely tight contact and the way you can check for a tight contact, it’s not.

Yeah, it helps to floss and see, okay, how tight it is. But even more important is you try and bring the floss out. And does it click on the way out, right? Does the floss hang there? That’s a really good test to see if you’ve got a nice tight contact. And so as a dental student, we were using a siqveland , whatever you want to call it.

And we’re doing amalgams back then. And then, yeah, some composites. And I was really saddened by the contact points I was getting like floss was passing right through and I was like, Oh my God, the patient’s going to get food packing, recurrent caries and stuff. But, but what we know is that more important than our skill, more important than how well you do the restoration is the patient’s caries risk.

[Emma]
Yeah. Okay.

[Jaz]
So caries risk and the more surfaces involved. So the number one thing we can do for our patients to make sure that they get as long as possible from their restoration is trying to actively work on reducing their caries risk, right? So all the usual things, diet advice, be very meticulous with their oral hygiene, keep giving them the coaching that they need, fluoride application.

If you can do this, it will make the restoration last longer. The other thing is making sure the patient takes ownership of it. The patient needs to understand that, okay, I’ve done the restoration, but now the restoration belongs to you and you need to look after it. And I think that’s the most important thing.

Just to share some more studies, actually with, with Nick Opdam, he then also did a systematic review meta analysis. They only include studies that had five plus years follow up and there were eight authors, again, about 3000 restorations approximately. And the same thing, they found caries risk and how many surface were the most significant predictors of failure.

So once you’ve done the multiple surface composite, The only real way to improve your success rate in the future is upgrading that to an indirect restoration that covers the custom stuff, right? So that’s one way, certainly if you’ve pushed the boundaries, maybe because Emma, you might be at a scenario where you got deep caries and you don’t want to do a crown.

Because this tooth might need root canal. And so you might do what we call a posh core, right? You do a giant, ginormous composite and try your best. And we see, okay, at the one year mark, is the nerve still alive? Or is it, has it gone kaput? And if it’s still okay, you might then say, okay, there’s no pain, there’s no issues, but this composite is going to fracture.

It’s just too big. It’s not fit for purpose. We should now do an overlay or an onlay and that’ll be a good thing to do to reduce your fracture risk and to reduce your caries risk would be all the things that we talk about prevention back to that study, they found an annual failure rate. This most important thing, annual failure rate of 4.6% on people with high caries risk and 1.6% on patients with low risk. I mean, that is really, really a big, big, huge difference.

[Emma]
Okay. So there’s loads of different factors, but the main takeaway is I suppose you can do the most beautiful composite or restoration in the world, but if it’s got a higher caries risk then it might not last as long as someone that doesn’t. Okay. That makes sense.

[Jaz]
And if it’s bigger, you’re more likely to run into fractures and issues. And so the larger a restoration gets, the more the tendency to go towards something like an indirect restoration of crown, although there are other parameters, which I know we will be talking about one day as well.

The other thing to consider is. When would a composite fracture? And a composite would fracture is perhaps if it’s been placed quite thin. Thicker the composite is going to have more strength, right? And so maybe if you’ve not added enough thick bulk because you’ve tried being ultra conservative, you might then get that failure of a fracture.

Or, here’s an important one which I didn’t learn for a few years after dental school is when you look at your cavity, is everything nice and smooth on that floor, right? If there’s like, sharp, spiky bits of dentine sticking out, perhaps you removed an old amalgam, right? You removed an old amalgam, and there’s spiky bits of dentine.

Just get your rugby ball, red bur, and smooth that sharp bit away, right? Because when you’re putting your composite on, it likes this nice, smooth surface. It doesn’t want these sharpnesses, which leads to my final point, which is not evidence based, not evidence based in terms of outcome, but evidence based in terms of process, which is what burs we use on the teeth.

Any guidelines that you’ve been shown or decision making in terms of when you’re removing caries, when you’re treating a tooth, what kind of burs are you using? What kind of shape of burs are you using?

[Emma]
So I’d say upon our main restorative clinic, we’ve got all your usual burs, like your rounds, your fissure burs. I have seen burs out there working as a nurse that I’ve never seen in the dental hospital, which is fair enough, I suppose, but a lot of clinicians will have different opinions on what you should be using in certain situations, like I’ll be using a large round bur to do something and the clinician will come in and say, I really think you should be using a fissure bur. But I don’t think, I really don’t think I’ve had that much experience in terms of using loads of different types of burs. Just your standard ones really.

[Jaz]
The main takeaway here Emma is like, if you look at the shape of the bur, things that are round in nature, so pear shaped and round, are more favorable before composites than your sort of fissure burs or square, rectangular, tipped.

Because, if you imagine cutting tooth structure away with the rectangular one, the corner that it has, it actually causes these micro fractures in the teeth. And you get left with these sharp bits in the cavity. If you’re using a round bur, you’re less likely to have those sharp bits and things are allowed to be smoother.

So a little thing like that, basically, which again is more process driven than outcome driven. But these little things, and if you look at all the things that what can we do to make sure at the time of restoration, we reduce the failure rate? Well, I think again, going back to isolation. Nice, clean and rough.

So following the bonding protocol, reading the directions for you. So bringing together the entire episode that we’ve discussed so far and making sure you do get a nice contact. And we’ll talk more about contact points in the future. So make sure you get a nice contact so you don’t get food trapping there, right?

And you coach the patient so that whatever cause the caries, it doesn’t happen again. You lower the patient’s caries risk and make sure that when you are doing your restoration, it’s thick enough and it’s not on a bed of sharp dentine that everything is nice and smooth. And with these foundational things, we’re hoping to get beyond 80% at 10 years and that would be nice.

[Emma]
Yeah, yeah, perfect. That’s actually really, really hard for me to hear about the round fissure, because I’m a fissure bur kind of gal, so that’s hard for me to hear.

[Jaz]
Maybe higher up for, if you use a fissure bur on a fissure, it makes sense. If you’re using a fissure bur down with the contour area, it doesn’t make sense to me.

[Emma]
Yeah. Okay. No, that’s perfect. That’s fine. Lots of good tips and tricks in there, Jaz.

[Jaz]
What’s the number one thing, Emma, that you think you’re going to change about and the change is harsh because you’re so new to it all, right? I would just love to know, what’s your big takeaway from our chat today on the really good questions that you come up with? What’s your big takeaway?

[Emma]
I suppose to take away today is just know what you’re using, what prime and bond am I using? I don’t know. So know what you’re using, know how to use it. Look at the manufacturer’s instructions. But yeah, just knowing what you’re using, how to use it, don’t just stick with what you’ve had forever and use the same techniques for everything, because all the materials are different for a different reason. So yeah, know what you’re using and know how to use it.

[Jaz]
Perfect. And so next recording, we’re going to find out which bond, do you think you’ll find out by then, right?

[Emma]
Yeah.

[Jaz]
Which bond you’re using, and then we’ll dig up the DFUs together and we’ll have a look at what does this particular bond say? And so just to whet everyone’s appetite for next month’s episode with Emma, we’re going to be talking about documentation. And so I know photography and videography is not something that you really get to do as much at dental school. But some things that we can talk about, maybe like documentation. What are the things that we’re looking for? How do we do a routine checkup? What do you think that would be useful when you’re actually doing checkups? What are we actually checking for? Would that be helpful?

[Emma]
Absolutely, like, one of the things that I found very hard at the beginning of third year, how do I do a checkup? And it’s easy enough learning about it in a lecture, you do this, this and this. But what does that actually look like with a patient and, okay, I’ve done this, I’m going to do this now. Like, how do you actually communicate that with a patient? And, yeah, like, just your steps and I know you find your own little way to do it in your own sequence. But how do you do a checkup like that was one of my huge questions and it seems so silly like it’s one of the basic things.

[Jaz]
It’s not silly. I remember Emma. I remember having this exact same thought like I remember being like a third or fourth year student and the tutor coming and is doing the checkup and I was really trying hard to watch exactly how they hold the mirror, exactly how they’re holding three in one and what they’re trying, what are they actually looking at?

How are they so quick? I was like, how are they just so quick and looking around? Like why am I taking like five minutes per tooth? So I’m super excited now to talk about my checkup protocol. And the lesson I can give you now, even before we record that is there’s a book out there and it’s called The Art and Science of Treatment Planning.

I haven’t read it. I don’t know if it’s any good, but it is the art. And the science. So what I mean by that is that my checkup will be different to the other hundred of checkups that you’ve seen with a hundred other dentists. And have you ever seen a routine examination that’s exactly identical between two clinicians?

[Emma]
No, never, never. It’s always a wee bit, it’s always a wee bit different.

[Jaz]
Well, then I think it’d be really good to, for me to share. So as part of documentation month, we’ll share my checkup, but also I’d like to know about some quirks or some things that you’ve noticed with some dentists that you’ve worked with, and then we’ll get everyone on the comment section to chip in.

I think this would make a really educational thing. I might pick up a few things that some colleagues are doing that I’m not doing at the moment and vice versa. So I think spontaneously we’ve decided our next topic quite nicely.

[Emma]
Yeah, perfect. No, I’m excited. I’m really excited for it and just getting more and more. I’m like a sponge at the minute, just taking in all the time.

[Jaz]
Never lose that, Emma. Never, ever lose that about you. It’s so, so important to have that enthusiasm and be like a sponge throughout your career. It will serve you well, serve me well so far. I’m still a sponge and I think not to insult the Protruserati, but we are sponges. We’re all sponges. Not spongers, but sponges. All right, Emma, thank you so much. I’ll see you next time.

[Emma]
Thank you so much.

Jaz’s Outro:
Well, there we have it, guys. Our first proper Protrusive Students episode. Thank you so much, Emma. You’ve got those revision notes promised in the crush your exam section of the Protrusive Guidance app.

Once again, you want to head to protrusive.App, the website, make your account, make a free account. And then email student@protrusive.co.Uk with your proof that you’re a student and try to join with your own personal email address. So even after you’re done with being a student, like I know we’re students forever.

I get that. But once you’re no longer at dental school, you want to have an email address so you can continue to engage on Protrusive Guidance. Once you do that, the team will invite you to the protrusive vault. And of course you get access to the crush your exam section and the student clinical videos. And lastly, we will see you on our own student forum.

So I’m excited to see the growth of Protrusive students. I’d love to see where everyone’s from, right? All I envisage dental students from all around the world. Remember some years ago when I was still early in podcasting, this German dental student, I bless her, I forgot her name now, but she reached out and she said that yours is my favorite English dental podcast.

And I don’t know if she’s qualified or not yet, but those kinds of interactions wherever you’re from in the world. It’d be great to have you on Protrusive Guidance. And I hope you gain from this. I hope you really, really gain from everything we’re doing with Protrusive Students, and I would love for you to hit the like button or comment below if you’re finding this helpful.

We’ll catch you same time next month for every monthly episode of Protrusive Student, but of course, there’s so many protrusive episodes you can listen to in the meantime. Bye for now.