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What are the Benefits of Pre procedural mouth rinsing?
Bond Or not to Bond Amalgam
Giomers are a relatively new type of
restorative material. The name "giomer" is a hybrid of the words
"glass ionomer" and "composite", which pretty well describes
what a giomer is claimed to be. Although glass-ionomer restorative materials
such as Ketac-Fil (3M ESPE) and Fuji Type II (GC America) have some very
important properties, such as fluoride release, fluoride rechargeability, and
chemical bonding to tooth structure, they also have well-known shortcomings.
Their esthetics, for example, are less than ideal and make them a poor second
choice to resin composites for restoring esthetically-demanding areas. Also,
they are sensitive to moisture contamination and desiccation, which can present
the clinician with challenges during their placement. In the 1990s manufacturers
improved these shortcomings by adding resins to glass ionomers to produce
resin-modified glass ionomers. These products (e.g., Fuji II LC, GC America;
Vitremer, 3M ESPE; Photac-Fil Quick, 3M ESPE) have much better esthetics and
handling characteristics than glass ionomers. Importantly, they also retain many
of the glass ionomer's beneficial properties, such as long-term fluoride release
and the ability to be recharged with topically-applied fluoride. They tend,
however, to discolor over time. In another attempt to "better" the
glass ionomer restorative materials, compomers were also developed. They were
touted as being similar to glass ionomers but having much better esthetics and
being easier to place and polish. Unfortunately, some of the manufacturer's
claims were not confirmed by published research. Although they handled better
than GICs, they released much less fluoride and could not be recharged.
In the continuing quest for improved
glass ionomer-like restoratives, manufacturers have developed and introduced a
new class of materials called "giomers." As noted earlier, the term
implies they are combinations of glass ionomers and composites. Their
manufacturers claim they have properties of both glass ionomers (fluoride
release, fluoride recharge) and resin composites (excellent esthetics, easy
polishability, biocompatibility). Giomers are distinguished by the fact that,
while they are resin-based, they contain pre-reacted glass-ionomer (PRG)
particles. The particles are made of fluorosilicate glass that has been reacted
with polyacrylic acid prior to being incorporated into the resin. The
pre-reaction can involve only the surface of the glass particles (called surface
pre-reacted glass ionomer or S-PRG) or almost the entire particle (termed fully
pre-reacted glass ionomer or F-PRG). Giomers are similar to compomers and resin
composites in being light activated and requiring the use of a bonding agent to
adhere to tooth structure. Only one giomer is commercially available at the time
of this writing, Shofu's Beautiful, (see at right) which uses the S-PRG
technology. According to Shofu, Beautiful is indicated for restoring Class I
through V lesions as well as for treating cervical erosion lesions and root
caries. It is available in 13 shades and is supplied in syringes.
Little published research is available on the
properties or performance of giomers. One recently published study compared the
fluoride release of a glass ionomer, a resin-modified glass ionomer, a giomer,
and a compomer. It found that while the giomer released fluoride, it did not
have an initial "burst" type of release like glass ionomers, and its
long-term (i.e., 28-day) release was lower than that of the other materials.1
Another study found that a giomer, after polishing with Sof-Lex disks, had a
smoother surface than a glass ionomer, and one that was comparable to that of a
compomer and a resin composite.2 A three-year clinical study
comparing the performance of a giomer with that of a microfill resin composite
in Class V erosion/abrasion/abfraction lesions has also been done. After
measuring eight performance characteristics, no significant differences between
the two materials were found.3
Almost assuredly, many other giomer products
will become available in the future.
1. Yap AUJ, Tham SY, Zhu LY, Lee HK. Short-term fluoride release from various
aesthetic restorative materials. Oper Dent 2002;27:259-265.
2. Yap AUJ, Mok BYY. Surface finish of a new hybrid aesthetic restorative
material. Oper Dent 2002;27:161-166.
3. Matis BA, Cochran MA, Carlson TJ, Eckert GJ, Kulapongs KJ. Giomer composite
and microfilled composite in clinical double blind study [Abstract]. J Dent Res
are the Benefits of Pre procedural mouth rinsing?
Pre-procedural mouth rinsing is the use of an
antimicrobial mouth rinse by the patient before a dental procedure. Its
objective is to reduce the number of oral microorganisms that may be released as
an aerosol or spatter from a patient's mouth during dental care that
subsequently contaminate equipment, operatory surfaces, and dental healthcare
A visible spray is created during the use of
rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers)
and air-water syringes. This spray contains, primarily, large-particle spatter
of water, saliva, blood, microorganisms, and other debris. Spatter travels only
a short distance and settles out quickly, landing either on the floor, nearby
equipment and operatory surfaces, the dental healthcare personnel providing
care, or the patient. The spray may also contain some aerosol. Aerosols take
considerable energy to generate, consist of particles less than 10 microns in
diameter, and are not typically visible to the naked eye. Aerosols can remain
airborne for extended periods of time and may be inhaled; they should not be
confused with the large-particle spatter that makes up the bulk of the spray
from handpieces and ultrasonic scalers. Appropriate use of dental dams,
high-velocity air evacuation, and proper patient positioning should minimize the
formation of droplets, spatter, and aerosols during patient treatment.
To date, no scientific evidence supports the
claim that pre-procedural mouth rinsing actually prevents disease transmission
in the dental operatory, but studies have shown that a pre-procedural rinse with
a product containing an antimicrobial agent (e.g., chlorhexidine gluconate,
essential oils, povidone iodine) can reduce the level of oral microorganisms
generated when performing routine dental procedures with rotary instruments.
Pre-procedural mouth rinses may be most beneficial before a prophylaxis using a
prophylaxis cup or ultrasonic scaler since rubber dams cannot be used to
minimize aerosol and spatter generation, and unless the provider has an
assistant, high-volume evacuation is not commonly used.
Bond Or not to Bond Amalgam
Multiple laboratory studies have found
definite advantages for bonded amalgam restorations including increased
retention,1 fracture resistance,2,3 and marginal seal.4
Staninec found that the use of adhesives provided greater retention than grooves
or dovetails.1 Oliveira and others found improved fracture resistance
in large MOD preparations when bonding amalgam compared to the use of Copalite
alone.2 A study by Burgess and others found no difference in the
strength of complex amalgam restorations using four TMS pins or bonding, but the
combination of the two significantly increased the forces necessary for
fracture.3 Studies have also shown increased retention of amalgam
when bonding with resins containing filler particles.5 The more
viscous bonding agent may improve penetration into the amalgam during
condensation.6 Also, research has shown a reinforcement of remaining
tooth structure with bonded amalgam restorations.7 However, the
ability to maintain this reinforcement over time remains equivocal with some
studies showing no increase in fracture resistance after aging and
thermocycling.8,9 The use of an adhesive agent under amalgam has been
shown in laboratory studies to decrease microleakage.4 Again, the
long-term significance of this decrease is unknown.
Most of the clinical studies have found no
decrease in post-operative sensitivity10,11 and no difference in the
performance of bonded amalgam restorations compared with traditional
mechanically-retained restorations.6,12 Contrary to popular belief,
the preponderance of clinical investigations has demonstrated no difference in
sensitivity reported by patients receiving amalgam restorations with or without
resin adhesives.10,11 Summitt and others published a clinical study
comparing the performance of bonded versus pin-retained complex amalgam
restorations and found no difference after five years between the two
techniques. They concluded that bonding with a filled bonding resin (Amalgabond
Plus, Parkell Inc., Farmingdale, NY) was a satisfactory method of retaining
large amalgam restorations replacing entire cusps.6 So, should you
place an adhesive agent under all of your amalgam restorations? Given the added
cost, time and technique sensitivity of using adhesive liners, there appears to
be no clinically-demonstrated benefit in bonding conventional preparations which
contain customary retentive features.13 However, given the advantages
of increased retention, strength and marginal seal found in laboratory studies,
the bonding of amalgam may be justified adjunctively with traditional mechanical
retention in large restorations replacing a cusp, when tooth structure may need
some reinforcement, and for crown foundations.13
1. Staninec M. Retention of amalgam restorations: undercuts versus bonding.
Quintessence Int 1989;20:347-351.
2. Oliveira JP, Cochran MA, Moore BK. Influence of bonded amalgam restorations
on the fracture strength of teeth. Oper Dent 1996;21:110-115.
3. Burgess JO, Alvarez A, Summitt JB. Fracture resistance of complex amalgam
restorations. Oper Dent 1997;22:128-132.
4. Meiers JC, Turner EW. Microleakage of dentin/amalgam alloy bonding agents:
results after 1 year. Oper Dent 1998;23:30-35.
5. Diefenderfer KE, Reinhardt JW. Shear bond strengths of 10 adhesive
resin/amalgam combinations. Oper Dent 1997;22:50-56.
6. Summitt JB, Burgess JO, Berry TG, Robbins JW, Osborne JW, Haveman CW. The
performance of bonded vs. pin-retained complex amalgam restorations: a five-year
clinical evaluation. J Am Dent Assoc 2001;132:923-931.
7. el-Badrawy WA. Cuspal deflection of maxillary premolars restored with bonded
amalgam. Oper Dent 1999;24:337-343.
8. Santos AC, Meiers JC. Fracture resistance of premolars with MOD amalgam
restorations lined with Amalgabond. Oper Dent 1994;19:2-6.
9. Bonilla E, White SN. Fatigue of resin-bonded amalgam restorations. Oper Dent
10. Mahler DB, Engle JH, Simms LE, Terkla LG. One-year clinical evaluation of
bonded amalgam restorations. J Am Dent Assoc 1996;127:345-349.
11. Smales RJ, Wetherell JD. Review of bonded amalgam restorations and
assessment in general practice over 5 years. Oper Dent 2000;25:374-381.
12. Browning WD, Johnson WW, Gregory PN. Clinical performance of bonded amalgam
restorations at 42 months. J Am Dent Assoc 2000;131:607-611.
13. Setcos JC, Staninec M, Wilson NHF. Bonding of amalgam restorations: existing
knowledge and future prospects. Oper Dent 2000;25:121-129.
It has become popular to routinely place a
flowable composite (e.g., Filtek Flow, Flow-It ALC, Tetric Flow, Revolution
Formula 2) on the pulpal floor and axial wall of a Class II preparation prior to
restoring the tooth with a packable resin composite (e.g., Pyramid, SureFil,
Solitaire 2, Prodigy Condensable).1 In fact, some manufacturers of
packable and flowable composites include recommendations in their instructions
to do so. Clinicians usually place a flowable liner because it reduces the bulk
of packable composite that has to be placed. This makes it easier and less time
consuming to restore the tooth. Others believe it helps reduce leakage at the
tooth/resin interface because the liner is flexible and absorbs some of the
packable composite's shrinkage as it cures. This, at least theoretically, may
result in a better bond between the resin and tooth with little or no gap being
formed. There is some evidence supporting this theory.2,3 Finally,
some users place a flowable because it contains fluoride, and they believe that
the fluoride release will have a anti-cariogenic effect.
If you routinely place a flowable composite
as a liner before restoring a tooth with a resin composite, be it a microhybrid
or packable, you should be aware of some precautions to take. First, the
flowables are essentially "thinned down" composite resins, which
accounts for their appealing characteristic of easy placement. The thinning down
process is accomplished, at least in part, by incorporating fewer filler
particles into the resin. As a result, physical properties such as strength and
resistance to fracture are lower. So we should be mindful of the need to place a
flowable in a relatively thin layer. Also, a study published a few years ago
found that a number of then currently-available flowable composites lacked a
sufficient degree of radiopacity.4 This means that on radiograph the
flowable would appear as a thin, radiolucent line extending from the margin to
the axial wall. Without a well-documented record, a clinician could misinterpret
this as caries, possibly secondary to microleakage. Unfortunately, cases have
been reported where the otherwise acceptable resin composite restoration has
been removed only to find that the radiolucent "line" was a non-radiopaque
Perhaps the best reason for using a flowable
resin as a liner beneath a packable composite is to make it easier to pack the
composite into the preparation. Packables are thick, and it can be difficult to
place them in a preparation (especially one that is irregular with undercuts)
without producing voids. By placing a flowable resin liner into areas of the
preparation that are difficult to access, the potential for producing voids is
The bottom line is not that we shouldn't use
flowable resins as liners, but that we need to be aware of their limitations, so
that we choose the right flowable product and use it sparingly so that its
lesser physical properties do not compromise the clinical success of the
packable resin restoration.
1. Fortin D, Vargas M. The spectrum of composites: new materials and techniques.
J Am Dent Assoc 2000;131:26S-30S.
2. Payne JH IV. The marginal seal of Class II restorations: flowable composite
resin compared to injectable glass ionomer. J Clin Pediatr Dent 1999;23:123-130.
3. Ferdianakis K. Microleakage reduction from newer esthetic restorative
materials in permanent molars. J Clin Pediatr Dent 1998;22:221-229.
4. Murchison DF, Charlton DG, Moore WS. Comparative radiopacity of flowable
resin composites. Quintessence Int 1999;30:179-184.
Shade selection and Management
Obstructive Sleep Apnea- Do you know about it?
Genetically modified bacteria may prevent cavities - Put you out of Business?
Fiber Reinforced composites
A primer on all composite class materials
Immediate and Early loading of Implants
Treatment of Fluorosis Stains
Emergency in a Dental Clinic
Preparation of Root Canal
Placement of gingival restorative margins
Bonding for the New Millennium
Nanodentistry- the Future
Access Cavity Preparation
Access Cavity Preparation - Molars
Selection of Analgesics
Fifth generation bonding
About whitening agents
Caries disclosing agents
LED curing lights
Recurrent Aphthous Stomatitis
New cavity-fighting agent shows promise
Tooth Loss Linked to Pancreatic Cancer in Smokers
2-min brush helps achieve cleaner teeth: Study
Snoring can kill
Gum disease raises death risk in diabetics: study
Brushing Right After Drinking Soda may Harm Teeth
What are Giomers
Benefits of Pre-procedural mouth rinsing?
To Bond Or not to Bond Amalgam
Restoration of endodontic teeth
Options for esthetic restorations
Oral Prophylaxis made Easy
Teeth Whitening Facts and Myths
Fiber reinforced composites in dentistry
Changing concepts in Class I and II cavity preparation
Curing lights for composite resins
Preventing dental diseases
Caries Prevention in Children - The Indian Challenge
Mouth Rinsing before dental procedures.
Aids and Dentistry
Dental Journals by Subject
Class II Composite Restorations
Rotary Endodontic Instrumentation
Mineral Trioxide Aggregate
Direct & Indirect Esthetic Adhesive Restorative Materials
Early and Immediate Loading of Implants
Lasers in Root canal treatment and Endodontics
Abfractions? How they are important in Restorative Dentistry
Latest Research On Dental Pain