1. RSD 810/814 2016 Spring Last Session- Wrapping Up C. Rodriguez D.M.D. Summit Sturdevant's

2. Composite Advantages: esthetics conservative to tooth structure less complex preparation insulating; having low thermal conductivity universal usage good retention due to bonding, relatively low microleakage, minimal interfacial staining, increased strength of remaining tooth repairable

3. Composite Disadvantages: may have gap formation due to polymerization shrinkage more difficult, time-consuming, and costly to place more technique-sensitive due to need for isolation and proper technique in etch, prime, and bond may exhibit greater occlusal wear higher linear coefficient of thermal expansion resulting in potential marginal percolation if bonding technique is poor

4. Composite Clinical indications: Class I, II, III, IV, V, and VI restorations Foundations or core buildups sealants and PRR esthetic enhancement procedures: partial veneers full veneers tooth contour modifications diastema closures cements temporary restorations periodontal splinting

5. Composite Clinical contraindications: inability to isolate patients with heavy occlusion, bruxism restoration must provide all of tooth’s occlusal contact extension of restoration onto root surface

6. Clinical indication comparison of the two most commonly used restorative operative materials: AmalgamComposite Heavy occlusionMinor occlusion Root surfaceEsthetic area Unable to isolateIsolate able Easyto fill, hard to prepEasy to prep, hard to fill CheapSolvent patient

7. The primary objective of operative dentistry is to repair the damage from dental caries or trauma while preserving the vitality of the pulp. The pulp should not be subjected to unnecessary abuse from poor or careless operative procedures. Isolation to prevent contamination The use of water-coolant is critical

8. In order to better understand restorative operative procedures, let us recall the caries process and discuss everyday treatment modalities.

9. Necrotic dentin is recognized clinically as a wet, mushy, easily removable mass. This material is structureless or granular in histologic appearance and contains masses of bacteria. Removal of this material uncovers deeper infected dentin (turbid dentin), which appears dry and leathery. Leathery dentin is easily removed by hand instruments and flakes off in layers parallel to the DEJ.

10. What you can leave Even when the lesion is limited to enamel, the pulp can be shown to respond with inflammatory cells Dentin responds to the stimulus of its first caries demineralization episode by deposition of crystalline material in the lumen of the tubules and the intertubular dentin of affected dentin in front of the advancing infected dentin portion of the lesion. It is softer than normal dentin.

11. What you cannot leave

12. Dentin that has more mineral content than normal dentin is termed sclerotic dentin. Sclerotic dentin formation occurs ahead of the demineralization front of a slowly advancing lesion and may be seen under an old restoration. It is usually shiny and darker in color but feels hard to the explorer tip. When sclerotic dentin is encountered, it represents the ideal final excavation depth because it is a natural barrier that blocks the penetration of toxins and acids. *By contrast, normal, freshly cut dentin lacks a shiny, reflective surface and allows some penetration from a sharp explorer tip.

13. In addition to the assault suffered from bacterial caries invasion, the pulp may be irritated during or after operative procedures by: heat generated by rotary instruments some ingredients of various materials thermal changes conducted through restorative materials forces transmitted through materials to dentin galvanic shock ingress of noxious products and bacteria through microleakage Liners or bases are used to protect the pulp or to aid in pulpal recovery or both.

14. Cavity Sealers Provide a protective coating on freshly cut tooth structure (i.e. seals the dentinal tubules) and is measured in microns (µm) In years past Copalite Varnish was used under amalgam. Currently UKCD recommends the use of Gluma to seal tubules when a shallow amalgam restoration is planned. It may also be utilized for some desensitizing procedures.

15. Fig 5-1a Bacteria will penetrate the marginal gap and dentinal tubules from the saliva, which may cause pulpal irritation, pulpal necrosis, or recurrent caries. Fig 5-1b If a restoration is not well sealed, fluid flows out of the dentinal tubules and into the space between the restorative material and the tooth surface (arrows). A stimulus such as heat or cold causes a change in the flow rate, which is interpreted by mechanoreceptors as pain. Rationale for the use of a dentinal disinfectant/sealer like Gluma. The thickness of sealers is measured in microns.

17. Amalgambond is the bonding method of choice under amalgam when isolation is possible. It is not required. It should not be used instead of conventional resistance and retention forms.

18. Liners normal thickness <.5 mm Initial electrical insulation Some thermal protection May provide fluoride release Can adhere to tooth structure May be antibacterial in promoting pulpal health

19. CaOH Auto-cure Light-cured Problems with Dycal: It degrades over time creating a “trampoline effect” Traditional CaOH liners may continue to dissolve over time (due to microleakage or dentinal fluid present) and can lose as much as 10-30 % of their original volume Light-cured CaOH (i.e. VLC Dycal) has overcome some of these weaknesses but is not as effective in releasing ingredients. Liners:

20. Place a glass ionomer liner such as Vitrebond or Fuji Lining LC over Dycal. Why? Compressive strength of Dycal is very poor, allows for condensation of amalgam. Glass ionomer liner will seal the margins around the Dycal allowing for acid etching under composite. Liner or Base (how thick is it, is it over Dycal?)

21. Glass Ionomers* Two types: conventional (GI) and light-cured (RMGI) Two outstanding characteristics of all glass ionomers  Fluoride release Anti-cariogenicity Mechanism: initial low pH, chemical bonding and the release of the metal cation fluoride  Adhesion to enamel and dentin Reduces microleakage (physical exclusion) Eliminates the need for dentin bonding agents Base: Normal thickness >.5mm * May be used in thin layer as a liner

22. Sealers- microns Liners- <0.5mm Bases- >0.5mm

23. Appropriate use of sealers, liners, and bases under amalgam and composite

24. In an indirect pulp capping procedure, all carious, demineralized dentin is removed in the periphery of the preparation (DEJ), but a small amount of demineralized dentin is left immediately over the area of the pulp(to within 1mm). If a pulp exposure is suspected, a calcium hydroxide (Dycal) lining material is placed to cover the remaining demineralized dentin. A sealing liner (RMGI) and/or a sealing restoration is then placed to seal out bacteria and their by-products. If no exposure is suspected, omit the CaOH.

25. For a direct pulp capping procedure, a calcium hydroxide lining material is placed on the exposed pulpal tissue and a small amount of surrounding dentin. A sealing liner and/or a sealing restoration is then placed to seal out bacteria and their by- products. This procedure is not indicated for carious exposures.

26. Clinical Scenarios

27. Excavation of existing occlusal amalgams reveals dentin that is discolored and hard. What would your next step be if you were restoring with amalgam? Composite?

28. Excavation of existing occlusal amalgams reveals dentin that is discolored and hard. No more excavation needed What would your next step be if you were restoring with amalgam? Gluma, then amalgam Composite? Etch, prime, bond, then incremental fill

29. This patient presents complaining of cold sensitivity and biting stress sensitivity on the right side of her mouth. Clinical exam reveals a broken amalgam restoration on # 31. Pulp testing is normal. What would you do next?

30. This patient presents complaining of cold sensitivity and biting stress sensitivity on the right side of her mouth. Clinical exam reveals a broken amalgam restoration on # 31, leaking margins#30. Pulp testing is normal for both. What would you do next? Excavate until all of the leathery dentin has been removed, especially from around the DEJ. Assess proximity to the pulp. Fill #30. Place RMGI, and amalgam or composite or a temporary restoration#31. Inform the patient of the need for more definitive treatment on #31.

31. This patient presents with continual pain of three days duration in his upper right jaw. Clinical visual exam reveals little, however radiographic exam reveals a large mesial lesion on #3. The patient states that he “just wants the tooth removed”. Pulp testing is positive for irreversible pulpitis. If you were to excavate you might find “D”.

32. This MOD preparation appears to expose slowly progressing caries evidenced by the darkly stained but hard dentin. What chief concern or clinical findings would have likely preceded this excavation?

33. Excessive abrasion has resulted in the exposure of the pulp of #6, deep lesion #7. The patient presents with symptoms consistent with irreversible pulpitis. Your clinical pulp testing results in a diagnosis of irreversible pulpitis #6, reversible pulpitis #7. What would your treatment plan include?

34. Your patient had a periodic oral evaluation at her last appointment with you. She has been treatment planned for an OL restoration on #18, and is ready for that procedure today. Judging from the radiograph you are prepared for a deep excavation and have CaOH, RMGI and amalgam ready. What’s wrong with this picture?

35. Carious tooth asymptomatic ( no indication of pulpal pathology ) symptomatic Short duration Long duration spontaneous endodontics extraction CaOH pulp cap, Temporary fill for 3 mo. CaOH pulp cap, RMGI, permanent fill Do not crown CaOH direct pulp cap GI or RMGI, Fill & observe????? For amal.: RMGI if deep. Gluma if shallow. For comp.: etch, prime, bond, RMGI if deep N.V. Pulp testing N.V. Pulp testing Excavate & pulpotomy or ectomy Excavate and fill V. Pulp testing N.V. Pulp testing By C. Rodriguez D.M.D. N.V. Pulp testing endodontics extraction

36. In the end there is rest…