HOW TO PROFIT FROM...adhesives – The wonderful world of adhesive dentistry

July 1, 2003
The wonderful world of adhesive dentistry enables the contemporary dental professional to accomplish tasks which were thought to be very difficult, if not impossible, just a few short years ago.

Christopher Pescatore, DMD

The wonderful world of adhesive dentistry enables the contemporary dental professional to accomplish tasks which were thought to be very difficult, if not impossible, just a few short years ago. Adhesive dentistry has not only changed the way we think about our profession, it has — more importantly — changed the way our patients think about dentistry and about us.

In this article, I would like to share my experiences with adhesive dentistry and how it has not only changed the procedures I perform in my practice, but everything about the way I practice dentistry.

Ever since I placed my first full-coverage porcelain-fused-to-metal (PFM) restoration, I have longed for the opportunity to place something that looked like God had created it. Unfortunately, I never quite got that feeling when placing PFM and amalgam restorations. Then, one day, while reading through a dental journal, I saw an ad for a videotape about tooth-colored restorations and how beneficial they were for our patients. Intrigued, I ordered the videotape and was mesmerized by this different approach to dentistry. What I also realized as I watched this fascinating tape was that adhesive dentistry was at the core of these types of restorations. In fact, for me, adhesive dentistry was the new specialty in dentistry. I was excited and enthusiastic about going to work the next day so I could offer these restorations to my patients.

From that day on, I began my quest for the truly aesthetic-based practice where I could do the type of dentistry I had always wanted to do ... dentistry that let me use my hands and my heart and that spurred my creative desires. Now, sometime later, I have accomplished what I set out to do and I have adhesive dentistry to thank for it.

When I had a general practice with a large staff (approximately 10 employees), people came to me out of pain and need. Now, I have only two staff members and my practice is focused solely on aesthetic dentistry. My patients come to me out of need and want. This is a big difference — especially since people spend more for things they want, rather than what they need. For instance, how many times has one of your patients said, "Hey doc, that silver-amalgam filling looks great! Can you do some more?" My guess is rarely.

However, in an adhesive-based, aesthetic practice, it is very common for a patient to say, "That tooth-colored filling looks great! I can't even tell where it is. Maybe we should take care of those other teeth!" Or, even better, the patient might say, "Wow, doc, my upper teeth look so great after you placed those veneers that I'm going to have to do my lowers now." I also found that I wasn't doing "single-tooth dentistry" anymore, but true comprehensive procedures and treatment plans. As a result, insurance became less and less of an obstacle because people spend money for what they want (and need).

In focusing totally on adhesive restorations, techniques, and protocols, patients were charged (and paid) my higher fees, and justifiably so. In doing adhesive dentistry, I am not only functionally restoring a tooth, but I am doing it in the most naturally aesthetic way possible. It is obvious to the patient that I am not just stuffing a material into their tooth to "fill" it; rather, I am creating a tooth! When teeth are prepared for veneers and the provisionals look as good as many porcelain restorations, patients understand why I charge more. When the anterior porcelain restorations rejuvenate their smiles and change their self-perception for the better, they more readily accept our higher fee scale and think of us as a "state-of-the-art" dental office.

I constantly feel energized about what I do now that I have focused my practice on adhesive dentistry. I no longer have to run from room to room to see patients. I can spend more time with each patient and build valuable relationships, something I could never do in a larger practice setting. A typical day for me is seeing anywhere from one to six patients, depending on the procedures that I'm performing. I usually work a four-day week from 8:30 a.m. to 4:45 p.m., with a one-hour lunch break.

Why do adhesive dentistry?

When you change what you think you are worth, dentistry is no longer a game of quantity, but a professional service dedicated to quality. Spending uninterrupted time with my patients is what I have to offer above all else, because our patients' time is valuable, too. The bottom line: I work less, make more money, spend more time with my family, and consider my patients friends. What more could I ask for?

So why don't more dentists offer adhesive procedures? Years ago, it was understandable why dentists did not want to deal with the techniques of adhesion. After all, we not only had to become "bondodontists" and have a chemistry degree, but we also had to have a lab for testing purposes. This is not the case today. Materials and techniques have changed so much — and will probably continue to do so — that anyone can perform these adhesive procedures with a high degree of success. Manufacturers also understand the need for simplicity and versatility, and today's adhesive products reflect that implicitly.

To understand why adhesive dentistry should be embraced, you need to understand why it might not be today. Most dentists don't perform adhesive procedures for three key reasons:

1 Sensitivity problems
2 Takes too long to do
3 Insurance reimbursement

Those are all valid issues, but they are not as applicable today as they were in the past. Years ago, sensitivity was a much more common problem than today. The lack of research was probably the key reason for this, because if we are not sure of the proper technique, protocol, and application, how can the manufacturers improve their adhesives? Time itself has led to a better understanding and improved product performance, and general evolution has created today's superior materials. At about the same time, we began to understand why we were having sensitivity issues. In the beginning, sensitivity probably was due to a combination of over-etching and overdrying the dentin. We treated dentin like enamel. Today, we know treating dentin like enamel is a big "no-no." Enamel is a very hard, primarily inorganic substance. Etch, dry, apply bonding resin, cure, and bond to it. Dentin is primarily organic, which means it is mainly composed of collagen and water. It also has direct communication to the pulp. Most of today's adhesives use an etch to demineralize the dentin and remove the smear layer, creating an unsupported framework of collagen fibers. These fibers must remain moist to prevent collapsing, so the applied adhesive will saturate the framework to form a micro-mechanical bond ... very similar to what we see in enamel. The resulting resin-reinforced dentin structure is commonly referred to as the "hybrid layer." With the advent of self-etching systems, this process is even more streamlined.

The view that an adhesive procedure takes longer is both true and false. I think any "newer" procedure will take longer to do, but in a relatively short period, the time it takes to do an adhesive procedure becomes inconsequential. Along these same lines is the "burden" of using a rubber dam for isolation. I disliked using a rubber dam in dental school, yet I have learned to embrace its use in everyday practice. Sure, you can get away with not using a rubber dam for adhesive procedures; you also can get away with running a "stop sign" while driving! But sooner or later, you will either get a ticket or cause an accident if you regularly run stop signs, and sooner or later, you will have problems with aesthetic procedures if you don't use a rubber dam. So why take the chance? It takes longer and costs more to redo a restoration than it does to do it right the first time.

Getting insurance reimbursement for adhesive restorations is becoming easier because time is proving their worth and longevity. Rarely is it considered just a "cosmetic" restoration, especially in the posterior area. These inlays, onlays, and veneers provide alternatives to traditional full-coverage (porcelain-fused-to-metal) restorations, which more and more insurance companies are covering. There also are a number of narratives you can use, many of which I learned from Dr. William Dickerson, founder of the Las Vegas Institute for Advanced Dental Studies. But don't lose sight of the bigger picture here: Dentistry should never be about what the insurance company will cover; it should be about the best restoration for that tooth and that client's mouth. It is about what you would want in your own mouth. It is rare when a client won't pay for the extra expense for a more conservative, aesthetic restoration. The real problem is usually the doctor's lack of confidence in offering it. I know — I've been there!

Clinical applications

Now that we have addressed some of the major issues practitioners have with adhesives, let's delve into clinical applications and how it has changed the way I practice dentistry. My favorite thing about adhesives is that they encourage me to "think outside the box." Adhesives allow me to challenge myself to restore teeth both conservatively and aesthetically. They make me think with my brain and create with my heart.

Direct restorative procedures utilize only composite-resin materials in the posterior, as well as the anterior. Incipient lesions can be addressed at a stage where the tooth is less likely to be structurally compromised. When amalgam restorations have to be replaced, direct-posterior resin restorations allow the tooth to regain most of the strength that was lost when the alloy was placed, not to mention its aesthetic value. This is where art meets science and anatomy is created as the restoration is placed. I find this extremely rewarding and my clients appreciate the attention to detail. For larger lesions or existing restorations, a laboratory-fabricated resin or porcelain restoration allows the patient to have the maximum amount of tooth structure saved, while receiving one of the most aesthetic restorations possible. I believe so much in the efficacy of these types of restorations that I have had all of my own alloys removed and replaced with ceramic and resin restorations.

Adhesive materials also allow us to perform, when applicable, direct pulp caps. This is a huge practice- builder when someone is saved from an endodontic procedure. Because the adhesive process will sterilize and seal the exposure, this should be the recommended procedure over the various calcium hydroxide and/or glass-ionomer treatments on an otherwise asymptomatic tooth.

Restoring endodontically-treated teeth has gone through a rejuvenation, thanks to adhesive dentistry. No longer is the proper protocol to blindly place a post and core and full-coverage restoration over an endodontically -treated tooth! First, we evaluate the remaining tooth structure and then decide whether it needs a direct or indirect restoration. If it is the latter, does the tooth require an inlay or onlay? If it needs a post due to tremendous structural loss, an adhesively-placed non-metal post is the best solution because it allows us to restore a tooth to a state very similar to that of its "virgin" condition. It also eliminates any possible dark shadowing of the tooth or tissue due to the use of a metal-post system. I can't remember the last time I placed a post in a posterior tooth — there are just so many alternative techniques to avoid it that still deliver a functionally beautiful restoration. Better still, when a tooth does receive root canal therapy through an existing restoration, adhesives frequently allow us to place a bonded material to seal the access opening. This is an option as long as the margins are not compromised.

In my opinion, performing "smile-makeover" procedures would not be as popular today if it weren't for adhesive dentistry. Your clients don't want their teeth "ground down to little pegs" for a crown to accomplish their smile makeovers. They want a more conservative approach. With adhesives and porcelain, we can — and have — been accomplishing this for decades. Let's face it: Attaching a thin veneer or laminate over a front tooth wasn't really possible for the long term until adhesives were developed. I describe adhesives to my clients as my "super glue." When anterior preparations go beyond "traditional" porcelain-veneer preparations due to existing restorations or the malposition of the tooth, adhesives allow these partial-coverage porcelain restorations to stay attached to the tooth. As a result, we don't have to remove healthy tooth structure for a full-coverage preparation. Because adhesives allow these nonmetal restorations to be placed, especially anteriorly, we have increased aesthetic quality because light can be transmitted through the restoration, mimicking natural tooth structure.

Another procedure we will be offering to our clients, thanks to adhesives, is the "repair" process. When porcelain chips off a fixed bridge, we now can replace the missing porcelain by either bonding composite resin or porcelain to the affected area. For porcelain, simply prep that part of the bridge for a veneer. Then, have your laboratory fabricate a porcelain piece for that area of the bridge. Not only will your client appreciate this technique, but it also will eliminate the need to remove an otherwise functional dental restoration. Other repairs such as chipped or slightly washed-out margins can be restored easily to complete integrity through the addition of an adhesive and composite resin.

The list of repair procedures is only limited by our imaginations. After all, look at what we've done with amalgam over the years ... and we can't even bond that stuff!

My story of how adhesive dentistry has changed my life might not be a unique one, but it is mine. I am so thankful that I ordered that tape many years ago, and I'm also thankful to all of the people who have taught me and supported me along my journey. It is because of them that I can fulfill my patients' desires for healthy, naturally beautiful teeth and smiles. I also thank the manufacturers who constantly improve their products, so we clinicians can move closer to our goal of clinical excellence. As someone once wrote, "Excellence is the result of caring more than others think is wise, risking more than others think is safe, dreaming more than others think is practical, and expecting more than others think is possible."

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