The following is a transcript of a recent interview with Dr. Raymond Bertolotti, conducted by Dr. Jeffrey Dalin.
Dr. Dalin: First of all, let me say that I am a huge fan of yours! I have been attending your lectures since the late 1980s. You are truly a pioneer in our field. You have fought for what you felt was right, even if it went against the mainstream theories of the times. Let’s go back to those 1980s. You were one of the first dentists to ever speak about “total etching” of the teeth. How did you find out about this technique?
Dr. Bertolotti: Thanks Jeff, it sounds like you have had great clinical success with what I teach. I am glad to hear that. I read Dr. Fusayama’s book, “New Concepts in Operative Dentistry,” in 1981, shortly after it was published. I realized that if his concepts were true, they would irreversibly change dentistry. After some research, I realized they were true and I asked Dr. Fusayama to be my mentor. He graciously accepted.
Dr. Dalin: And how did the so-called “dental experts” react to these radical ideas?
Dr. Bertolotti: Dr. Fusayama told me he was unsuccessful in publishing his total etch research in the major journals. His papers were in long reviews and always rejected, presumably by the “dental experts.” So I was prepared to do what Dr. Fusayama advised - “Continue to tell the truth and someday they will believe us.” I got a lot of harsh criticism, too, but I was convinced that he was correct. I told my audiences to try it for themselves and they would be “immediately convinced.” Hearing constantly about success, my widespread teaching started in 1984 when we launched Fifth Quarter Seminars.
Dr. Dalin: You have always been one to stress minimal reduction of tooth structure while working on your patients. Can you explain why this was such an important philosophy for you?
Dr. Bertolotti: These days, most dentistry is replacement. Every successive restoration you place ends up larger and more invasive. Some statistics for frequency of replacement are appalling. Much of it is probably attributable to poor technique. That is a focus of my lectures. The need for endodontics seems to often correlate with the amount of tooth reduction. I definitely want my patients to avoid the need for endodontic work because that procedure often precedes tooth loss. There is a cycle: small filling, large filling, crown, root canal and second crown, tooth loss, and implant. I want the total cycle time to exceed the patient’s lifetime so they never reach the end. The key is minimal invasion.
Dr. Dalin: Are there any dental materials or pieces of equipment that you think every restorative dentist ought to have as we enter 2006? You don’t have to name any brands, just give us some ideas of items we all need to be thinking about.
Dr. Bertolotti: Here are some of my favorite items I think every office needs to have: DIAGNOdent, digital camera, and air abrasion. Watch for HealOzone next year because it is expected to receive FDA approval.
Dr. Dalin: Adhesion dentistry is now the way to think about everything we do in the restorative field. Let’s talk about some of the important aspects of this. First, let’s discuss self-etching primers. These are getting a lot of attention these days.
Dr. Bertolotti: Self-etching primers are not all the same. One big problem is that a lot of opinion leaders tend to group them together. This is the “generation” mentality. For example, when dentists read a report on a poor-performing brand of self-etching primer, they tend to think all self-etching primers are like that. This is not necessarily so. There are some great ones, as well as others that should have never been sold. The major issues to consider are the compatibility with all types of composites - light-cure, dual-cure, and self-cure - and whether the self-etcher is effective on uncut enamel.
Stability in the bottle is another major consideration. One “no mix” self-etching adhesive I tested actually polymerized in the bottle within a few months, rendering it useless. I have heard about a lot of clinical failures with that particular product. We call that product liability. For the clinician who doesn’t want to treat patients like guinea pigs, getting good independent evaluations can be a problem. I test leading candidates myself and look at places like Reality (www.realityesthetics.com) for this sort of evaluation that is done by others.
Dr. Dalin: I remember attending one of your Fifth Quarter Seminars not too long ago. You mentioned some of the problems with the one-step bonds. Why do you consider the two-step bond to be the gold standard in bonding agents?
Dr. Bertolotti: The one-layer bonds all seem to exhibit “transudation,” which is the permeation of pulpal fluids through the bond. The fluid finds its way through channels that previously held water from the self-etching all-in-one bond. On the other hand, a second, water-free hydrophobic layer in the two-layer bonds seals the tooth and does not permit transudation.
Dr. Dalin: While we are talking about bonding agents, shouldn’t we talk about the stability of these bonds as well?
Dr. Bertolotti: Yes, stability is a concern. One Australian study found a self-etching product stable on dentin at eight years, while finding a total-etch product unstable. The stability of the bond is most likely due to the quality of the hybridized layer that is the mix of dentin and bonding agent. Total-etch tends to result in over-etching - etching so deeply that the bonding agent cannot penetrate as deep as the tooth was etched. Self-etching generally produces a hybridized zone where the etched dentin is fully penetrated with resin. Additionally, clinical evidence suggests some self-etched enamel bonds are stable and others are not.
Dr. Dalin: Let’s talk about resin pulp caps. This is a technique that is getting a lot of attention these days. How successful are you finding these to be?
Dr. Bertolotti: I would say about 70 to 90 percent successful. I think the difference in success rates may well be attributable to how “gutsy” the doc is in taking a chance on failure. Of course, it could be related to operator technique or products used. Calcium hydroxide is not the magic bullet it was historically believed to be. A nice study I read compared hard-set calcium hydroxide with a self-etching bond with composite resin placed on pulp-exposed monkey teeth. The result was equal inflammation. I believe the old adage, “If we seal, it will heal.” The quality of the seal is the main thing that matters. Keep in mind that calcium hydroxide is well known to soften with time. I find it hard to believe that it would maintain a good seal. We need to do more research on this.
Dr. Dalin: Here is one thing I have often admired about you and your work. You seem to have a great mind for engineering dental products. You often will encounter a clinical problem and then come up with a new material or piece of machinery that will help you correct the problem. How are you so successful at doing this, and what should Dental Economics® readers do if they ever want to accomplish this sort of thing?
Dr. Bertolotti: Actually, I am a ceramic engineer by degree. One of my first jobs was basically a “trouble shooter” at a nuclear power test facility. That experience sure helps at times. I would advise a dental student to look outside of dentistry for some knowledge before entering dental school. Come to think of it, most of the top dentists I know have degrees in other fields.
Dr. Dalin: That is quite a background and job experience! I feel like I need to go back to college to earn another degree or two! While I have you here, I have to ask about ozone therapy and your experience working with Julian Holmes and the idea of ozone-initiated caries removal.
Dr. Bertolotti: Ozone is working very well for remineralizing the last 1.5 to 2 mm of carious dentin. Glass ionomer by itself seems more limited in what it can accomplish, perhaps to about 0.5 mm. I just returned from an ozone seminar in South Africa and this was the consensus. Additionally, ozone works for desensitizing roots even when self-etching primers fail. It arrests herpes lesions and greatly accelerates healing of aphthous ulcers. I even found it to work on athlete’s foot (a study of one - me).
Dr. Dalin: Thank you, Ray, for taking time to talk with me. I know how useful your ideas, techniques, and materials recommendations are for all of us practicing dentists. We need more educators like you - pioneers willing to stick their necks out for what they feel truly works. We will all keep our eyes and ears open to what you are proposing in your lectures and on your Web site - www.adhesion.com.
Dr. Bertolotti: Thanks, Jeff. It’s a pleasure talking with you. What keeps me in this education business is watching others increase their clinical success.
Dr. Raymond L. Bertolottireceived his DDS degree from the University of California, San Francisco after working as a PhD metallurgical and ceramic engineer at Sandia National Laboratories. He is currently a clinical professor in Biomaterials Science at the University of California, and conducts a private practice in San Leandro. Much of his private practice is involved with conservative crown and bridge techniques and adhesion dentistry. He may be reached by e-mail at [email protected].
Dr. Jeffrey Dalin practices general dentistry in St. Louis. He also is the editor of St. Louis Dentistry magazine and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. Contact him by e-mail at [email protected], by phone at (314) 567-5612, or by fax at (314) 567-9047.