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The Jameson Files: Better bonding with Dr. Larry Rosenthal

June 1, 2001
In this month's column, Dr. John Jameson interviews Dr. Larry Rosenthal, a true trendsetter in the field of aesthetic dentistry, about the benefits and types of post-graduate education available in aesthetics.
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This month, Dr. Jameson interviews Dr. Larry Rosenthal of New York City, a true trendsetter in the field of aesthetic dentistry.

Dr. Jameson: In your practice, you've witnessed the evolution of aesthetic dentistry, from enamel bonding to dentinal bonding and all of the other extraordinary things in the industry. As you look back, how has this affected you and your proteges?

Dr. Rosenthal: You're talking about a period that spans three decades! The initial phase, in the early 1970s, was only the tip of the iceberg. Mostly, we worked with enamel - not deep dentin bonding. The evolution of the bonding process began with effective agents that would give us good bonding strengths to dentin as well as enamel. These came along with the first systems of adhesives. This first system required us to use a 35 percent phosphoric acid to etch the enamel, rinse, and then follow with a primer and an adhesive that were mixed together and applied to the tooth. Some dentists are still using some of these materials like 3M's Scotchbond MP or Bisco's All Bond 2.

The evolution continued when some clinicians began to speak about etching both enamel and dentin. This was common practice in Japan at the time that Dr. John Kanca began espousing the "Total Etch Technique." This was treated as blasphemy by many other clinicians and TET became quite a controversy within the dental community. A common thread was that only endodontists would benefit from total etch. Of course, we all know now that Dr. Kanca's report of the Japanese research was correct; now, total etch is common practice.

The benefits of this breakthrough have been evident throughout the late 1980s and the 1990s to the present. Many new materials and products have been developed to help us do better dentistry. Next, we needed a new bonding system to give us stronger bonding strengths in the dentin. The second system came along with only one bottle. This system has the primer and the adhesive together in the same bottle. This includes such standbys as Kerr's Optibond Plus, Caulk's Prime & Bond NT, Ultradent's PQ1, Ivoclar's Excite, Bisco's One Step, and 3M ESPE's Single Bond.

With this latest system, we used a 35 percent phosphoric acid to etch the tooth and remove the smear layer from the dentin. The dentinal tubules were now exposed, and we entered a new phase of bonding. In the past, moisture had been our enemy! In dental school we were taught to dry the tooth to place an amalgam.

With the early composites, we were told the same. Now, we were being taught that moisture was our friend. In order to get the best bonding strengths, we need to bond to moist dentin. The reason for this is that the adhesive carriers are attracted to moisture. After etching, the adhesive is applied to seal the dentin and provide bonding for the composite.

These one-bottle systems have worked well for us except for the problem of occasional sensitivity. The reason that more dentists have not embraced the use of composites is sensitivity. We are constantly searching for something to end this vicious cycle of occasional, unexplained sensitivity. We feel like we have done everything right, followed all the protocols, but the next morning the patient calls to complain about the tooth hurting. These complaints are often difficult to resolve, and there are no easy answers.

In the search to find a solution to this constant problem, the Japanese have come to our aid again. The development of new adhesives that are self-etching seems to be the answer. New products have recently been introduced like Kuraray's Clearfil Liner Bond 2 and Kuraray's SE Bond. These new adhesives do not require the use of phosphoric acid etch. The dentist starts with a dry tooth (no more worries about how moist the tooth is) and applies a primer that is self-etching. The primer simultaneously treats the dentin and enamel surfaces. No rinsing is necessary. A light-cure bonding agent is then applied and cured. Dentists who use this system report no sensitivity.

Other companies have come along with improvements and are providing one-step systems. These are self-etching primers with the adhesive included so that everything is done in one step. These products are 3M ESPE's Prompt, Parkell's Touch & Bond, and J. Morita's One-Up Bond F. Dentists who are using these systems also report no sensitivity problems. Perhaps we are on our way to a new era of the aesthetic revolution - no sensitivity!

Dr. Jameson: It sounds like there's been an evolution of not just the bonding technology, but an evolution of restorative materials used to place the restorations.

Dr. Rosenthal: Most materials were macro-filled; some were micro-filled. The materials were a great improvement over what we previously had to work with; however, it was not until the 1980s that the technology advanced enough to allow placement of indirect restorations, particularly porcelain. There was a margin of failure; some restorations broke. The evolution of restorations into the 1990s has brought us longer-lasting materials. Dentists are more secure about placing these restorations with the confidence that they will last 10 years or more.

Certain products like pressed ceramics - such as Impress and OPC - now allow us to do tooth-colored restorations. Manufacturers have played a huge role in exposing the possibilities to dentists; it's certainly changed the nature of how we do things.

I've noticed in my teachings in the last 15 years that the knowledge of students has increased exponentially. Dentists today have a much better feel for these procedures, because the materials are much more user friendly. But it's not just the materials - it's how you diagnose and treat cases for more complete comprehensive care. Dentists have reached another level - restorations are becoming an indispensable tool in dentistry.

Dr. Jameson: Dental students are experiencing a paradigm shift; they now receive some training in these procedures. However, postgraduate training, through manufacturers and specific education, has been and is still vitally important today. You've been a real pioneer in postgraduate education. What kind of changes have you seen in this area?

Dr. Rosenthal: There are two types of postgraduate education. One is to attend lectures by a doctor. When I first started, this was the accepted method. Does this have any benefit? Absolutely! Now, the instruction involves two- or even three-weekend courses that include live models. These types of courses have brought the educational level to tremendous heights. To truly learn the total technique and philosophy behind aesthetic dentistry, the instruction must be hands-on.

There is, however, a major caste system that exists today. In one class, we have dentists who are totally ignorant and have never done an aesthetic restoration, along with practitioners who have done quite a few and have the attitude of "what can you teach me?"

But I learn every day - from students and instructors. There is a wealth of knowledge out there, and we learn something new with each and every case. I believe you cannot become a bona fide cosmetic or aesthetic dentist unless you're involved in teaching it or attend Level One, Level Two, and advanced-level courses.

Dr. Jameson: Doctors are now, more than ever, looking for ways to add services to their treatment mix that will elevate their practices and increase their aesthetic quotient. What type of increased profitability have you seen from dentists who have gone through these types of courses?

Dr. Rosenthal: On average, every person who has taken our course has, within a year, grown a minimum of 25 percent. It's not just economics, but their knowledge, skill, and approach to the entire concept that changes. Their staffs get involved; the way they deal with their patients and treatment plan totally evolves as well.

We teach not just technique, but a comprehensive practice-management concept for implementing those techniques. Any hands-on course must focus on not just didactics, but how to take your practice to the next level.

Dr. Jameson: To have the type of experience necessary to truly increase profitability, dentists must have an all-encompassing educational experience.

Dr. Rosenthal: We have had people who have taken our courses five, six, or seven times. One person, a prosthodontist, has taken our course 10 times! I asked him why, and he said, "Why not? Every time I take the course, I learn something. Every time I come back from a course, my practice grows!"

I can't understand why more practitioners don't take these courses, when an increase of just one or two cases will pay for the course!

Dr. Jameson: You've been very progressive in the type of dentistry you practice, and you likely have a real sense of what the future holds for our profession. Where is dentistry going as far as the type of procedures added to the treatment mix and the amount of fulfillment for doctors?

Dr. Rosenthal: Dentistry is already taking on a wholly new connotation with the public. With the advent of implants and cosmetic dentistry - I call it "Smile Dentistry" - the profession has evolved from the negative "drill, fill, and bill" stereotype to one on par with plastic surgery. It's developed not out of patient need, but patient want. It's an adjunct to dermatology, hair transplants, and liposuction. It's taken dentistry out of managed care and third-party payment plans to elective status. If a patient has a hole in the back of the mouth or eight front teeth that need restoration, he or she will choose to have the eight front teeth fixed. Vanity takes over!

No matter what, all dentists should offer aesthetic services as part of their treatment mix. We will keep evolving and keep getting better, not just in technique, but in the artistry and level of service to our patients.

Dr. John Jameson is chairman of the board of Jameson Management, Inc., an international consulting firm. Dr. Jameson lectures internationally on high-tech dentistry and its integration into the dental practice. He provides research for manufacturers and marketing companies. Dr. Jameson may be reached at (580) 369-5555 or by e-mail at [email protected].

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