1. RESTORATIVE – WHAT MATERIALS SHOULD BE USED AND WHEN SHOULD WE USE THEM? Daphne C. Ferguson-Young, DDS, MSPH

2. Learning Objectives Understanding the benefits of the various restorative materials Understanding the benefits of the various restorative materials Review of the current trends of various restorative dental materials Review of the current trends of various restorative dental materials Understanding the appropriate criteria for specific dental procedures Understanding the appropriate criteria for specific dental procedures Understanding the advantages and disadvantages of different dental materials Understanding the advantages and disadvantages of different dental materials

3. Current Restorative Dental Materials Amalgam Amalgam Composite Composite Porcelain Porcelain Metals Metals Porcelain fused to metal Porcelain fused to metal

4. Direct and Indirect Amalgam Amalgam Composite Composite Porcelain Metals

5. Criteria for Restorative Material Selection Dental Material Patient Dentist OPTIMAL RESTORATIVE HEALTH

6. Ideal Restorative Patient’s oral and general health Patient’s oral and general health Use ( location of restoration) Use ( location of restoration) Longevity Longevity Durability Durability Patient’s tolerance Patient’s tolerance Appearance Appearance Cost Cost

7. Amalgam Widespread use for over 150 years Widespread use for over 150 years Chemical makeup: elemental liquid mercury Chemical makeup: elemental liquid mercury ( 43-54%), alloy powder ( 57-46%) composed of silver, tin, copper, and small elements of zinc, palladium or idium. ( 43-54%), alloy powder ( 57-46%) composed of silver, tin, copper, and small elements of zinc, palladium or idium. Most studied and tested filling material Most studied and tested filling material

8. Composite Over a 50 years use Over a 50 years use Composed of organic polymer matrix, inorganic filler particles, coupling agent, and the initiator- accelerator system Composed of organic polymer matrix, inorganic filler particles, coupling agent, and the initiator- accelerator system Used for all aspects of dental cavity classifications Used for all aspects of dental cavity classifications

9. Restorations Classification Recommended Composite Class IAll-purpose,packable,microfilled (post),compomer ( post) Class IISame as above Class IIIAll-purpose, microfilled, compomer Class IVAll-purpose Class VAll-purpose,microfilled, compomer Class VI (MOD)Packable CervicalFlowable,compomer PediatricFlowable, compomer Core TemporaryProvisional High caries-risk patientsGlass ionomers,hybrid ionomers Restorations and Recommended Composites Source :Craig,R, Powers,J,Restorative Dental Materials, 11 th edition

10. Indirect Restorative Materials Porcelain Porcelain PFM PFM Gold Alloys Gold Alloys CAD/CAM made restorations CAD/CAM made restorations

11. Direct Materials Comparisons AmalgamCompositesGlass Ionomer Resin Ionomers Principle Uses fillingsFillings, inlays veneers Small fillings, liners, temp Small fillings, liners, cement crowns DurabilityDurable Non-stress areas Resistance to Surface Wear LowMay wear slightly faster than dental enamel Poor in stress bearing areas Resistance to Facture May fractureGoodBrittleTougher than glass ionomer Post-OP Sensitivity MinimalModerateLow EstheticsPoorExcellentGood CostsLowModerate

12. Indirect Materials Comparisons PorcelainPFMGold (Noble) Base Metal Alloys UsesInlays, Crowns,Veneers, Fixed Crowns Fixed Bridge Cast Crowns, Bridge, Some RPD Most RPD, Crowns, Fixed DurabilityModerateVery goodExcellent Resistance to Surface Wear Resistance Hardness similar to enamel Minimally abrasive Resistance to Fracture PoorMay fractureDoesn’t fracture in bulk Post-Op Sensitivity No May EstheticsExcellent Poor CostsHigh

13. Mercury Controversy No scientific studies shows any link between amalgam fillings and health Patients should be given information on the benefits and risks of various restorative dental materials

14. Historical Record of Amalgam Mercury 1832 – Crawcou Brothers 1832 – Crawcou Brothers 1860’s – Amalgam War 1860’s – Amalgam War 1890’s – Amalgam Science 1890’s – Amalgam Science 1920’s Mercury Challenge ( Germany) 1920’s Mercury Challenge ( Germany) 1980’s - Dr. Hal Huggins ( USA) 1980’s - Dr. Hal Huggins ( USA) 1990 – 60 Minutes Program 1990 – 60 Minutes Program 1991 – FDA Review; NIH-OMAR-NIDR Assessment Conference 1991 – FDA Review; NIH-OMAR-NIDR Assessment Conference 1992 – FDA and CDC Conclusion on Dental Amalgam Safety 1992 – FDA and CDC Conclusion on Dental Amalgam Safety 1993 – Sweden begins to phase out dental amalgam 1993 – Sweden begins to phase out dental amalgam 1995 – Germany shifts amalgam liability to materials suppliers 1995 – Germany shifts amalgam liability to materials suppliers

15. Evaluating Oral Health Information Consider the contents provider ‘s qualifications Consider if the material comes from an objective source such as the U.S.FDA, ADA or a medical or academic institution Consider if the argument or conclusion is supported by sound scientific evidence

16. Future Demand for Restorative Dentistry Between 1990-2050, population estimated to increase to 394 million people Between 1990-2050, population estimated to increase to 394 million people Significant increase in the number of older adults Significant increase in the number of older adults Depending on the amount of discretionary cash available will dictate the demand for dental services Depending on the amount of discretionary cash available will dictate the demand for dental services Access to care dependent on number of dental healthcare providers available Access to care dependent on number of dental healthcare providers available

17. Cost of Dentistry to Patients According to Delta Dental, the cost is $1788.00 to maintain a single filling in an anterior tooth Cost of $2108.00 in the premolar tooth.

18. Challenges to Clinician and Patient Insured or uninsured Insured or uninsured Reimbursement rates Reimbursement rates Coverage provided Coverage provided Private practice vs. public facility Private practice vs. public facility

19. Dental Tourism Dentalcations based on price of dental work Dentalcations based on price of dental work Popular destinations include Africa, Costa Rica, Thailand, Mexico Popular destinations include Africa, Costa Rica, Thailand, Mexico Quality of dental materials used may be questionable Quality of dental materials used may be questionable Insurance will not cover to have overseas work corrected Insurance will not cover to have overseas work corrected

20. Examination Boards Continue to have amalgam on Boards Continue to have amalgam on Boards Incorporating options for posterior resins Incorporating options for posterior resins

21. In conclusion, the right dental material selected for the patient is a case by case situation. All factors based on the medical and dental histories, should be utilized to develop a treatment plan. Today’s economics plays a critical part in patient’s decisions to accept a plan, proceed forward or delay. Community Health Centers help close the gap for the uninsured, underinsured and the working poor. As Oral Health Clinicians, we must continue to be vigilant in promoting preventive care and good oral health practices.

22. Resources Craig,R,Powers,J; Restorative Dental Materials, 11 th Edition. Craig,R,Powers,J; Restorative Dental Materials, 11 th Edition. Roberson, T.,etc; Sturdevant’s Art and Science of Operative Dentistry, Fifth Edition. Roberson, T.,etc; Sturdevant’s Art and Science of Operative Dentistry, Fifth Edition. www.ada,org www.ada,org www.ada,org www.dentalwatch,org www.dentalwatch,org www.dentalwatch,org www.ncahf.org www.ncahf.org www.ncahf.org www.deltadental.org www.deltadental.org www.deltadental.org www.mdpi.com www.mdpi.com www.mdpi.com worldental.org worldental.org Kaiser Low-Income Coverage and Access Survey Kaiser Low-Income Coverage and Access Survey Conservative Operative Dentistry Lecture: “ The Mercury Controversy” Conservative Operative Dentistry Lecture: “ The Mercury Controversy” www.fda.org www.fda.org www.fda.org www.slate.com www.slate.com www.slate.com www.nih.gov www.nih.gov

23. Questions