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COMPOSITES VS. AMALGAMS
L E T T E R S
yet, the insurance company) what level of disease to accept. Most patients are not given the option to have ideal treatment, and that is our profession’s downfall. J. Mark Jensen, D.M.D. Moscow, Idaho Author’s response: I appreciate hearing Dr. Jensen’s beliefs on this concept. It is obvious that many dental and other medical treatments are elective. However, the typical practicing dentist can usually differentiate between those items that are necessary and those that can wait. In my own practice, I treat those things that I would want treated in my own mouth. Certainly that would be true of any other medical condition in the body. We can wait until a skin lesion turns into overt cancer, or we can treat it before that time. I appreciate Dr. Jensen’s thoughts on the subject and trust that our views are quite similar. Gordon J. Christensen, D.D.S., M.S.D., Ph.D. Provo, Utah COMPOSITES VS. AMALGAMS
Dr. Karl Leinfelder’s brief comments on the durability of composites vs. dental amalgams (“Do Restorations Made of Amalgam Outlast Those Made of Resin-Based Composite?”, August JADA) leave disturbing questions unanswered. Why does the resin “encourage the growth of microorganisms” under fillings and not under sealants? Dr. Ronald Jordan convinced me in 1986 that sufficient research had been done to jus146
tify a switch from dental amalgams to composite in posterior teeth. It was necessary to wait another year before dentin bonding agents were available in the United States, so for about a year these restorations were placed with glass ionomer bases. However, I’ve used just composite with dentin adhesives since 1987 (no more amalgam), and there seem to be no problems with wear or recurrent caries. Of course, crowns are still indicated in bruxers, and others are advised that that alternative is available if needed, but overall crowns are used a lot less than in the old days before dentine adhesives and goodquality posterior composites. It seems reasonable to expect this switch from dental amalgams to bonded composites will reduce the incidence of fractured cusps, reduce periodontal disease owing to less extensive subgingival margins, and reduce the need for endodontics owing to good sealing of dentin, which has not suffered quite so much trauma to begin with. It seems likely the real culprit, when “the rate of secondary caries associated with resin-based composite restorations is substantially higher than that associated with amalgam restorations,” is the bacteriologically sloppy technique most of us settled into, knowing that we could get away with it (even before we understood how the amalgam vapors were helping us). I challenge Dr. Leinfelder to cite a study in which cavities were prepared with rubber-dam isolation and an assist from Fusayama’s cavity-detecting dye where he can demonstrate substantially higher secondary
caries. It just isn’t going to happen. It is too bad that so many dental schools pay lip service to teaching rubber dam technique, yet so many students graduate feeling very uncomfortable and inept with this approach to operative dentistry. Leon L. Wiggin, D.D.S. Oneonta, N.Y. Author’s response: Posterior composite resins can be considered as having two distinctly different personalities. One that is properly and carefully inserted into the cavity preparation is characterized by excellent performance. As mentioned in Dr. Wiggin’s letter, the composite resin restoration has the potential for supporting tooth structure and thereby reducing the potential for fractured cusps. Furthermore, as he states, the potential for bonding the composite resin to the preparation permits the operator to be considerably more conservative in terms of cavity design. This, of course, can lead to better tissue response, since in many cases it may not be necessary to extend the preparation to the gingival tissue. When placed properly and in accordance with the concepts supported by clinical research, the posterior composite resin can last as long as a corresponding amalgam restoration. In addition, the potential for esthetics is, of course, far superior. The other personality of posterior composite resin restorations is far different. When handled inappropriately, this material can create serious clinical conditions far worse than amalgam. These include
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
yet, the insurance company) what level of disease to accept. Most patients are not given the option to have ideal treatment, and that is our profession’s downfall. J. Mark Jensen, D.M.D. Moscow, Idaho Author’s response: I appreciate hearing Dr. Jensen’s beliefs on this concept. It is obvious that many dental and other medical treatments are elective. However, the typical practicing dentist can usually differentiate between those items that are necessary and those that can wait. In my own practice, I treat those things that I would want treated in my own mouth. Certainly that would be true of any other medical condition in the body. We can wait until a skin lesion turns into overt cancer, or we can treat it before that time. I appreciate Dr. Jensen’s thoughts on the subject and trust that our views are quite similar. Gordon J. Christensen, D.D.S., M.S.D., Ph.D. Provo, Utah COMPOSITES VS. AMALGAMS
Dr. Karl Leinfelder’s brief comments on the durability of composites vs. dental amalgams (“Do Restorations Made of Amalgam Outlast Those Made of Resin-Based Composite?”, August JADA) leave disturbing questions unanswered. Why does the resin “encourage the growth of microorganisms” under fillings and not under sealants? Dr. Ronald Jordan convinced me in 1986 that sufficient research had been done to jus146
tify a switch from dental amalgams to composite in posterior teeth. It was necessary to wait another year before dentin bonding agents were available in the United States, so for about a year these restorations were placed with glass ionomer bases. However, I’ve used just composite with dentin adhesives since 1987 (no more amalgam), and there seem to be no problems with wear or recurrent caries. Of course, crowns are still indicated in bruxers, and others are advised that that alternative is available if needed, but overall crowns are used a lot less than in the old days before dentine adhesives and goodquality posterior composites. It seems reasonable to expect this switch from dental amalgams to bonded composites will reduce the incidence of fractured cusps, reduce periodontal disease owing to less extensive subgingival margins, and reduce the need for endodontics owing to good sealing of dentin, which has not suffered quite so much trauma to begin with. It seems likely the real culprit, when “the rate of secondary caries associated with resin-based composite restorations is substantially higher than that associated with amalgam restorations,” is the bacteriologically sloppy technique most of us settled into, knowing that we could get away with it (even before we understood how the amalgam vapors were helping us). I challenge Dr. Leinfelder to cite a study in which cavities were prepared with rubber-dam isolation and an assist from Fusayama’s cavity-detecting dye where he can demonstrate substantially higher secondary
caries. It just isn’t going to happen. It is too bad that so many dental schools pay lip service to teaching rubber dam technique, yet so many students graduate feeling very uncomfortable and inept with this approach to operative dentistry. Leon L. Wiggin, D.D.S. Oneonta, N.Y. Author’s response: Posterior composite resins can be considered as having two distinctly different personalities. One that is properly and carefully inserted into the cavity preparation is characterized by excellent performance. As mentioned in Dr. Wiggin’s letter, the composite resin restoration has the potential for supporting tooth structure and thereby reducing the potential for fractured cusps. Furthermore, as he states, the potential for bonding the composite resin to the preparation permits the operator to be considerably more conservative in terms of cavity design. This, of course, can lead to better tissue response, since in many cases it may not be necessary to extend the preparation to the gingival tissue. When placed properly and in accordance with the concepts supported by clinical research, the posterior composite resin can last as long as a corresponding amalgam restoration. In addition, the potential for esthetics is, of course, far superior. The other personality of posterior composite resin restorations is far different. When handled inappropriately, this material can create serious clinical conditions far worse than amalgam. These include
JADA, Vol. 132, February 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.