Dentists love the handling of self-leveling bulk-fill composites because we do not need to move the tip around, which can introduce voids, and we do not need to use a condenser to reduce voids.

A lot of science has gone in today’s bulk fill composites.

• As manufacturers have advanced the science of composites, they have had to balance the percentage of filler content and the viscosity of the material so it flows and has good handling properties.
• We now see bulk fill composites that are relatively translucent when they are non-polymerized, and when they are polymerized, they become opaquer. To increase the depth of cure, manufacturers came up with new photo initiators that require less light to activate an equal amount of polymerization.

Cap Layers

The percentage of filler content in the bulk fill composite determines whether you must do a traditional high fill cap layer. A traditional high fill, nano composite cap layer (veneer) is going to have superior physical properties, including wear resistance, esthetics, and flexural stress. When a cap layer is optional, my decision is based on whether the restoration is in a visible place, how fussy the patient is about esthetics, and if the patient is at high risk for functional wear.

A cap layer should be only 1-2 mm in thickness because our traditional high fill composites have a depth of cure of 1-2 mm. In my practice, I use a perio probe to measure the depth of the prepared cavity. When I do a class I filling, where the prep cavity does not descend beyond 4 mm, I can make the decision to fill the cavity partially with bulk fill and add a cap layer or to completely fill the cavity with a high fill bulk fill composite like SonicFill or G-aenial BULK Injectable (discussed below).

When I do a class II filling, I often place a bulk fill layer and then a cap layer. If the cavity is 6-8 mm or greater in depth, two increments of bulk fill composite can be used before adding a cap layer.

Bulk Fill Composites I Use

Personally, I prefer radiopaque materials. On radiographs, I want to easily see any voids and be able to distinguish the composite from the dentin, the enamel, and possible decay.

I’ve tried SonicFill™ by Kerr. A special handpiece injects a high filler composite while delivering sonic vibration. This composite has a higher percentage of filler content than the bulk fill “flowable” composites. The high percentage improves the physical properties of the composite, so you do not need to add a cap layer unless esthetics are important. The sonic kinetic energy temporarily lowers the viscosity of the composite so it optimally flows. This filler has a 6 mm depth of cure because it is very translucent.

Most manufacturers have a flowable composite. For these to flow, they have a lower percentage of filler content. The flowable composites self-level and have a 4 mm depth of cure. All manufacturers’ versions of flowable require a cap layer because they have lower physical properties to withstand occlusal wear.

I’ve used both Venus® Bulk Fill by Kulzer and Tetric EvoFlow® by Ivoclar in my practice. Both allow me to easily fill class I and II cavities in increments of up to 4mm. I classically use Tetric EvoFlow for my class II boxes because it is radiopaque and nicely self-levels. There are many versions of advanced bulk fill composites and veneer systems on the market, like the Tetric EvoFlow® and Tetric EvoCeram® that I use.

G-aenial™ BULK Injectable by GC is different because it has a higher percentage of filler content. This injectable bulk filler is radiopaque and can be used without a cap layer. I’ve used this in my practice to do some small class I and some class IV restorations.

There are even “condensable,” bulk fill deposits on the market with high percentage fill materials that do not require a cap layer and are highly durable. If you use these, you will have the challenge of placing more viscous materials and condensing them.

My Bulk Fill Technique

What I like to do is inject flowable material in a central position, for example, in the center of my class II box, and move the tip of the syringe as little as possible. I watch for the flow to reach the buccal, lingual, and axial walls of the cavity prep, and then I slowly lift the tip of the syringe as the occlusal is filling. I strive to not lift the tip prematurely and put it back in, because this introduces “stuck back” porosities. I do not play with the composite with an explorer or condenser because this creates “stuck back” porosities. I wait 10 full seconds to allow the composite to self-level before I begin light cure polymerization.

For years and years, we were trained to not use bulk fill composites. We were well trained to layer composites to improve the success of their longevity. For years, it was smaller layers and angled layers. What was that about? The primary issue we were trying to overcome was the shrinkage of the composite material. Shrinkage stress could destroy adhesion and fracture enamel. Another issue was depth of cure. Traditional composites couldn’t be cured in bulk. Between shrinkage and polymerization, layering became important. We would also layer to ensure we condensed the fill.

In time, scientists and manufacturers looking at this were able to alter the chemistry of the composite to alter the impact of polymerization shrinkage. When bulk fill composites first came on the market, despite what the manufacturers told me, I felt some internal resistance and it took me a while to step into the bulk fill arena. What drove me to take that leap of faith was looking into the science behind bulk fill composites.

The Science

I spoke with different scientists, from different manufacturers, and with independent scientists who created these materials. What I came to understand is that bulk fill composites are an improvement in composite technology.

The manufacturers learned how to direct shrinkage away from the bonded interface. Across the category of bulk fill materials, all these materials have a lower shrinkage stress numbers than the categories of composites that came before them. They do better at maintaining the integrity of the interfaces between the composite and dentin adhesive and the dentin adhesive and the walls of the cavity preparation.

The manufacturers increased translucency to increase the depth of cure. In general, when a manufacturer says they have a bulk fill composite, what they mean is that the depth of cure is somewhere between 4 to 6 mm. I often hear the complaint that bulk fill composites are not as esthetic as traditional composites. Each of us must answer individually for ourselves how exact and perfect we want to make the match of the composite to the surrounding tooth. Manufacturers have attempted to address this and now offer bulk fill composites that become opaquer as they cure.

Multiple Choices

Like everything else in dentistry, there are many choices. There are multiple types of bulk fill composite, even from single manufacturers, with variances in the specific depth of cure they recommend. When evaluating bulk fill composites, consider these questions:

• What is recommended depth of cure for that specific composite?
• Is the composited graded high enough to withstand occlusal loading and wear, or does the manufacturer recommend you use a different composite to create a 1 to 2 mm cap layer (typically, a more traditional nano category of composite)? The silver lining is that this provides an option when esthetics are of high concern.
• Is the composite condensable, requiring you to use condensing instruments, or is the composite more flowable and referred to as self-leveling, because it flows perfectly across to perfectly fill the preparation cavity? Self-leveling composites have a chemistry that allows them to have less initial viscosity and then thicken after they have flowed.
• Among your choices are bulk fill composites that come in small containers to go in composite guns, compules, and syringes. The less viscous, flowable composites come in a syringe that looks like a flowable and you can put a flowable tip on it.

I’ll be back with Part 2 of this blog to present more about bulk fill composites. To leap ahead, you may want to visit the Pankey YouTube channel to view the webinar I presented on this topic in 2020. You can view it here.

At my Falmouth, Maine dental practice, we worked as an entire dental team in 2021 to identify the ways we were and could reduce waste, reduce pollution, save water, and save energy. Then, we posted our Go Green efforts on our website and social media. Our patients and community are responding well to knowing we are doing our part to reduce the impact on the environment.

Below are some ways we reduce, re-use, and recycle. By doing these, we’ve also saved money. I wouldn’t be surprised if you are doing the same in your practice. If so, our experience suggests you can publish your list of actions to boost environmental awareness and appreciation for your dental practice in your community.

Note: Although we’ve practiced most of these for many years, most patients were oblivious to the fact that these are green activities. This is just “out of sight, out of mind” typical human behavior. Also, our team collaboration on intentionally “going green” heightened every team member’s awareness, cooperation, and sense of pride.

Waste Reduction

• We are reusing lab and shipping boxes.
• We order our often-used items in bulk from local businesses and combine orders to cut down on shipping products needed to fulfill our orders.
• Utilizing digital x-rays significantly reduces a patient’s exposure to radiation 60% compared to conventional films. Also, there are no hazardous processing chemicals or lead-lined plastic packaging to dispose of.
• We recycle virtually all our paper and plastic products that have no patient contact. We do this through our community weekly recycling pick up.
• We always use washable dishes, coffee mugs and utensils in the staff kitchen.
• We save approximately 12,000 pieces of paper a year by using chartless software. All appointment reminders are sent by email.

Energy Conservation

• We installed programmable thermostats.
• We installed motion sensors and turn off power at night.

Water Conservation

• We use a dry evacuation (waterless) vacuum system to reduce the amount of water waste. By using this type of system, we save approximately 360 gallons of water per day.
• We turn our Water and Compressor Vacuum system off at lunch and at the end of the day.
• We incorporated waterless hand sanitizers in addition to soap.

Pollution Prevention

• The amalgam separator we installed keeps mercury-containing filling materials from entering our water supply. The EPA estimates that 50% of all mercury entering the local wastewater treatment facilities comes from dental offices.
• To effectively sterilize our instruments, we use a steam sterilization system. We do not do cold sterilization that requires toxic chemicals.

I think all dentists would agree that mutually beneficial and enjoyable relationships with patients are key to a dental practice’s long-term success. But what does that “relationship” look like in a health-centered practice?

To some, a good relationship represents two people who get along and perhaps enjoy being in each other’s company. But I would argue this is not enough to build a successful health-centered dental practice. Getting along and even enjoying the presence of another person alone doesn’t go deep enough. It only addresses good rapport, and good rapport is only the starting point of a truly helping relationship. We need more to help patients achieve optimal oral health.

The More We Need

We need shared values, shared understanding, and shared goals. And to a large degree, we also need a shared vision of a preferred future so that all the goals are oriented in a specific mutually agreed upon direction. That vision must largely originate from the patient because it is their water to carry, and not ours. We can facilitate the development of the patient’s vision, but we cannot realize it for them.

This type of relationship is often called “patient-centered” or “client-centered.” And it is only possible through mutual trust — and a lot of it at that. We must have enough trust present within the relationship to allow for open and transparent communication to occur. This type of communication is much deeper.

The Deeper Communication We Need

Communication that is deeper includes discussions around:

• concerns,
• personal challenges,
• barriers,
• fear,
• short-term agendas, and
• longer-term goals.

When a patient trusts us, they are essentially allowing themselves to be vulnerable to our actions, which could, if something went wrong, harm them physically, emotionally, and/or financially.

A first sign of trust is the willingness to have these types of discussions.

Some patients will trust us quickly because we have big capital letters after our name, but this de facto trust is becoming rare. We must EARN our patient’s trust through the quality of the relationships we build, our attitude, our philosophy, and our actions that lead to deep communication and development of shared understanding and goals.

I would argue that meaningful conversations around important issues are what distinguishes a “health-centered” or “patient-centered” dental practice from one that is an attractive and pleasant place where dental services are provided in exchange for money. A key metric to monitor in each patient record is whether the deeper discussions are taking place. A key objective is to schedule time to gently have those discussions.

I had a great reminder recently while I was working with a patient that listening to patients’ intuitions and beliefs about their own dental health and care can be valuable. I’ve had this experience with many of my patients. Sometimes that value is clinical, and sometimes it is in increased patient understanding and relationship development.

I treat a lot of patients who have chronic TMD…oral facial pain…occlusal muscle disorders. You have them, too, in your dental practice. We try to help them understand that there is no “treatment,” but we have management strategies. Even when patients know this, it is frustrating for them when they have flare ups.

My patient had been comfortable and symptom free for the better part of a year, which was a long period for her. Recently, though, she had started waking up with headaches and muscle tension in her masseters and temporalis. She came in to talk about “What now?” And the answer to “What now?” is always “What has worked in the past?” We walked back on our options.

She wondered, “Can you add some material to my appliance? I always feel better at a slightly open vertical.”

The question didn’t surprise me. She’s been a dental patient for a lot of years and knows the meaning of “open vertical.” My first gut reaction was to dismiss her suggestion because it ran counter to what I know about the science and my clinical experience with other patients. I honestly didn’t want to change her appliance. But I intentionally put a pause on that resistance and sought clarification from her about what she has experienced.

Over the years, it has amazed me how knowledgeable patients are about their own dental health. They are receiving physiological data that so often they don’t know how to describe. Assessing the validity of what patients describe can be a challenge, but I’ve learned the value of acknowledging the information and asking the patient to tell me more. I ask, “Why do you think that? What have you experienced in the past that has led you to that belief?” Often, I can access the data and understand the validity of the information to help the patient.

When I don’t have a really good idea of what to do next and the TMD patient has an intuitive idea, I’ve come to respect their intuition and do what they suggest. Many, many times I have no evidence to explain why it works but their intuition works. And when it doesn’t work, it’s still okay because the patient has been validated. We’ve demonstrated we’re in a partnership in their care, and we move on to try something else.

I’ve learned to stop and recognize there must be something behind intuitions patients share. Seeking to learn more about their intuitions has led to trying new types of care and always deeper relationships with patients.

We had another interesting week at the dental office when a patient (I’ll call Ron) came in. Ron has been a patient of mine for over 20 years and is nearing 80. Whenever I saw him, we would have interesting conversations about what he was doing and thinking about doing next. He was the kind of person I love to be around, always positive with a “can-do” attitude.

This time was different. I hadn’t seen Ron in over three years, because he suffered a heart attack which led to some other complications. He came in using a cane.

When it was time for my hygiene check, Julie came to me and said, “I don’t know what’s going on with Ron, but he was really hard for me to work with today. I tried to get as much accomplished as I could. I’m sorry.”

Ron was previously very health-centered but now he was behaving like he wasn’t. Do values change in that short a period? No, but a person’s priorities might, particularly when they have developed a distorted perspective due to some traumatic events.

When I entered the room, Ron’s attitude perked up. He was positive and respectful — he was honoring our long history of mutual respect. He updated me on what happened and how he was doing. Not only were his physical disabilities frustrating, but he had rarely left the house for over a year.

Following my exam, we discussed an area of decay and several cracked teeth — all restorable with crowns. He responded that he was old and wasn’t sure how much longer he would be around. He asked, “Is there an inexpensive way to fix this? I don’t want to spend a lot of money on my mouth.”

Dentists hear this every day, but in this case, I knew the REAL Ron. I knew it was his depression speaking to me. I told him it would make sense for us to develop a Phase 1 plan, meaning, “Let’s remove the decay and get everything stabilized like they would do for you in the ER if you had an emergency, and then we can talk later about restoring things back to the way they need to be — strong and secure.”

“I don’t think I want any restoration work,” he replied.

Then, I said, “Ron, I know how much you love to eat fine food, and it would be tragic if, in your last decade, you were limited to eating only soft food or you had to fumble around with a partial denture that catches food around it all the time. Like I said, let’s focus on Phase 1 and then talk about restoration later. We have time on our side.”

“Ok,” he said, “I can go along with that.” He needed to feel like he was in control.

I finished by using words that would resonate with him, “You know Ron, despite these things that need to be addressed, you have great bone around your teeth and a great smile, so there are good reasons to restore things and finish out strongly. If you were an old, uninspiring ‘84 Oldsmobile, I’d say there is no point in restoring things, but you’re like a 1956 Corvette barn find that’s still in good condition. You’re worth it. Let’s save the conversation about restoration for another day when you are feeling better. I’m so glad that you came in, I miss talking to you.”

Ron’s eyes lit up. He smiled and said, “Yea, maybe you’re right. I can’t move like a Corvette any longer, but I understand what you are saying. I really appreciate it.”