I need your help! What would you do...

[SeattleRDH]

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Today my boss had a dentist he recently met at a CE (and hasn't seen his work) come in and cover for him. It was a short notice thing as my boss's father passed away suddenly last weekend. Now, I don't want to get him more stressed out than he already is, but this is the conversation his assistant and I had at the end of the day:

Her: "It's funny how different doctors are in the way they do fillings."
Me: "What do you mean?"
Her: "Well, when it came time to fill the box with composite he placed flowable like Dr. [my boss] does but then he stopped me when I went to cure it. He then asked for the paste (Z250) and just packed it in there until the prep was completely full. He only had me do one final cure."
Me: "That doesn't sound right but I'm going to ask SDN tonight to see what people think because there are different ways of doing things (like total etch vs. self etch)."
Her: "Oh good. Because that looked kind of sloppy."

So, what would you do? I mean, the standard is to cure in increments right? This wasn't just a one time event either. She assisted over 10 composites on 3 people today. Should I say something to my boss?

 

[lemoncurry]

unless it was composite that is meant to be bulk fill (not sure if they work, even), it should be cured in increments or else it either won't completely cure or it will shrink too much leading to microfractures, open margins and increased sensitivity.

I would mention in passing what the assistant said about different filling techniques and put the ball in his court to find out what the other dentist did.

 

[DrJeff]

Its a total depth of cure issue, with respect to the power output on your curing light. If you've got a strong light, getting 5mm depth of cure shouldn't be an issue, and hence bulk filling should be an issue either. Greater than 5mm, well then there could be some issues with the curing of the composite in the box. Most of the time, if this is the case, as soon as one starts to finish the gingival margins of that restoration, you'll know that it didn't fully cure, as the composite will be "pasty" as opposed to solid in that area.

If your boss doesn't want to see those patients to check, might not be a bad idea to get a bitewing in the area worked on at their next recall visit to check. This is a tough situation for your boss, because to the patient, it could look like your boss doesn't trust the work of the temp dentist, and then the patient can think something like "well if Dr X doesn't trust the work of the other guy, then why didn't Dr X just cancel my visit that day and reschedule me for another day??"

As for the not curing of the flowable before placing the "regular" composite, also not an issue. This is a technique that is taught by a number of leading CE lecturers. I've used this technique with great clinical success for years now. Basically in applying the "regular" composite directly ontop of the uncured flowable, the flowable will flow into any voids that can occur as the "regular" composite is placed and compacted (if you haven't removed a matrix band and seen a corner of that box on a class II free of composite after placing the curing, then it's only a matter of time 😱 ) Once again, as long as the depth of the material being cured doesn't exceed the reach of the light, not a big deal.

The other thing is, that different dentists DO do procedures differently, and even if different techniques are used, they can get the same longterm successful clinical results. I know that in my office, myself and my partner, while we use the same bonding agent and the same brands of regular and flowable composite, how we go about placing and finishing our restorations is different (sometimes this drives our assistants crazy when say my usual assistant is occasionnally workign with my partner, and vice versa). We both have the same level of restoration success (and failure - and yes restorations sometimes inspite of your best effort do failure prematurely) rates longterm. The key is to find what technique works best and is repeatable in YOUR hands, and that may very well be different than what technique works best in someone elses hands!