When to place Gluma

[SeattleRDH]

---

Members do not see this ad.

This is the order I was taught:

Vitrebond
Etch
Gluma
Single Bond
Composite

But today I saw:

Gluma
Vitrebond
Etch
Single Bond
Composite

Does it matter at which step you place Gluma?

 

[cjb04]

Gluma is placed on dentin. It acts as a desensitizing agent by occluding the dentinal tubules, which is why it is placed first. Next would be RMGI (vitrebond) as a liner or base. This acts as a thermal insulator (again, reducing sensitivity). Enamel is total acid-etched for 30 seconds. If we're in to dentin, we prefer to self-etch and bond the dentin rather than total etch. Finally, composite is packed and cured incrementally.

If you place vitrebond first, it will prevent the gluma from accessing any of the dentin that has been covered.

 

[longhornpride]

This is the order I was taught:

Vitrebond
Etch
Gluma
Single Bond
Composite

But today I saw:

Gluma
Vitrebond
Etch
Single Bond
Composite

Does it matter at which step you place Gluma?

'

where I work at, the dentist does it the way your were taught (the first order you have listed)

 

[SeattleRDH]

Gluma is placed on dentin. It acts as a desensitizing agent by occluding the dentinal tubules, which is why it is placed first. Next would be RMGI (vitrebond) as a liner or base. This acts as a thermal insulator (again, reducing sensitivity). Enamel is total acid-etched for 30 seconds. If we're in to dentin, we prefer to self-etch and bond the dentin rather than total etch. Finally, composite is packed and cured incrementally.

If you place vitrebond first, it will prevent the gluma from accessing any of the dentin that has been covered.

Yes. I know what all of the materials do. In Washington hygienists are licensed in restorative. My question is: does it matter at what point in the process Gluma is placed? Wouldn't Vitrebond do the job of sensitivity reduction regardless of whether Gluma is placed under it?

 

[DentinBond]

Good heavens, still etching dentin? Dr. Ray Bertollotti's newsletter has some brief reviews of Self-Etching Primers versus Total Etch:

http://www.adhesion.com/index.php?page=the_archive&akey=19

Here's a quote:
Van Meerbeek and colleagues currently state: "When bonding to enamel, an etch and rinse approach is definitely preferred, indicating that simple micro-mechanical interaction appears sufficient to achieve a durable bond to enamel. When bonding to dentin, a mild self-etch approach is superior, as it involves (like with glass-ionomers) additional ionic bonding with residual HAp. This additional primary chemical bonding definitely contributes to bond durability."

Definitely have a look at the SEM photos at the bottom of the page, and the commentary on the products they represent.

And:
http://www.adhesion.com/index.php?page=the_archive&akey=18
Speaks about Gluma a bit.

Truly, though, this article explains enamel and dentin bonding as well as any I've ever read, it's from an impartial and brilliant author, and the literature cited is impeccable:

http://www.dentistrytoday.com/materials/1483.html

(And looky where it was published, of all places! You just never know.)

There's more literature since 2003, of course. Yet to my knowledge no major practical developments have occurred since except the introduction of Danville Engineering's Prelude SE, which tweaked the chemistry of the already excellent Clearfil SE Bond.

Here's a suggested rubric:

If bonding largely to enamel or porcelain, Etch and bond. And Clearfil Photobond predictably gives among the highest bond strengths in the business. It also costs about 50 cents for a one-drop/one-drop application.

If bonding largely to dentin, which includes pretty much every posterior Class I and II and even V, Self-Etch! Please consider it strongly. Clearfil SE Bond and Danville Prelude SE give the highest consistent bond strengths, with Prelude SE having the advantages of lower film thickness, less transudation (though both are excellent on that score) and it does not stick to your metal sectional matrix bands. At all. Both also cost about 75 cents per one-drop application, though Prelude SE may be less.

We're talking consistent 32MPa bonds on dentin here, that hold up remarkably well over time.

I refer to cost because some systems overcharge and deliver lower, less consistent bond strengths. For example, the Prompt L-Pop system, while packaged cleverly, is $4.00 per application last time I checked, for far lower and less consistent dentin bond strengths than Prelude SE, and with transudation issues.

Did I mention no sensitivity? If used properly (and often if not) sensitivity with Self-Etch Primers is usually nil. I went through a brief but regrettable phase where I placed too thick of a first layer of flowable composite in a number of Class II preps. It shrank (not towards the light, that's a myth- towards the best bonded surface, which is the enamel walls of the proximal box). Later on we'd take our routine bitewings and I'd see a horrifying gap. For which I'd apologize to the patient for having to get them numb again and, of course, replace the restoration at no fee. Here's the thing though- even with 1mm+ gaps at the gingival margin, no one was ever sensitive. It took a bitewing to find the problem.

By the way, as of 2010, to the best of my knowledge, compared to SE Bond and Prelude SE, every other Self-Etch product on the market had higher cost and greater transudation, which is probably what's driving the recommendations to use glass ionomer bases. I never use such bases and can never blame clinical failures, rare as they are, on Prelude SE or SE Bond. It's always me if something is flawed in a composite resin restoration. (Using an operating microscope for 6 months now, the issue of finding occasional gaps between the composite and the cavosurface has disappeared. Placing composite in a prep is now rather like spackling a wall. In the noonday sun at the beach. On #15. Distal.) Anyway I'd much rather bioengineer a hybrid layer over all the dentin than place a non-adhesive base over much of it.

Apologies for riffing so far afield on your Gluma question, and it CAN be used under Self-Etching Primers. See Bertollotti's newsletter. Yet I felt compelled when I saw the rubric of Total Etch on dentin. The science on dentin bonding has regrettably not been disseminated widely enough though and I almost feel like saying:

"Friends don't let friends Total Etch dentin."

Read Pashley's article if you haven't by this point. You, and your patients, will not regret it.

 

[lemoncurry]

"Friends don't let friends Total Etch dentin."

I was fortunate enough to have Dr. Bertolotti give us a lecture for our esthetics/composites class last quarter. You hit all the main points in your post! I was especially grateful for Dr. B today as I did a very large class II comp on #5. I used the SE and his technique for placing a drop of flowable on the floor of the box, curing it, and going from there.

 

[DentinBond]

I was especially grateful for Dr. B today as I did a very large class II comp on #5. I used the SE and his technique for placing a drop of flowable on the floor of the box, curing it, and going from there.

You rock!! Keep your eyes open for the success this technique has compared to Total Etch. You will be amazed.

By the way, from an SEM standpoint, it's all about respecting the demineralized collagen net. It looks rather like a big bowl of angel hair pasta, roiling in the water. If we etch and dry, we collapse it totally. The compressive strength of human dentin is 19,000 MPa. The compressive strength of etched human dentin is one MPa. That's right, just one. So it collapses upon being dried with air. You go from a beautiful high-surface-area chemically reactive collagen net (angel hair pasta) to a flattened mass of gunk (like pizza dough that has been pounded down into a flat smooth layer) that no one can bond to. Self-Etching Primers don't do this- they virtually can't!

It's all about respecting the pasta. Uh, collagen net.

 

[The Hammer]

You rock!! Keep your eyes open for the success this technique has compared to Total Etch. You will be amazed.

By the way, from an SEM standpoint, it's all about respecting the demineralized collagen net. It looks rather like a big bowl of angel hair pasta, roiling in the water. If we etch and dry, we collapse it totally. The compressive strength of human dentin is 19,000 MPa. The compressive strength of etched human dentinn in one MPa. That's right, just one. So it collapses upon being dried with air. You go from a beautiful high-surface-area chemically reactive collagen net (angel hair pasta) to a flattened mass of gunk (like pizza dough that has been pounded down into a flat smooth layer) that no one can bond to. Self-Etching Primers don't do this- they virtually can't!

It's all about respecting the pasta. Uh, collagen net.

I started doing total etch in 1993 when Bertolotti and Fusayama were both controversially advocating the technique. At the time it was controversial because etching the dentin and enamel at the same time where thought to cause pulpal death. Here's a little interview with Ray from back in the day
http://www.dentaleconomics.com/index/display/article-display/242757/articles/dental-economics/volume-95/issue-11/features/an-interview-with-dr-ray-bertolotti.html

I still use the total etch technique and I also (oh dear God no!) bevel my enamel margins. After 18 years of doing this my success rate is pretty high. Rarely do I ever have sensitivity and what very few failures I've seen over the years were usually due more to the size of the restoration and the hygiene of the patient rather than any procedural technique.

The moral to this story is find a technique that works for you. If you get good results with it then try to continually improve on it. While you are doing this I assure you that your technique will fall into and out of favor many many times. Don't EVER think that research and clinician promoted techniques aren't affected by the manufacturers and their money. Don't be a sucker, trust what your own eyes and hands reveal to you👍

 

[DentinBond]

The moral to this story is find a technique that works for you.

Agree to a point. For instance, every single Captek crown that I've ever done (using two different labs) has failed through fracture except for four upper anterior crowns in one patient.

So I don't do Captek. Nothing could convince me to. Probably not even threats from the Taliban.

Thus, Hammer, I do as you have done when it comes to crowns and many other things in dentistry and do what works in my hands, so to speak.

Still, the science marches on. Bertollotti marches on, always innovating and improving. There is a tremendous body of research out there that shows the superiority of Self Etch over Total Etch, and even if our clinical results are acceptable with one technique, when things like transudation are proven to be less with Total Etch, we kinda have to listen. I'd encourage you to trial Prelude SE and make your own evaluation. Franklin Tay's SEM studies alone are highly compelling. We need to know what's going on under those enamel margins, down in the dentin...

And thus "Nothing could convince me to", above, is not quite true. If there was a large body of science that demonstrated in reproducible statistically significant fashion that Captek crowns (which do have excellent gingival response, that's their main allure) could be made with low fracture risk on premolars, I'd try 'em again.

 

[The Hammer]

Agree to a point. For instance, every single Captek crown that I've ever done (using two different labs) has failed through fracture except for four upper anterior crowns in one patient.

So I don't do Captek. Nothing could convince me to. Probably not even threats from the Taliban.

Thus, Hammer, I do as you have done when it comes to crowns and many other things in dentistry and do what works in my hands, so to speak.

Still, the science marches on. Bertollotti marches on, always innovating and improving. There is a tremendous body of research out there that shows the superiority of Self Etch over Total Etch, and even if our clinical results are acceptable with one technique, when things like transudation are proven to be less with Total Etch, we kinda have to listen. I'd encourage you to trial Prelude SE and make your own evaluation. Franklin Tay's SEM studies alone are highly compelling. We need to know what's going on under those enamel margins, down in the dentin...

And thus "Nothing could convince me to", above, is not quite true. If there was a large body of science that demonstrated in reproducible statistically significant fashion that Captek crowns (which do have excellent gingival response, that's their main allure) could be made with low fracture risk on premolars, I'd try 'em again.

Just curious but how long have you been out in practice?

 

[DentinBond]

Just curious but how long have you been out in practice?

Ugh- THAT question! haha Graduated from my residency in 1988. And so yes, the implication is true- I'm a few months older than the President of the United States. The first time that happens to you is shocking, let me tell you.

 

[DentinBond]

Just curious but how long have you been out in practice?

By the way, Hammer, I recall from your main thread that you're considering writing a book based on it all. And my feeling is:

Do it!

I'm writing a novel that is the first (to my knowledge) fictional treatment of the decidedly non-fiction business concepts of Seth Godin, Anne McCrossan, Chris Anderson and, underlying it all, Everett Rogers and Diffusion of Innovations research. I believe that a fictional treatment will help spread these ideas and clarify them through examples involving characters and such. Anyway writing is an excellent thing to be doing, and it's among the most fun I've had in ages.

I treasure my patients and love serving them; it's also nice to do something that may have an impact on a larger field. The combination provides balance.

Now I have to say something else about bonding so that I'm not guilty of derailing this vitally important thread!

Beware the one-bottle, one-liquid Self Etch product. Where primer and bond are all in the same liquid. In fact, don't use any of them- yet. They don't work.

First of all, there is no advantage to having one bottle or two- it's just a facile marketing technique. You will lose speed! With Prelude SE or SE Bond it takes 50 seconds max to do everything up to placing composite- 20 seconds to apply the primer and agitate, a few seconds to dry lightly, and 20 seconds at most to apply the bond and light cure and wick away the excess. The one-bottle systems take five applications (usually, can be more) of something like 20 or 30 seconds each counting evaporating time. You could write a book a day while you're waiting if you do a lot of composites...

And then:

There's a lot of chemistry in those single bottles. If you don't stir and shake them a lot, you're not getting all the chemistry to the tooth and the bond fails.

There's a lot of chemistry in those single bottles, and each and every component evaporates at a different rate. The bonding agent that you have in a month-old bottle is vastly different than the bonding agent that you have in a new bottle.

Transudation issues are severe with one-bottle Self Etch systems, as of July 2011.

Bond strengths with one-bottle Self Etch systems, to both enamel and dentin, to use the vernacular, suck. Again, as of July 2011; perhaps they will eventually be made better.

They're also more expensive by far. Please, everyone, don't ever pay more in dentistry for an inferior result! Looking at the science not the marketing will, to an extent anyway, protect us all from that. We just have to watch out for when the science is the marketing. Reproducibility of studies is, in the long term, what protects us from that. We have to do some homework and remain vigilant.

 

[DentinBond]

I was somewhat surprised when this thread faded off a bit, because so many dental schools are still mainly teaching Total Etch. Self-Etching Primers could be expected to foment a little controversy, what?

I just wanted to point out some of the main ways that we can mess up the bond of Self-Etching Primers. They are extrremely technique insensitive because of how they treat the collagen layer in the demineralized dentin. So it's hard to mess them up. Yet I wouldn't want anyone to try them and develop a distorted, negative view of their effectiveness because of a preventable mistake.

Here, then, are a few things that can reduce the bond to enamel and dentin as created by Self-Etching Primers:

A too-thick first layer of flowable composite. As I mentioned in a reply above, I had a short but regrettable phase where I did this in Class II gingival box areas. Self-Etch Primers create such an effective dentin seal that my patients were not even sensitive, but the resin shrank towards the best bonded surface (not towards the light, that's a myth) and left gaps larger than 1mm on the gingival wall. Which I saw on the next routine bitewings. Gack! Time to apologize to the patient for having to get them numb again, and then replace the restoration at no charge. Luckily it wasn't very many of these that went awry... So. Place a very thin layer of radiopaque flowable composite first, then another, and then start banking the main composite in a few asymmetric layers. In Class II preps the C-factor is appreciable so one bulk fill is not a great way to fill- too much stress, you will either debond or perhaps crack cusps a bit.

Handpiece oil. We use Kavo Electrotorques but it happens with any type of handpiece, electric or air turbine. Standard procedure is to spray and clean handpieces with oil before they hit the autoclave. That oil is ready to spray out once the handpiece is used for the first few seconds. If the water is on, as it normally should be, the oil gets dissipated a bit but sometimes we'll roughen up an abfraction with the water off. The oil often blasts out and makes a mess of the entire arch. If oil gets on your prep, wiping it off with alcohol before any attempt at bonding is indicated.

The alcohol that you no doubt have in your operatory will suffice, there's no reason to serve every patient a House Cab or something. Still, that could make you rather popular...

Strong acids are contraindicated before self etching agents, unless you only use them on the enamel. Don't even try that- you're too likely to mess up the dentin. If the prep is mostly enamel, like anterior Class III's and IV's, use Total Etch from the get-go. This is more complex than you'd think, though. Most hemostatic agents are as or more acidic than 37% phosphoric acid. Hemodent is, for example. If these agents get all over a gingival wall or Class V, the bond from a Self-Etch Primer will be reduced. Solution? Visine makes an excellent hemostatic agent, it's cheaper, and since it's for ocular use you can imagine that it has a neutral pH. Thanks to Dr. Ray Bertollotti for pointing that out. Plus just about everything else! Or, we can use a laser. The Picasso is now under $3500 depending on options.

If a little saliva gets on a self-etched prep, you can dry it. If bleeding occurs into a prep, better to rebond.

I can only speak for Prelude SE and SE Bond in that these are light-cured only and if you placed a deep self-cure resin onto them, like a core buildup, it will not bond, it will fall off. Do you know why?

The air-inhibited layer never cures. Self-cure resin on top of light-cure bond will never let that layer cure unless light somehow gets to it. Fortunately, both systems have a third liquid that turns the bond into a self-cure. As long as that third liquid is used, everything works fine with self-cure or dual-cure materials when the light cannot penetrate to the bond layer.

Plus, whenever my assistants Helen and Alicia ask, with arched brow, "Third Liquid?", we share the inside joke- wouldn't that make a superb title for a suspense film, a la Hitchcock? "The Third Liquid".

For that, I'd go to the midnight premiere...

 

[crazy_sherm]

Yes. I know what all of the materials do. In Washington hygienists are licensed in restorative. My question is: does it matter at what point in the process Gluma is placed? Wouldn't Vitrebond do the job of sensitivity reduction regardless of whether Gluma is placed under it?

If you really do understand what the materials do, then just think about what you are trying to accomplish with the Gluma. If Gluma only works when it is placed on dentin, what would be the point of applying it AFTER you've already covered the dentin with Vitrebond?

 

[SeattleRDH]

If you really do understand what the materials do, then just think about what you are trying to accomplish with the Gluma. If Gluma only works when it is placed on dentin, what would be the point of applying it AFTER you've already covered the dentin with Vitrebond?

Because I often place Vitrebond in only one spot (the deepest part of the box) and then place Gluma on the rest of the dentin that is exposed. Does Gluma need to be placed under Vitrebond? Does it make that much of a difference?

 

[haisha ni narou]

Because I often place Vitrebond in only one spot (the deepest part of the box) and then place Gluma on the rest of the dentin that is exposed. Does Gluma need to be placed under Vitrebond? Does it make that much of a difference?

If you are going through the trouble to place Gluma, you might as well do your Pt a service and apply it to all of the exposed dentin, at least the internal preparation walls prior to Vitrebond application. Not only does Gluma precipitate the plasma proteins within the tubules up to 200microns, but it has recently been proven to be a great disinfectant when scrubbed onto the prep for 2 separate 1min applications. On the same token, if you apply vitrebond, you might as well do your Pt a favor and apply it to the internal walls as well. The Gluma provides an internal protection, the Vitrebond provides an outer layer of protection. My thoughts on direct composites are if you place Gluma, vitrebond, and use a self-etching bonding technique, chances are pretty darn low your Pt is going to have post-op sensitivity secondary to material/bonding/restorative technique.

So to answer your question, yes, it does make a difference to place Gluma under your vitrebond simply because Gluma does not penetrate Vitrebond.

 

[SeattleRDH]

If you are going through the trouble to place Gluma, you might as well do your Pt a service and apply it to all of the exposed dentin, at least the internal preparation walls prior to Vitrebond application. Not only does Gluma precipitate the plasma proteins within the tubules up to 200microns, but it has recently been proven to be a great disinfectant when scrubbed onto the prep for 2 separate 1min applications. On the same token, if you apply vitrebond, you might as well do your Pt a favor and apply it to the internal walls as well. The Gluma provides an internal protection, the Vitrebond provides an outer layer of protection. My thoughts on direct composites are if you place Gluma, vitrebond, and use a self-etching bonding technique, chances are pretty darn low your Pt is going to have post-op sensitivity secondary to material/bonding/restorative technique.

So to answer your question, yes, it does make a difference to place Gluma under your vitrebond simply because Gluma does not penetrate Vitrebond.

Thanks!