Synthesizing Research to Create Practical Dental Protocols

How does peer-reviewed literature make it into the hands of practicing dentists? Sometimes it doesn’t. Other times research can be misinterpreted and applied incorrectly. The process of analyzing and applying current research is time consuming for practitioners to the point where new dental findings often fail to be widely adopted in practice.

Reminiscing on his first meetings with researchers John Purk and Jack Ferracane, Dr. David Alleman discusses how synthesizing research into practical protocols requires a deep understanding of how research is conducted and a treatment-focused view of how different protocols interact with others. Without this perspective, research may be applied incorrectly, but with productive conversations and large-scale clinical examples, his Six Lessons Approach protocols show how using current literature to benefit patient outcomes is possible.

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Transcript

0:33

well, welcome to episode six of season three of the Six Lessons podcast. Today we're going to be talking about some real life experiences that unite clinical practice with dental research and conferences that many dentists attend. So today we're going to talk about a historical event. History can be yesterday, it can be a few months or years ago. This event happened in. the year 2006. In the year 2006, I traveled to University of Missouri in Kansas City. The School of Dentistry was putting together and advertise a conference. In this conference, hundreds, maybe even thousands of dentist were invited to. But a couple of hundred dentists from around the world who were interested in research came to University of Missouri, Kansas City, dental School to talk about the title was Oral and Craniofacial Biological Symposium. That sounds pretty, comprehensive in some of the lectures were on some cranial facial biological investigations that have nothing to do really for everyday clinical dentistry. But what, really interested me is the person who was putting it on was a name man named David Eick. And in 2006, he had been working for about ten years on a new composite. The composite had a foundation not of methacrylate polymerization, but of what are called silorane chemical polymerization. silorane were what's called a heterocyclic chain or a heterocyclic monomer. You have a molecule that has a ring in it that has a double bond. And when a free radical, it's said double bond the ring expands. So this molecule, instead of contracting as normal methacrylate polymerization do, actually expanded. So this was supposed to solve the problem of shrinkage of composite. Because these composites didn't shrink when they polymerize they actually expanded got a little bit larger. So they're going to act like amalgam, which had the ability to expand a little bit upon its phase changes from soft material to a hard material. Amalgam expanded. Well for ten years, three M had been funded. David. Eick David, I'm not a dentist, but a PhD in chemistry, worked on this and they finally came out with a product. They tested the product in the tests. They thought it was promising in clinical application. It was no better, even worse than amalgam, because it didn't polymerize and connect with the molecules that connected the composite material to the tooth, which is called the hybrid layer formation. And the reason why that happened is because these molecules were too big. they weren't small and skinny, they were large. And this prevented them from integrating in a deep mineralized part of the dentin which was necessary for hybrid formation. Oh, well. In 2006, I was excited to hear from the actual creator of this new material about its maybe strengths, but I had heard and read that we didn't have this real breakthrough. But I wanted to meet David Eick and I also wanted to meet a member of his faculty named John Purk. So John Purk had published articles in 2004 and again in 2006, the year of the conference that, confirmed some of the conclusions I had made about the difficulty of bonding to the box. Of a deep margin because a box had parallel tubule preparations. In other words, the preparation of the floor of a box. The axial wall has a perpendicular cut. The floor of the box has a parallel cut and exposed large amounts of peri tubular dentin, almost 100% hydroxyapatite in a total etch approach. This allows a lot more pulpal fluid to be expressed and to dilute the priming stage. I could see from previously published literature that this was probably one of the reasons why failure in adhesive restorations almost always started on the floor of a deep box, so I wanted to meet John Purk I want him to meet David Eick. I was one of the few private practice dentists, but, in 2006, I'd already started teaching six lessons, for three years. And so it wasn't exactly a full time practicing. dentist I was teaching part time these advanced adhesive concepts that had been emerging that I had synthesized into the six lessons. So I show up, the room is filled with faculty members from all over the country, even the world, and they're talking about what their research in different universities was doing. And, one of the researchers that I really wanted to meet was Jack Ferracane from University of Oregon in Jack Ferracane again, not a dentist, but an engineer, had published a lot on composites. He was and is still considered one of the world's experts on composites. And, at this conference, as I signed up for the conference, you know, I think the the tuition was $900, something like that. But for an extra $50, I could have lunch with the experts. That's what they advertise. But So I signed up for Jack Ferracane's table, and, during the lectures of that day before lunch, there was a lecture given by another researcher And in her lecture, she made some very bad conclusions about composite modeling. I was on the front row. all of her conclusions were technique based failures, because she had a poor technique, she had failures in composite bonding. And in 2006, I'm expecting all of the experts who will see the advancements in bonding, solve the problems of traditional fillings and crowns and solve the failures of early composite, bonding attempts, which I experienced personally in the 80s. But now, in 2006, 20 years later, I expect only the people who had had success to be talking about. But she also signed up for the table with Jack Ferracane and John Purk signed up for the table with Jack Ferracane And so John Purk I had met at the break before lunch because this presentation She showed a slide. And the slide that she showed, she gave credit to John Purk providing the slide. It happened to be an SEM which is one of my favorite SEMs in the world. on the screen. And then in the credit for this slide, she gave credit to John Purk One of her faculty colleagues during the break. I looked in the poster area where different posters had been presented by different researchers that weren't speakers in the conference, but the poster session was there and so I was looking around to try to find this John Purk who I didn't know personally at that time. and I introduced myself. You know, I really appreciate your published articles in the Journal of the American Dental Association. 2004. And then this year I've came here to meet you, David Eick I asked John Purk a question that I knew the answer to. I said, you know, put up a slide and she gave you credit for it in her lecture. And John Purk was like, oh. Oh, yeah. Really? What slide was he says, well, it's a slide that your chairman of your department, John Eick published in Nakabayashi Pashley book in 1998. So this is eight years previous. John Eick's SEM was in Pashley’s and Nakabayashi's book and they gave credit to Eick. And then this slide in this lecture in 2006 giving credit to John Purk Well, that's a real No-No to take credit for somebody else's work. So I said, you know, I, I think that's that's what she said. he was like, oh, really? Well, maybe I gave her that slide, but which slide is it? And I said, it's on page 21 of hybridization of dental hard tissue. It's a John Purk said, oh I should we should go look that up. So we, we left the conference, got in his car and drove to his office at the dental school. The conference was at a hotel in Kansas City. We drove to his office and, he looks up on his computer to find that slide and that she had given him credit for. But it wasn't his work. He found it on the computer and then he didn't know where it came from. And so I said, well, do you have the copy of the book hybridization, Dental Hard tissue? It's obviously part of your, you know, expertise as an adhesive dentist that you published on he looked on his shelf. He didn't have a copy. So John Purk and I went to the dental school library, checked out a copy of this book, and I said us on page 21. He opened it to page 21, and that was the slide And she had given him credit. And on page 21 it says, courtesy Doctor JD Eick University of Missouri, Kansas City. He was embarrassed. Well, he was going to rectify it apology to Doctor Eick I don't even know if doctor I noticed it in the lecture because he's in charge of the whole conference. He probably wasn't listening, but, John Purk and I drive back to the hotel because we're both signed up for the lunch with Jack Ferracane. during our conversations, I just happened to, you know, show John Purk binder that had about 100 articles that are now part of the mastership, but I kind of use those as kind of a test to see how much an expert knew if they had a pretty good working knowledge of those 100 articles that I always carried with me in those days Anyway, I made it very clear to to John Purk that, when I taught adhesive dentistry and I used some information from him, I always gave him credit. When I used stuff from Pashley Nakabayashi always gave them credit. Obviously. Doctor Eick expert in his, field of research in this picture was very important because it actually showed in detail the size of a collagen fibril was compared to, orifice of a dentinal tubule. Just a just one of the most instructive, SEMs that you could learn from when you go on a, talk about dentin and the relationship of collagen and hydroxyapatite and pulpal fluid is just fantastic. But then when we came in, we just were late to the lunch, but there were eight other people, we were on the other side of the tell tables around table that had, ten doctors, Jack Ferracane and And then as we were eating, we would have conversations with, Jack Ferracane and, you know, I was trying to introduce myself to Jack as somebody who knew what I was talking about, and, and, I made some references and estimates of specific questions about certain, adhesive concepts that had been published in the literature. And John Purk was right next to me. And he was saying, yeah, he really knows his stuff. He's got this big notebook. And I showed him my notebook. You know, the other doctors around the table were like, well, what? You know, who's this guy? No, I don't have any reputation. Nobody knows anything about the elements except people in Utah at this time. I've been teaching for three years there, but very few had any, knowledge of me from around the country. But I was trying to impress Jack fabricate. And so I wanted to have a, a discussion on a very important article was published in 2001 by Sema Belli. And, doctor Inokoshi her mentor at TMDU because it had shown the reversal of the flow of composite from enamel, which all of the other experiments had always shown composites moving towards the enamel surface, which was associated with where the light was coming. So the misconception that composites shrink towards the light was a very common misconception. 1998 it was disproven by FEA analysis by by a doctor, Versluis but still still taught in dental schools. You put the composite light here. Composite moves towards the light. It was really moving towards the enamel because there was a hierarchy of bondability that nobody had ever talked about, nobody had described. I've been teaching it for three years, but the idea that the composites move towards the best bondable surface that they're attached to at that particular time means that there is a competition between different bond abilities, and I had to do that. That was a direct relationship to the concentration of the amount of hydroxyapatite in different surfaces enamel versus superficial dentin, deep dentin versus superficial dentin outer caries versus any types of dense inner caries versus other types of dentin This hierarchy of vulnerability that I had discovered and been teaching to other dentists for three years, nobody knew about that. So I wouldn't expect Jack Ferracane to know about it, for sure, but I was trying to see how much Ferracane had looked at this article in 2001, because it actually showed composite moving towards the dentin not towards the enamel. And my deduction was it was because they had taken the time to resin coat that surface. And after the immediate and sealing the resin, coating now neutralize the hierarchy of bond ability. And actually the resin coating gave the hierarchy of bond ability a little bit of a nod towards the resin coated dentin. But that time that it took to put the resin coating and take of photography a photograph in a lab, you know, do the lab stuff, you're taking your time, you know, it's not a patient, it's an extract, the tooth you're working on. But however it happened Inokoshi and Belli showed that once you place that resin coating. Now the composite was stressing the enamel, fracturing enamel and now moving towards and staying sealed at the bottom of this, preparation on this extracted tooth. It was a very important piece of research. And I told Jack Ferracane I said, this research is just fantastic. He really knows what he's doing. And as soon as I said, he associated with the name some of Belli Jack Ferracane sat back and started laughing. You know, obviously you've never met Sema Belli She is not a he. She's a woman. And everybody around the table had a big laugh, you know. And but John Purk was like paying attention because all of a sudden this guy that nobody knew knew more than everybody, maybe Jack Ferracane did, but he hadn't demonstrated the. Oh, yeah, I love that 2000 or 1 publication up or Operative Dentistry by Sema Belli And Inokoshi, it's one of my favorite. Not me. Jack Ferracane basically didn't know have a working knowledge of that article, but I had read it so many times and I felt like it was one of the top articles of the hundreds that I had mastered at that time. And so to me, it was like, hey, Jack, Ferracane knows that. He knows John Purk knows that he knows But those are judgments that I'm making of everybody in the world that's trying to have some influence on adhesive dentistry. And if you said he said dentistry doesn't work. And I've been making it work for ten years, then I have a problem with that because it's not the material, it's how you use the material. Sure, materials do matter and you should try to innovate new materials, but the new techniques that had been innovated by myself, Simone Deliperi and others that were not really recognized, although Jack Ferracane did have a relationship with Simone Deliperi at that time. And, we've had some, some conference calls and courses at Simone and I have taught and Jack Ferracane is very open. You know, we've spoken with him on numerous international stages. Davey and I, and we consider him a colleague, a friend. But on the same token, he knows most about what he knows the most about. I know most about what I know most about Davey is obviously, you know, using the same scientific foundations to go from. But, over the years after that 2006, interaction with John Purk he always sought Simone and I out. We were in Chicago for seven years, pretty much from 2006, to, the early 2000. We would go to the Academy of Operative Dentistry, you know, another meeting that cost $1,000 to attend. Plus, you got to live in Chicago for a few days, you know, $2,000 out of your pocket. It's not a cheap unless a dental school's paying for which most of the people at the Academy of Dentistry are faculty members. Not all of them, but most of them are getting their trip paid for. But Simone and I are there on our own nickel, and we're recruiting doctors to try to get training in these advanced techniques that we taught together for ten years. But, every time we would go, John Purk would seek out Simone and I because, we always had a good relationship. The other thing we had in common, John Purk had the same amount of kids that I do. Seven kids. So So John Purk and I could always talk about what it's like to raise seven kids. Never a boring day in the life of a large family like that. But John Purk you know, he's a researcher who I respect. The anyway, we we are all human beings trying to figure out our human life. And if somebody wants to criticize me, which I get criticized a lot, what can I say? I'm doing my best. I hope you're doing your best. But the science is something they can give us. I believe the only sure foundation to make progress in dentistry, if there wants to be, disagreements about what the science means or how it should be applied. I mean, that's always, up for a discussion. But, the discussions that I've had with, various top researchers, I would say all of the top researchers in the world, these researchers, when you read an article and there's one, two, three, four, five, six researchers, how do you get to know if this researcher is really, out of the box thinker, somebody who's really taking all that was there before and trying to synthesize it, and it takes time and effort to do that. It's a lot easier just to assume that other people who have been your mentors got it all figured out. I tried to do that with my first mentor, Ray Bertolotti He didn't have enough. I tried to do that with my second mentor, Gary Unterbrink He didn't have enough. I tried to do that with my third mentor, Didier Dietschi He didn't have enough for. So for five years I did everything I could to connect with the best minds that were available through conferences or research, obviously. And finally, in the year 2001 2002, I kind of said, look it. I've figured out things that nobody else has figured out. I've named phenomena and concepts and nobody else has named. And I know that they are the foundation to making adhesive dentistry work quite often, and adhesive restoration that last. The protocol isn't defined even in a research paper, that they don't understand what the difference is, because they never identified how long it took to do any particular step in the restorative process. And if time is a critical element in every chemical reaction and every adhesive restoration in dentistry is a chemical reaction. You have to have a direct bond to dentin to make a long term, successful adhesive restoration, sometimes restorations because the dentist does the right thing, but they don't know why they did it. That's a confounding variable. If you do something and it works like in a golf swing, you just make a swing and the ball goes straight, but you don't have any idea how to do it again, it doesn't make for a good golfer and it doesn't make for a good adhesive dentist. If you don't have a defined protocol and define protocols come from people who think in the idea that you have to have a system if you're going to have consistent results, and that's the foundation of science, you try to create a system that gives consistent results. all of the conferences in the past, obviously you can't go there, you can't take a time machine back to 2006. But this is a couple of stories from my experience. Other clinicians will have other experiences, but I believe that the more you know, the people who actually write the articles that we recommend that you read, the more you understand they're not perfect. Nobody does everything just right all the time. But you have a group that's emerging right now in the six Lessons Network that have consistent results because they're following a system. Last night, we had an hour long discussion with one of our first masters from India. Six years ago. She enrolled in six lessons. She's an endodontist her husband's a prosthodontist for five years, she's had consistent results with large adhesive restorations that have eliminated crowns and eliminated a lot of the endo that she was doing before. This is an endodontist trained in India. Her husband's a prosthodontist trained in India. But the idea is around the world, systems are in place, and if you talk to doctors who have a system and they have long term results, five years, ten years, 15 years, 20 years, now we're into our or third decade, I should say, of success. Using the six lessons approach. That's where you can have the confidence that if you follow the same protocols, using the same techniques, with the same materials, you'll have the same long term results that will keep pulp healthy. Conserve to structure and make patients really happy because they won't have to come and see you very often. Anyway, thanks for letting me talk. Hope you enjoyed it. Till next time, get bonded, stay bonded.