CDEN0210

34 I I opinion _ dental materials _We’ve all heard the term “gold standard” ap- plied to many items in our everyday lives as well as thoseusedinourpractices.Forthesakeofdiscussion, we’ll define “gold standard” as the product in a spe- cific category that reaches the highest level of achievement sought after by all competitors. But is this nebulous concept static or dynamic? In my view, ithastobedynamicinourfast-changingworld.Here are some gold standards in general dentistry and my view on whether they need to be updated. _Cast gold restorations Itseemsappropriatetostartherewhendiscussing gold standards. According to several widely quoted surveys1 ,dentistswouldprefertohavetheirownteeth restored with gold, even as they recommend tooth- colored alternatives for their patients. Although this may have been true in the past and still may be ap- plicable to the “senior” members of our profession, I doubt it applies any longer to most mainstream practitioners. Traditionalists also will argue that no matter how well-madeaceramicrestorationis,itwillnevermatch the amazing longevity of gold, which will not cause accelerated wear to the teeth against which it oc- cludes. But with the advancement of ceramic tech- nology, specifically in relation to zirconia-supported crowns and bridges, excellent-fitting and durable restorations are no longer the exception. Neverthe- less, if a patient desires the ultimate in strength and esthetics are not an issue, then cast gold is still the standard. _Bonding agents With self-etch products being introduced on al- most a weekly basis, you would think that the gold standard had shifted away from total-etch. But even the owner of one of the most prolific manufacturers of both types of adhesives was quoted recently as stating that he still considers “fourth generation, total-etchadhesives”asthepinnacle.2 Inaddition,the only bonding agent to receive a five-star rating (the highest possible rating based on clinical and labora- tory testing) in the 2009 Annual Edition of REALITY happens to be a fourth generation, total-etch prod- uct.Furthermore,thebondingagentthatcreatedthe so-called seventh generation (that is, an all-in-one self-etch material) has recently undergone brand ex- tension with the introduction of a total-etch sibling. Even though there are several very good self-etch adhesives,Ibelievethatthegoldstandardstillbelongs to total-etch. This is due to the virtually universal application of total-etch products, including their utilityonunpreparedenamel.Granted,youneedtobe somewhat more conscientious when applying total- etch adhesives than you would be with self-etch ad- hesives, to prevent postoperative sensitivity. Rinsing offtheetchantisanextrastepandanunpleasantone at that, especially when you are not using a rubber dam. In addition, self-etch adhesives usually are more than adequate for certain restorations, such as full crowns. Having said that, if you could have only one bonding agent in your office, it should still be a total-etch version. _Curing lights Halogenlightswerefirstintroducedapproximately 30 years ago and ruled the roost for most of this time despite the brief and rather tepid challenges of argon lasers and plasma arcs. During this time, these lights havereliablycuredallphoto-activatedmaterialswith reasonable efficiency and economy, due to the wide bandwidth of halogen bulbs. However, light-emitting diode (LED) units have stolen the thunder of halogen lights,duetotheirrelativelysmallsize,mostlycordless design,andmoreefficientenergymanagement. cosmeticdentistry 2_2010 The gold standard Author_ Dr Michael B. Miller, USA Dr Michael B. Miller