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February 2022, Volume 15 Issue 2

CR is the original and only independent dental product testing organization with funding only from dentists! ISSN 2380-0429

Why Composite Restorations Fail… and How to Manage Them

Gordon’s Clinical Observations: You carefully place many composites every day. The restorations often initially look like the teeth have
never had a restoration placed in them. However, a few years later, all too often the margins have cracked open and/or are decayed especially
on the apical portion of the proximal box forms, the marginal ridge has chipped off, or a crack has
appeared in the restoration. What has made the restorations degenerate to this level in just a few
years? More importantly, can you prevent these challenges? There are many potential reasons. This
article includes a survey of the most important observed composite failures, what dentists feel cause
failures, and how to potentially prevent them.
CR survey respondents attributed wear (10%), fracture (12%), and caries (70%) as the primary
causes of failed composite fillings.
In the following article, CR scientists and clinicians investigate composite failure modes,
Failing margins (staining, gaps, cracks, etc.)
explain whether wear, fracture, and caries are the actual causes of failure or just merely the
effects, and offer suggestions for composite restorative success. Continued on Page 2

Best Pediatric Restorative Materials for 2022

Gordon’s Clinical Observations: The most widely used restorative material for pediatric patients is resin-based composite. Is that the most
appropriate material? Logic indicates that in young, high-caries risk patients, preventive materials would be a better choice. The new glass
ionomers are a logical choice, but are they better and easier to use than the older variety? Is resin-modified glass ionomer an acceptable choice,
and where is amalgam in this decision? CR clinicians, project directors, and scientists have reviewed the materials used on primary teeth and
identified the best pediatric restorations.
Dental caries is the most common childhood disease. Parents and children need to be educated in areas they can influence caries potential,
including diet, hygiene, fluoride use, and routine exams and cleanings. But when the need arises to treat dental caries in the pediatric
population, what are the best restorative materials to use on primary teeth? Several challenges exist with many of the existing materials,
including shrinkage and no cariostatic activity. In this report, CR clinicians, project directors, and scientists have identified the best
pediatric restorative materials and techniques to make pediatric dentistry faster, easier, and more predictable.
Continued on Page 3

Why Everyone Needs to be Thinking about Retirement—NOW

Gordon’s Clinical Observations: Many dentists wait until a few years before retirement to decide what to do about leaving practice. Is this an
appropriate time? The answer is a strong NO. Plans for reducing or leaving practice should start early in a dental career. Should you retire? If
so, what do you do after retirement? What are the decisions you must make? Do you need professional help to make the important decisions?
How much is your practice worth? CR clinical staff have studied these questions and consulted with dentists who have retired to help you answer
these important questions for your specific situation.
Every change in your professional dental life is a transition. Whether you own a practice, are an
associate or partner, work in military or public health dentistry, work for a dental corporation, or
teach, every transition you make is part of your dental career with retirement being the greatest and
most challenging transition to make. Additionally, preparing for the consequences of retirement is
extremely important. In 2017, the average retirement age for dentists was 68.9 years. Only 4% of
dentists have the retirement assets needed to maintain their lifestyle to age 90 and beyond according
to recent studies. Preparation, planning, and guidance from a team of professionals you select is very
essential in these transitions and must begin immediately.
This article discusses all the phases of practice transition starting immediately and leading to a successful and fulfilling retirement.
Continued on Page 5

Products Rated Highly by Evaluators in CR Clinical Trials

The following products were rated excellent or good by CR Evaluator use and science evaluations.

✪ G-CEM ONE,
GC America ✪ Natural Elegance Premium
Flow, Henry Schein ✪ Attachment,
UDM
Laboratory Distribution ✪ IIA, Zest Dental Solutions
Pickup Proven Classic: MicroEtcher
(Universal Denture Material)

Network
Continued on Page 8
A Publication of CR Foundation • 3707 N. Canyon Rd, Bldg 7, Provo UT 84604 • 801-226-2121 • www.CliniciansReport.org
®

©2022 CR Foundation®
Clinicians Report 2 February 2022

Why Composite Restorations Fail… and How to Manage Them (Continued from page 1)
CR Clinicians’ Insight—CR Survey Results (n=686)
Why do composites fail? Do you etch dentin? Do you use a desensitizer? What brand of desensitizer?
73% Caries 57% Total etch (all surfaces) 44% Yes 49% MicroPrime G (Zest)
12% Fracture(s) 34% Selective etch (enamel) 21% Sometimes 29% Gluma (Kulzer)
10% Wear 8% No separate etch step 35% No 12% G5 (Clinician’s Choice)
Do you use a rubber dam How do you maintain a non-contaminated operating What is your preferred adhesive?
when placing a composite field? 25% ScotchBond Universal + (3M)
restoration? 24% Gauze, cotton rolls, dry-angles 16% Clearfil SE 2 (Kuraray)
13% Always 28% Use specialized isolation products, e.g., Optidam 7% All-Bond Universal (Bisco)
26% Sometimes (Kerr), Umbrella (UPI), Mr. Thirsty, DryShield 6% Adhese Universal (Ivoclar Vivadent)
60% Never (DryShield), Isolite 3 (Zyris)
Composite
Marginal Issues
Caries, staining, and crumbling margins are often indications of a failed composite restoration, but are not Adhesive Layer
the causes of the failure itself. The majority of failed composite restorations initiate from the breakdown
of the bond interface (hybrid layer), the part associated with sealing intact dentin from the external
environment. This is one of the most critical aspects of the restoration, as well as its weakest link. Hybrid
Layer
The Body’s Natural Defense Exposed
Immediately after exposing dentin to acid etch and/or acidic bonding primers, the body begins the Collagen

Tubule
process of ridding itself of the novel restoration. Matrix enzymes (MMPs), triggered by low pH, actively
cleave collagen fibrils within the hybrid layer which tether the restoration to the tooth. Further, studies Dentin
show production of these enzymes is up-regulated when odontoblasts are exposed to many of the resins
commonplace in current bonding adhesives.

Bad Bonds—Contributing Factors Composite Red Flags

Location
• Polymerization shrinkage: Shrinkage stress produced during curing induces open margins,
Molars 3× the failure rate vs premolars
fractures, microleakage, and bond failure.
• Surface contamination: Saliva contamination reduces bond strength by 90%. Surfaces (vs. a single surface)
• Cariogenic bacteria: The process of etching and curing adhesive does not kill bacteria remaining 2-Surface: 2.8× failure rate
on the bonded surface(s). This is a common misconception. 3-Surface: 3.3× failure rate
• Insufficient resin penetration into hybrid layer: Intact Existing Restorations
“Glutaraldehyde Collagen Cross-linking smear layer obstructs resin penetration to sound tooth High numbers of existing restorations
Stabilizes Resin–Dentin Interfaces and structure, preventing formation of a quality seal. indicative of increased caries risk
Reduces Bond Degradation”(1) • Residual solvent left in adhesive/primer: Solvent and elevated failure rates in future
Products containing 35% HEMA and 5% inhibits polymerization. restorations
glutaraldehyde (GA) have been known • Low pH (etchant, adhesives, bacteria): Activates Size
for decades to be effective in combating enzymatic (MMP) cleavage of collagen fibril anchor As volume of the restoration increases,
post-op sensitivity. However, recent studies points along so does the likelihood of failure. (Lack of
the base of the hybrid layer, creating voids.
demonstrate this class of materials does • Patient bruxing, clenching, grinding (mechanical), tooth support, temp related changes in
much more than calm irritated nerves. and exposure to acid volume, polymerization shrinkage, etc.)
erosion (bulimia, soft drinks, etc.).
• Effective bactericidal with two 60-second • Cavo surface margins in the cervical third are prone
applications to tooth surface. to failure due to thinning enamel and patient difficulties in keeping it clean.
• Seals dentin by penetrating intra-tubular
space and prevents water permeation. Clinical Tips
• Coats collagen fibrils protecting them • Isolation is the KEY: Make a concerted effort to keep the operating field contamination free.
from enzymatic breakdown and cross-links Contaminants block resin penetration to solid tooth structure, cause matrix enzymes to degrade
with bond agent. hybrid layer (bond), and harbor continued caries. Rubber dams are preferred, but other concepts
• Inactivates destructive matrix enzymes come close. (See PCC Vol 3531 “Successful Isolation of Operating Fields” for more info.)
(MMPs) providing significant protection • Treat tooth with desensitizer containing 35% glutaraldehyde and 5% HEMA.
from bond margin degradation. – Seals dentin: inhibits destructive enzymes within hybrid layer preserving bond
Application(2) Enzyme Activity – Proven effective bactericidal with two consecutive 60-second applications
Time Reduction • Create rounded internal angles in the prep. Acute angles within prep become stress centers,
5 Seconds 44% amplifying destructive forces along the bond margin due to polymerization shrinkage.
15 Seconds 50% • If using a single bottle, self-etching adhesive, confirm it has MDP, a functional monomer.
30 Seconds 84% (Present in majority of “Universal” bonding agents on the market.)
60 Seconds 86% • Removing residual solvent from bond agent best accomplished using a scrubbing motion
(1) Sabatini, et al., Eur J Oral Sci 2017; 125: 63-71. while applying (20 sec.) followed by gentle airflow until material becomes visibly more viscous.
(2) Inhibition of endogenous human dentin MMPs by • Studies suggest that removing the smear layer by briefly etching dentin allows the desensitizer
Gluma.,Tay, et al., Dent Mat 2014; 30: 752-758. to penetrate the dentin more thoroughly, resulting in a durable, longer-lasting bond interface.
Clinicians Report 3 February 2022

Why Composite Restorations Fail… and How to Manage Them (Continued from page 2)
Clinical Tips (Continued)
• The layering technique presented in the illustration below is just one of many accepted methods. The important aspect of any composite
placement method is the complete adaptation of the composite to the adhesive layer, void-free—a significant challenge to accomplish if using
a “bulk-fill” technique. For larger/deeper restorations, consider the “Sandwich Technique” (page 4) which combines the therapeutic benefit of
glass ionomers with the strength profile of filled composite.
• Pack composite and cure incrementally—no more than 1.5–2 mm per layer. Cure Layering Technique to Combat Shrinkage Stress
each layer thoroughly by curing through the tooth and then from the top. Layer composite in increments <2mm. Avoid
connecting opposing vertical walls in a single
L R
• CR suggests non-stick composite instruments with tip diameters of 1.0–1.5 layer to minimize tooth flexure due to shrinkage.
mm. Use gentle tapping motions to prevent pullback as composite is thixotropic
Place a thin layer across pupal floor (<1mm).
and will flow better with vibration. Avoid connecting layer with vertical surfaces.
• Adhesive flash along the cavo surface margins is very porous and promotes Cure from the occlusal.
bacterial adhesion. When finishing, preserve bond margins by removing Layers and : Cure through Cure layer through tooth from
marginal flash with a polishing disc and a dull 7901 bur for interproximal areas. tooth from the L side first, followed the R side first, followed by curing
• Always ensure proper occlusion after placement. by curing from the occlusal. from the occlusal.

CR CONCLUSIONS:
• Surface decontamination and preparation are two of the most critical aspects of creating successful composite restorations.
• Inclusion of a quality desensitizer containing 5% glutaraldehyde and 35% HEMA for a minimum of 60 seconds is strongly recommended
for all composite restorations to minimize the effects of enzymatic degradation and decrease dentin permeability. As a bactericide, two
60-second applications are necessary. (Do not use air to thin material.) After second application, remove excess with HVE.
• Incremental placement (no greater than 2 mm thick) and minimizing the number of surfaces being bonded to in each layer lowers the effects
of polymerization shrinkage stress on the bond margins.
• Composite restorations have certainly changed the face of modern dentistry, but until dental manufacturers solve the 2% shrinkage issue
inherent in dental resins, the creation of a durable, long-lasting resin restoration will continue to be a challenge to any dentist choosing to use
these materials as a primary restorative.

Best Pediatric Restorative Materials for 2022 (Continued from page 1)

CR Survey Results What is your primary material for pediatric restorations?
• Do you treat children? 70% Yes, 30% No
Composite 51%
CR Note: Best comment from survey was, “God made pediatric dentists to treat
children so I don’t have to.” RMGI 16%
CR Note: Although resin-based
• Do you routinely place stainless steel crowns? 80% No, 20% Yes Amalgam 10% composite is used most, research and
CR Note: Stainless steel crowns are routinely placed by pediatric dentists and clinical observation support the use of
GI 7% glass ionomers (GI) and resin-modified
are an excellent alternative for general dentists. glass ionomers (RMGI) in pediatric
• Do you use silver diamine fluoride? 52% No, 48% Yes Compomer 7% patients with caries challenges or in
CR Note: Silver diamine fluoride is a useful adjunct for behavioral management moderate to large preps.
Sandwich 7%
patients and as a Class I caries indicator. 10% 20% 30% 40% 50%
Best Pediatric Restorative Materials
Selecting the best type of RESTORATIVE Glass Ionomer:
MATERIAL for the PEDIATRIC PATIENT based Often the material of choice for restoration of primary teeth
on CARIES ACTIVITY CR Choice products: New Conventional GIs (Glass Ionomers)
MINIMAL MODERATE
Caries Activity Caries Activity
Small Moderate to Large
Tooth Preps Tooth Preps
• RMGI: fast, light cured, self- • RMGI or New Conventional
adhesive. GI: internal with resin-based
• New Conventional GI: composite on the occlusal
high fluoride release and surface (sandwich technique,
see Figure 1, page 4). Equia Forte, GC America Ionostar Plus, VOCO Ketac Universal, 3M
complete seal of the margin.
Companies recommending • Stainless Steel Crown:
CR Choice products: RMGIs (Resin-Modified Glass Ionomers)
GI for small Class I, II, and provides durability and
V. (See Figure 2, page 4) predictability. Cement with
• Resin-Based Composite: RMGI.
acceptable for small preps
and minimal caries activity.
NO cariostatic activity and
NO complete seal.
* Longevity: The restoration choice is also influenced by the
amount of time the tooth will be in the mouth. If a tooth is close
Fuji Automix LC, GC America Ketac Nano, 3M Riva Self Cure HV, SDI
to exfoliation, a minimally invasive and conservative restoration
should be considered.
Clinicians Report 4 February 2022

Best Pediatric Restorative Materials for 2022 (Continued from page 3)

Best Pediatric Restorative Materials (Continued)
There are several alternatives for the restoration of primary teeth. Many of these relate to caries activity and size of the restoration. Although
resin-based composites dominate restorative dentistry, these might not be the best materials for selective restorative dentistry in children.
The following is a list of potential pediatric restorative materials for primary teeth.
Restorative Material Potential Indication Advantages Limitations Example Materials
• 80% glass ionomer, 20% resin • Learning curve for use • Fuji Automix LC,
• Light cure • Somewhat sticky GC America
Resin-Modified
• Fluoride release • Less fluoride release than conventional glass • Ketac Nano, 3M
Glass Ionomer Moderate caries
• Faster finishing than glass ionomer ionomers • Riva LC HV, SDI
(RMGI)
• Less chair time • No seal like conventional glass ionomers (Southern Dental
• Self-adhesive • Slight polymerization shrinkage Industries)
• Significant fluoride release • Continued wear, strength, and esthetic • Equia Forte and
• Complete seal of restoration to the tooth (see Fig. 1) challenges Equia Forte HT, GC
• Improved handling (putty consistency) • Requires triturator America
• Less sticky than previous version • Self cure (need to wait) • Ionostar Plus, VOCO
New Conventional • Promoted conservative Class I, II, and V • Internal use only for larger restorations • Ketac Universal, 3M
High caries
Glass Ionomer (GI) restorations
• Can be used internally as a dentin replacement or
under larger restorations
• Self-adhesive
• No shrinkage
Combination of Glass Ionomer and Resin-
Use of RMGI or GI internally (dentin replacement) with resin-based composite on the occlusal surface (see Figure 1).
Based Composite (Sandwich Technique)
• Strength • No cariostatic activity Many
• Wear • 2% shrinkage
Resin-Based Low caries (small
• Esthetics • Margins of all composite restoratives are open
Composite prep)
• Technique sensitive
• Moisture sensitive
• Putty like, easy to use • Similar negative characteristics of resin- • Dyract Extra,
• Hydrophilic resin based composites Dentsply Sirona
Alternative with slight
Compomer • Light cured
F release
• Slight fluoride release
• Used in some countries
• Most durable restorative in primary teeth • Expense to patient • Stainless Steel, 3M
Stainless Steel • Best restoration for extensive caries • Extensive tooth preparation • 3S Stainless Steel,
Gross caries
Crown • Children at high risk for caries • Esthetics Acero Crowns
• Patient cooperation
• Esthetics • Expense • ZR Zirconia,
Zirconia
• Strength • Extensive tooth preparation NuSmile
Prefabricated High esthetic need
• Durability • Lack of long-term research
Crown
• Extensive caries primary posterior/anterior teeth • Learning curve
• Relatively technique insensitive • Alleged health concerns Various
• Speed • Not esthetic
Low budget, high
Amalgam • Low cost • Not as acceptable to some parents
caries
• Durable • Banned in some countries
• Easy to use

Figure 1: Suggested Sandwich Technique Figure 2:

Glass Ionomer Restorative Margin Seal
Materials: Year 1 Year 3
• RMGI or GI internal
Enamel Enamel
• Resin-based composite on the occlusal surface
Technique:
1. Disinfect and desensitize prep with 5% glutaraldehyde, 35% HEMA. Two
1-minute applications. (MicroPrime G, Gluma)
2. Place RMGI/GI in the bottom of the prep as a dentin replacement. Light cure
the RMGI or let the GI material set to a heavy putty (if used internally, the GI
does not have to set completely). Equia Forte Equia Forte
3. Acid etch the enamel and the glass ionomer. CR research demonstrates that 1000× 1000×
the acid etch roughens the GI enough to bond to resin-based composite. The major advantages of the new conventional glass ionomer materials are their
4. Place bonding agent and composite of choice. high fluoride release and complete seal of the material between the tooth and
the restoration. This is the first category of restorative materials to receive such
See Clinicians Report July 2020 achievements in the long history of research by CR Foundation.

CR CONCLUSIONS: The best restorative materials for primary teeth are determined by caries activity, size of the restoration, longevity of the
tooth, and behavior of the patient. Although resin-based composites dominate restorative dentistry, their use in pediatric dentistry should be
limited to small preps, minimal caries activity, and optimal isolation. Resin-modified glass ionomers and the new conventional glass ionomers
are the restoration of choice for most situations because of their fluoride release and improved properties. Stainless steel crowns are indicated
for moderate to extensive breakdown and gross decay.
Clinicians Report 5 February 2022

Why Everyone Needs to be Thinking about Retirement—NOW (Continued from page 1)

NOTE: There is so much information on the topic of Practice Transition leading to Retirement that this is a condensed version.
The complete detailed version of this “must read” important subject can be found on the CR Website, CliniciansReport.org.
Start Now for Retirement—Why?
• Retirement happens faster than you think—you must be prepared.
• ADA News 2003: Only 5% of dentists had more than $1.5 million in retirement net assets. This means fewer than 5% had retirement assets to
sustain their lifestyle in the ways they had grown accustomed.
• Currently, most dentists will need over $2.5 million at retirement. Those retiring in the future will require even more because of inflation.
• Money saved early (20s and 30s) has the time to grow dramatically; saved later (50s) will not have time to grow (see blue box: Rule of 72).
• Starting and building your tax deferred retirement plans (e.g., 401k, 503b, simple IRAs, and others) is the first critical step in planning for
retirement.
• Plan for the Unexpected. Changes that can affect your retirement plans: Practice Transitions: All Leading to Retirement
– Your current practice situation; becoming an owner, associate, partner, etc. • Practice transition includes all the changes in your dental career.
– Your current and future financial situations • Every transition becomes an opportunity to think about your retirement plan.
– Disabilities; your physical or mental health • Practice Transition ultimately leads to retirement.
– Your family situation • All transitions can be traumatic, exciting, and will cause changes in your life.
• Begin immediately. Every year, starting at the first year out of dental school,
at least 10% of gross income should be put away “before tax” automatically. If it’s not in your “paycheck,” it is not missed.
• Time is needed to be continually increasing the wealth (in your practice).
– Monetary wealth: establishing, maintaining, and improving your net worth Financial Planning for Retirement:
leading to financial freedom Use the “Rule of 72”
– Creating a long-term legacy and equity in your practice How money builds with compound interest
– Creating the financial freedom to live and maintain your desired lifestyle • Estimate a “Rate of Return” that you will obtain. Divide that into 72, and you get
the number of years it takes for money to double.
• Be proactive! You need time to create plans for something to retire to.
• 7% doubles roughly every 10 years, 10% doubles roughly every 7 years
– Start thinking and dreaming now what you will do in retirement
• At 7% return, $50,000 put away at age 25 becomes nearly $800,000 at age 65.
– Time to acquire a “reason to retire” $50,000 put away at age 55, only grows to around $100,000 at 65.
• If in a Dental Service Organization (DSO) or traditional practice, you could • Money put away early is the MOST VITAL money. Don’t Wait!
build equity ownership, but don’t count on this equity to fund your retirement. • Your Retirement lifestyle and happiness is often dependent upon your savings.
Plan a retirement without these assets.
What Surveys tell us about Dentists and Retirement
• Anecdotally, Gordon, during his lectures, has found that some retired dentists have told him that “they have flunked retirement.”
CR Survey Results (n=660; average respondent age: 54 years)
• Expected retirement age: 9% ≥60, 21% 61–65, 31% 66–70, 24% ≤71, 15% will practice as long as health allows.
• 63% of respondents do NOT have a plan in place for retirement. Get Help:
• Over 1/4 are NOT maxing out their tax-deferred retirement savings. Assemble a Team of Professionals to
• Nearly 1/2 did NOT feel they were currently on pace for retirement or did not know. Guide Your Transition to Retirement
• Clinicians who felt uncertain or who were NOT on pace for retirement were: Professional assistance is definitely necessary and will
contribute to all your decision-making processes leading
– 2.7 times more likely to NOT have a plan in place for retirement. to retirement. Acquiring this team can be accomplished
– 2.6 times more likely to expect to practice as long as health will allow. DURING and THROUGHOUT your career, by adding the
– 5 times more likely to NOT save any money tax-deferred. necessary expertise when needed. Creating this Practice
– ~2 times more likely to NOT max out tax-deferred retirement savings. Transition Team is a requirement.
– ~1.5 times more likely to NOT utilize practice transition/retirement professionals. • Attorneys and CPAs that have dental experience
• Practice Consultants and Practice Management Companies
Define your Priorities and Goals for Retirement— • Colleagues who have experienced the transition to retirement
• Financial Advisors and Wealth Managers
Begin Immediately Planning your Exit Strategy • Dental Supply Company Advisors
In dentistry, we have been taught to gather all the information, diagnose, and then • Family members who have your best interests
recommend treatment, and with every practice transition, especially retirement, it’s the same • Brokerage Firms, but be CAREFUL. Their main interest is
process. Planning and developing the correct strategy are the key elements. Be proactive! making a commission.

A. Plan ahead. During our careers, we tend to push back the age at which we plan to retire. Some surveys show that professionals are not very
good at retirement planning. Dentists in their 40s expect to retire at 65. In their 50s, at 67 or later. Avoid this by starting to plan early!
B. Establish and maintain an accounting system: A personal financial software program is a very helpful tool. You need discipline and the
tools to make sure that your practice transition team is helping you hit your goals each year. Select a date each year (e.g., March 1) when you
will review your progress and set new goals.
C. Planning Where to Retire. If your dreams are to retire to a different climate or moving nearer to family (children and grandchildren are
strong “magnets” prompting a move”), then you must consider planning a move, buying and selling properties, and all within your financial
situation. Incorporate them into your goals.
Clinicians Report 6 February 2022

Why Everyone Needs to be Thinking about Retirement—NOW (Continued from page 5)

Define your Priorities, Goals for Retirement—Begin Immediately Planning your Exit Strategy (Continued)
D. Insurance considerations. Speak with your insurance agents on all your insurances—disability, malpractice, healthcare, and life. Changes
usually need to be considered and made, especially you and your family’s health insurance, which will change without your practice policies.
E. Emotional changes: Since your life will be impacted with EVERY transition, especially with retirement, you need to prepare for changes in
your emotional condition. (See section on “Life in Retirement and its Consequences.”)
F. Retiring in practice: Having the ability to continue working part time keeping your free time and advantages of practicing dentistry.
G. Resources for developing transition strategies to retirement:
• ADA Adapt Company: This company focuses on facilitating dentist–to–dentist sales.
The ADA Practice Transition Webinar series is helpful.
• PCC video V4790 “Preparing for an Easy Practice Transition”
• Monday Morning Millionaire by Dr. Milan Somborac. Valuable investment resource.
• Schwab, Vanguard, Fidelity, and others have valuable interactive websites.

How Much in Savings Do You Need for Retirement?

No one knows how much is needed for any individual; however, there are some guidelines. The 4% Rule is a good “yardstick.” With a proper
investment strategy, you likely can withdraw 4% of your savings at the time of retirement yearly. For instance, if you felt like you needed
$120,000 per year income, you would need $3 million in retirement savings ($3,000,000×4%=$120,000).
Financial planning (follow the “Rule of 72” and Gordon’s Guidelines on Savings):
• Start and plan early. Invest Properly. There are many ways to “save” for financial Gordon’s Guidelines on Savings
• Determine your actual take-home money per month after federal taxes.
security during retirement. Choose the best method wisely. Your plan will take
• Determine state and local taxes.
into account your estimated longevity. • Now you know what can be spent (actually used).
• Remember that the market is always volatile and ever changing. • Place 10% of that in an account-savings, retirement.
• Account for inflation which reduces savings and increases the amount you will • Place 10% in a charity organization, religious or otherwise.
need yearly in retirement. • With what is left, make a budget with monthly allotments for every
remaining financial aspect of your life.
Live within your means: • Don’t spend more than your monthly budget.
• Budgeting is the key. It includes income, debt reduction, and retirement planning. • As your gross income increases, your standard of living increases—
Retire debt as soon as possible. not the reverse.
• Then, as a typical dentist, you will be very wealthy if and when
• Home mortgages and savings plans are important ways to plan your budgets.
retirement comes.
Other issues to consider in planning how much savings will be needed:
• Health Care Coverage: what will you want (and need) and at what cost.
• Life Insurance: Continue current policies or create new ones.
• Assisted Living Policies: Usually recommended to continue them for life,
but discuss with your insurance experts.
• Home Improvement: It’s harder to get loans when you are not working.
Life in Retirement and its Consequences
There will be many CHANGES and CHALLENGES in your life in retirement.
1. Time challenges and what to do with your time is often the 3. Positive consequences
biggest change. Without a schedule to keep, your time can become • You have UNSCHEDULED days and activities, the free time
a joy or a frustration. you’ve always wanted
• Time for spouse and family life (being aware of the negative • No “office” headaches
time effect of too much time with your spouse and family) • No staff challenges and responsibilities
• Personal time • Ability to learn “new” things
• Time for giving back to dentistry • Taking “fun” CE courses
• Time for service activities • Renew your old hobbies and take on new hobbies: all the
2. Emotional challenges (this is VERY IMPORTANT and must be things you’ve dreamed of
recognized in advance)
• Loss of contact with dental colleagues Additional Practice Transition Sections
ONLY found on CliniciansReport.org
• Loss of patient interaction • Preparation Guidelines to Sell Your Practice for Retirement
• Stress of not being “needed or wanted” • Key Transition Terms in selling a practice
• Do you still “feel” like a dentist, especially not having a license • The Valuation of a Practice
• Do I keep my dental licenses active? • Practice Transition: “Relationships” (Partnerships and Associateships)
• Do I remain in dental organizations? • Avoiding Failures of Practice Relationships

CR CONCLUSIONS: There is no time to waste. Start immediately in planning for, and funding, your retirement. Although there is no specific
prescription to follow in your transition to retirement, there are many avenues to explore in the planning process. Having a solid plan in place
is important for your future in retirement, for your patients and your staff. Preparation, planning, professional guidance, and implementation of
your plan will provide you with the skills necessary to complete your practice transition into retirement successfully and rewardingly.
Clinicians Report 7 February 2022

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Earn 1 credit hour for successfully completing each test. Tests are also available at www.CliniciansReport.org. This is a self-instruction program.
At the completion of this test, participants should be able to:
• Assess composite restorations for success • Discuss the phases of practice transition leading to retirement
• Identify the top restorative materials and techniques for pediatric dentistry • Evaluate new products and their potential clinical usefulness
Self-Instruction Test, February 2022, 1 CE Check the box next to the most correct answer.
1. Which of the following contribute to bond margin degradation? 6. According to the “Rule of 72,” a rate of 7% doubles your investment
q A. Surface contamination savings in how many years due to compounding?

q B. Polymerization shrinkage stress q A. 7 years

q C. Cariogenic bacteria q B. 10 years

q D. All of the above q C. 14 years

q D. 21 years
2. Acute angles within preparations become _______, amplifying destructive
forces along the bond margin due to polymerization shrinkage. 7. G-CEM ONE has improved bond strength compared to previous G-CEM
q A. Stress distributors versions.
st online q A. True
q B. Stress centers Take your CE te
iv e im m ed iate results! q B. False
q C. Stress relievers and rece epor t.org
iansR
www.Clinic
q D. None of the above 8. Natural Elegance Premium Flow had the following advantages:

3. What is the challenge of resin-based composites for pediatric restorations? q A. Lowest cost of flowables compared.

q A. Strength q B. Medium flow that is easy to manage.

q B. Wear q C. Easy to achieve initial polish.

q C. No fluoride release q D. All of the above

q D. Esthetics 9. UDM Pickup Material:

4. The new conventional glass ionomers are being promoted for conservative q A. Was received well in clinical use trial.
Class II restorations of primary teeth. q B. Has adequate pink color.
q A. True q C. Is available in multiple pink colors.
q B. False q D. Both A and B

5. What percentage of dentists had enough assets to retire according to ADA 10. MicroEtcher by Zest has many uses, including increasing bond strength
data in 2003? to metal, resin, and Class V zirconia (original BruxZir).
q A. 33% q A. True
q B. 22% q B. False
q C. 10%
q D. 5%

Submit your test answers online at www.CliniciansReport.org and receive immediate results;
To receive credit, all 2022 tests are due by mail to Clinicians Report, Attn CE Tests, 3707 N Canyon Rd, Bldg 7, Provo UT 84604;
DECEMBER 15, 2022 fax 888-353-2121; or scan and email to CR@CliniciansReport.org
CR Foundation®
Nationally Approved PACE Program
CR Foundation® is an ADA CERP recognized provider. ADA
Provider for FAGD/MAGD credit.
CERP is a service of the American Dental Association to Approval does not imply acceptance by any
assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does regulatory authority or AGD endorsement.
not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by 1/1/2018 to 12/31/2023
boards of dentistry. CR Foundation® designates this activity for 1 continuing education credit. Provider ID# 216561
 Clinicians Report 8 February 2022

Products Rated Highly by Evaluators in CR Clinical Trials (Continued from page 1)

Newest Universal, Self-Adhesive Resin Cement in the G-CEM Line
G-CEM ONE is a self-adhesive, dual-cure resin cement dispensed from an auto-mix syringe. It is indicated for
G-CEM ONE all cementing applications, simplifying inventory, and clinical technique. The optional Adhesive Enhancing
GC America Primer increases strength for non-retentive preps and accelerates chemical cure of the cement when used under
opaque restorations. CR testing showed improved bond compared to previous G-CEM cements. Use of primer
and light cure further improved bond. Four shades are available: A2, Translucent, AO3, BO1 (White Opaque).
Advantages: Limitations:
• No reports of post-operative sensitivity • Original instructions required clarification by GC America
• Easy clean up • Tack-cure was sensitive (<1 second), depending on light. Test
• Simple to use material with your light to avoid over curing and difficult cleanup.
$26.85/ml CR CONCLUSIONS: 83% of 18 CR Evaluators stated they would incorporate G-CEM ONE into their practice.
89% rated it excellent or good and worthy of trial by colleagues.

Flowable Resin-Based Composite Restorative Comparable to Premium Brands at Lower Cost

Natural Elegance Premium Flow nano composite is a light-cure, resin-based flowable restorative. It is available
Natural Elegance in six shades (A1, A2, A3, A3.5, B1, and C2) and received highest position in a recent comparison of flowables
Premium Flow (Clinicians Report July 2021) for best value cost and desirable low flexural modulus. CR’s field evaluation
Henry Schein identified additional advantages listed below.
Advantages: Limitations:
• Best value cost, simple, six shades inventory allows • No dark shades
easy introduction into practice • More opaque than desired by some Evaluators
• Medium flow is easy to spread and place
• Material cures hard, and initial polish is easily achieved
CR CONCLUSIONS: 83% of 18 CR Evaluators stated they would incorporate Natural Elegance Premium Flow
$80/4 2gm Syringes ($16/mL) into their practice. 83% rated it excellent or good and worthy of trial by colleagues

Easy-to-Use Pickup Material with Favorable Clinical Reviews and Good Price
Universal attachment pickup material with a bonding agent. Claims material does not have odor and does not
UDM (Universal Denture Material) exotherm during this chairside procedure. It is a pink, auto-mix, dual-cured composite. Available in 10 gm
Pickup Attachment syringe with 15 mixing and intraoral tips.
Laboratory Distribution Advantages: Limitation:
Network • Odorless and flavor free • Set time longer than desired by a few Evaluators
• No temperature change and biocompatible Kit: 10 gm pickup, 3.5 gm block out, 3 mL bonding
• Easy to use with helpful working time and set time agent
• Faster than acrylic repair
CR CONCLUSIONS: 80% of 20 CR Evaluators stated they would incorporate Universal Denture Material UMD
into their practice. 85% rated it excellent or good and worthy of trial by colleagues.

$152/Kit ($8.90/gm)

Proven Classic: MicroEtcher IIA is an Easy-to-Use Device with Many Desirable Advantages
Most mature practitioners quickly learned the advantages of chairside sandblasting the internal of metal restorations
MicroEtcher IIA which produced pockmarks adding mechanical retention for final cementation. CR research has also demonstrated
Zest Dental Solutions the benefits of easily sandblasting (30 psi and alumina 50 microns) the internal of Class V (3Y) zirconia (original
BruxZir) removing saliva contamination following try-in. Zirconia contaminated by saliva resulted in no adhesion
to the primer or the cement (Clinicians Report January 2021). MicroEtchers connect easily to existing air ports
on most dental units. They also remove residual cement from internal of de-bonded crowns and aid in intraoral
porcelain repair. Additional uses are described by manufacturer. Caution: Check with your lab to confirm the
composition of the zirconia you are using (3Y, 4Y, 5Y) prior to sandblasting in-office. Literature reports a link
between sandblasting and a decrease in the flexural strength of e.max and some 4Y and 5Y zirconia.
$450 CR CONCLUSIONS: MicroEtcher IIA is a product CR Evaluators “Can’t Live Without” and should be a part of
your armamentarium.

Products evaluated by CR Foundation® (CR®) and reported in the Gordon J. Christensen Clinicians Report® have been selected on the basis of merit from hundreds of products under evaluation. CR® conducts research
at three levels: 1) multiple-user field evaluations, 2) controlled long-term clinical research, and 3) basic science laboratory research. Over 400 clinical field evaluators are located throughout the world and 40 full-time
employees work at the institute. A product must meet at least one of the following standards to be reported in this publication: 1) innovative and new on the market, 2) less expensive, but meets the use standards,
3) unrecognized, valuable classic, or 4) superior to others in its broad classification. Your results may differ from CR Evaluators or other researchers on any product because of differences in preferences, techniques,
product batches, or environments. CR Foundation® is a tax-exempt, non-profit education and research organization which uses a unique volunteer structure to produce objective, factual data. All proceeds are used to
support the work of CR Foundation®. ©2022 This report or portions thereof may not be duplicated without permission of CR Foundation®. Annual English language subscription: US$229 worldwide, plus GST Canada
subscriptions. Single issue: $29 each. See www.CliniciansReport.org for additional subscription information.
 CR Foundation — 2021 Donors
CR Foundation® and Gordon J. Christensen recognize the generosity of the dental community and their
commitment to unbiased dental research. We thank all those who have contributed funds during 2021 and
helped CR in its mission to provide clinicians with the truth about dental products and techniques.
Jerry C. Kelly DDSv David P. Garrett DDSv
Christensen Order of Distinction Wayne E. Kerr DDS MAGDv A. J. Gerathy Jr. DMD MSv
$100,000 and up Arthur M. Korb DDSv Abe Gershonowicz DDSv
2 Anonymous Donorslv Kowalski Dental PCv Sam Gittings DDSv
Douglas A. Krueger DDSv Thomas M. Green DDSv
CR Legacy Society (Diamond) Les Latner DDSv David Groenke DMDv
$50,000–$99,999 Steven J. Little DMD FAGDv Maurice R. Growney Jr. DDSv
1 Anonymous Donorlv Patricia A. McConnell DDSv Robert A. Gruenberg DDSv
Robert G. Fox DDSv James E. Mills DDSv A. Al Gulum DDS MAGD
“Bimbo” Pietro DDSv Mike Hamby DDSv
Roberta Rams DDSv John Harrington DDSv
CR Fellows Society (Platinum) John K. Rhicard DMDv William G. Harrisonv
$25,000–$49,999 Philip M. Robitaille DDSv Christopher Harter DDSv
The late W. Boyd & Jean Christensenlv James Rodgers DDSv Steven R. Hein DDS FADGv
Theodore P. Croll DDSlv Karol H. Scheiner DDSv Brandon Helgeson DDSv
Raymond Schneider III DDSv George Heller DDS FAGDv
CR Associates Society (Gold) Michael Smith DMDv Joseph C. Hillier DDSv
$10,000–$24,999 John Stangl DDSv R. Lee Hinson Jr. DDSv
Terrence P. Kunkel DDSv Byron W. Wall DDSv Michael J. Hoffmann DDS DADBAv
Evan Perry DDSv W. Kenneth Horwitz DDSv
CR Foundation Community Jack M. Hosner DDSv
Bret M. Jerger DDSv
CR Service to Dentistry Society (Bronze) Brad D. Justesen DDS PCv
(Silver) $500–$1,999 Tae H. Kang DDSv
$2,000–$9,999 29 Anonymous Donors Anna Karidas DDSv
5 Anonymous Donors Stephen Akseizer DDS MAGDv C. Katz DDSv
Brent D. Bailey DDSv Alex Alemis DDSv Ben Kawasaki DDS MSDv
Christopher L. Barnes DDS FAGDv David Archibald DMD SCDv Paul Kollath DDSv
Rex Baumgartner DDS ACPv Steven M. Balloch DDSv Wendy Koury DDSv
Diane M. Bird DMDv Martin L. Baumgardner DDSv David S. Kuban BDS DDSv
Kelly D. Bridenstine DDSv Bernhard Bayer DDSv Reed Kuratomi DDSv
Dennis E. Brown DDSv Glenn Beck DMDv Frederick C. Lally DDS MAGD FACDv
J. Bruce Burley DDS FAGDv John E. Bennett DMDv Patrick Latcham DDS MAGDv
John F. Coakley DMDv Stanley L. Bettin DDSv R. Capers Lee DMDv
Stacy V. Cole DDSv Ted Brasky DDSv Gertrude Lee DMDv
Ron Crabtree DDS MAGDv Tipton Brown DDSv H. Ronald Levin DDSv
R. E. Crawford DDSv Robert Burks DDSv Dennis T. Lindo DDS FICDv
Scott H. Dahlquist DDSv Scott D. Carlson DDSv Donald J. Loomis DDS MAGDv
Doug Disraeli DDSv Merlyn L. Carver DDSv Timothy J. Loughran DDSv
Dennis G. Donoho DDSv Conrad C. Casler Jr. DDS FAGDv Joy Kathleen Lunan DDSv
Darrell N. Drissell DDSv Joseph A. Catanzano III DDSv Kevin Mailot DDSv
John W. Drumm DMDv John J. Christensen DDS MAGDv David P. Marion DDS PCv
Charles R. Fields DDS MAGDv Brian D. Christian DMDv Albert Mategrano DDSv
David R. Giaquinto DDSv Chester V. Clark Jr. DDS MPHv Terry G. Max DDSv
Shauna Gilmore DDSv Robert Convissar DDSv Robert E. McArthur Jr. DDSv
Kurt Gossweiler DDS MDv Thomas Cunningham DDSv Timothy McCabe DMDv
John Terry Green DDS MAGDv John D. Dinka DDSv Mark Mihalo DDSv
Deidre East Guerrettaz DDSv Nicholas J. Drzycimski DDS MAGDv Paul T. Murphy DMDv
Harry Habbel DDSv Robert Dubanski DMDv Robert D. Murray DDSv
George J. Hadeed DMDv David Ducommun DDSv Joel I. Nathanson DMD MAGD D.
Susan Hale DDS & Brent Hale DDSv Joseph Fahl DDSv ABDSMv
Greg Hattan DDSv Christopher Gall DDSv Justin Nylund DDSv
Ralph K. Jenke DDSv Jolynn Galvin DDSv Richard F. Pfeiffer DMD FAGDv
We appreciate our numerous donors, many of whom have chosen to remain anonymous.  l CR Founder and/or Board Member v Accumulated Giving (multiple donations)
 CR Foundation — 2021 Donors (Continued)
Steven Polisuk DDSv E. Bonilla-Vosburgh DDSv Cleveland Mann
Steven Rabedeaux DDSv Robert C. Brei DDS FACDv Michael J. Maser DMD MAGDv
Larry F. Rakowsky DMDv James Brodfuehrer DDSv Kelly A. McNally
Ron Rankin DMDv Tim Burgiss DDSv Steven Melonakos DDS
Mary F. Riley DDSv Jeffrey D. Carl DMDv Ben Merrickv
Joseph W. Robbv Mark Carreira Paul D. Mighion DDS MAGDv
David P. Robertson DDSv Jerome S. Casper DMDv Michael Morris DDSv
Herschel Ross DDSv Janice Cazes DDS MAGDv Mt. Vernon Dental Arts
Gary McCabe Ross DDS FAGD FICOIv Kenneth L. Childersv Steve Murphree DMDv
Jason Sala & Todd Sala DMDv Helen Chiu DMD FAGDv David Nalchajian DMDv
D. Milton Salzer DDSv Robert Chorney DDSv Todd O’Neil DDSv
Charles S. J. Samborksi DDSv Mark Christensen DDS MBA Ted Oellerich DMDv
Peter J. Scelfo DDS FAGDv Brian J. Cook DDSv Suzette Olson DDSv
Helene F. Schaeffer DMDv Carl H. Dahlquist DDSv Jane A. Otto DMD FICDv
Larry Schneider DDSv Rachel Anne Day DDS FACD FAGD Carl Papa DDSv
Jeffrey Seiler DDSv FICD Pamela Patten DDSv
Joseph Sexton DDSv Gary DiSanto-Rose DMDv A. Elizabeth Patterson DMDv
Jeff Shadid DDSv Byron P. Dixon DDSv Tom Petraitis DMDv
Uday N. Shah DDSv Christopher J. Donohue DMDv Bryan Petryszak DMDv
Richard Shanty DDSv Donald A. Fanelli DMD FAGD Larry E Price DDSv
Shahram Shekib DDS FAGD FICD Robert A. Finkel DDSv Clifford Prince DDS
FAADS FPFA FACDv Kelly Frandsen DDSv John Rajniak DDS FAGDv
Deborah Shiba DDSv Mark Frizzo DDS PLLCv Donald L. Rastede DDSv
Bryan G. Sicher DMD FAGD FICOIv Amy Fuller DDS FAGDv Dominic Raymond II DDS
Michael C. Smuin DDS FAGDv Robin Gallagher DMD MAESv Theodore Rechtin DDSv
Charles Smurthwaite DDSv Roger Garrett John W. Rosenlieb DMD
Daniel Spellman DMDv Gregory L. Goding DMD MAGDv Royann Royerv
Craig Spletzer DDSv Ronald Goersv Robert S. Ruhl DMDv
Richard L. Taliaferro DDS MAGDv Gerhard Goorhuis DDS MAGDv Daniella Salomon DDSv
David S. Teufel DDSv Doug Graydon DDSv Todd A. Sarauer DDS
John H. Thee DMDv Jerry C. Han DDS Charles Schein DDS
Donald E Vollmer DDS & Dwight E. Harding Gregory J. Schmitt DMDv
Mary Lou Vollmer RDHv Kevin J. Hester Sheila K. Shah DMDv
Gary Walker DDSv Alex Hutcheon DDSv Drew A. Shulmanv
Michael P. Wallace DMDv Tak Inaba DDSv Harchand Singh DDSv
Donald J. Wickstra DDSv Alvin Jenkinsv Mark Smyth DMDv
Philip C. Wilkins DMDv Mark M. Johnston DDSv John L. Soldano DDSv
Richard E. Wolfert DMDv Steven Kacel DDS MAGD FADIv James E. Sorge DMD
Clark J. Wright DMDv Paul E. Kellerv Keyla Springe
James C. Kincaid DDSv David R. Stebbins DMDv
Christy Kirchner DDSv Jack Stephens DDSv
Friends of CR Foundation Michele Knabe Robert B. Stewart DDS MSv
Up to $499 John D. Koons DMDv Lee Stewart DMDv
14 Anonymous Donors Tom Kovaleskiv Daniel Stults DDS FAGDv
Jim Abramowitz DDSv Stephen E. Kozelko DDSv Keith A. Stummer DDSv
J. Mark Albertson DMD Ramzi S. Kurban BDSv Vatsal Suthar DMD FAGD
Lawrence S. Awbrey DDSv Victor R. Kvikstad DDSv Greg Swica DDS
John M. Baarcke Thomas J. Lambert DDS John B. Thomas DMD MPAv
Sharon Bader DDSv Karen Lawitts DDSv Charles Tucker DDSv
David Bailey DDSv Kieu Le Mark I. Uyehara DDSv
Keith A. Barnhartv Ryan Leaman DDSv Marcia L. Valente DMDv
Sanford L. Barr DDSv Nathan E. Leavitt DDSv Thomas Verna DMDv
Trish A. Barsanti DDSv Sigmund Lee DMDv Wendy Wakaiv
Michael Beck DMDv Theodore Lempert DDSv Ali Weiselberg DDS FICOIv
Vincent E. Biank DDSv Thomas Livingstone Jr DMDv Stephen Wessels DMDv
Mark Birnbach Corbet C. Locke DDSv Tom Wodniak DDSv
Gerald A. Bloom DDSv Stan Lowrance DDS FAGD Steve Yang DDSv
Kory Blythe DDS Dan M. Luther DMD
We appreciate our numerous donors, many of whom have chosen to remain anonymous.  l CR Founder and/or Board Member v Accumulated Giving (multiple donations)