Written by Lou Graham, DDS Saturday, 31 January 2009 19:00
An interview conducted by Dr. Damon Adams, Dentistry Today’s Editor-in-Chief, Dr. Lou Graham discusses his experiences with some of the latest technological developments in dentistry. Dr. Graham is extensively involved in lecturing and continuing education, focusing on incorporating clinical advancements through “conservative dentistry.” He is in private practice in Chicago and holds a part-time faculty position at the University of Chicago.
Dr. Adams: Tell us about your experience in integrating technology into your practice.
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Dr. Graham: Let’s first begin with what our definition of “technology” is. The definition is so broad that if you use a thesaurus, words that come up are skill, knowledge, expertise, know-how, equipment, machinery, and tools. Now, that’s amazing in itself because doesn’t that describe dentistry and what we as general dentists do every day? Technology does not have to mean “space age” and it can cover far broader ranges. I really break this term down into 2 categories: the first being “must-have” technologies for everyday dentistry and the second being additional technologies that help customize our own individual practices. Such additional technologies can include lasers, digital scanning, cone beam imaging to name a few.
Dr. Adams: What about an “everyday” practice such as yours? How has technology really altered how you practice dentistry?
Dr. Graham: The answer is really an amazing one. I use so few products from even 10 to 15 years ago, so without question, technology has changed how we all do dentistry. Though these changes can be overwhelming, such advancements have really become standard in our profession.
Dr. Adams: What would be a “mainstay” of technology?
Dr. Graham: A “mainstay” of technology for absolutely everyone practicing today: loupes. When I graduated in 1982, I cannot remember a pair in the entire dental school and yet today they’ve become a staple in schools and private practice operatories. The question is, why? It’s because the technologies that we have adapted into our daily practices have required us to be more detailed versus the days of amalgams and crowns. With loupes you can now see better than you ever have before, allowing you to accomplish the procedure with the detail and skill that is required for the technique. Bonding itself has placed such a great emphasis on technique that in fact there is little leeway with such materials. They have to be done in an exact manner and when they are not, negative outcomes become routine. So, without question, to me loupes are an essential technology for everyone’s practice today.
Dr. Adams: Loupes certainly help doctors visualize their work in much better detail. Are there any other technologies that you can recommend to help a practitioner “see” better?
Figure 1. An OralCDx (OralCDx Laboratories) brush biopsy (1a) is being done on a visually suspicious lesion (1b) on the buccal mucosa.
|Figure 2. A post-ortho dentition with hypocalcification (white-spot lesions). This represents a typical case that can be conservatively treated with PROSPEC MI Paste (GC America).|
Dr. Graham: Another advancement is transillumination technology. I utilize this to review my preparation routinely. I use transillumination to look for cracks, additional decay, and far more. Transillumination can come in some unique formats. For example, SDI (SDI North America) makes the Radii LED curing light which utilizes multiple heads so you can use a diagnostic head for transillumination, or change to a different head using a blue LED light to cure and bond composites. The idea is finding new multiple-use technologies in a product.
Speaking of lights, these are often the most overlooked problem in dentistry, and often the leading source of failure in our restorative bonding procedures. All too often we think we can cure everything in 10 seconds and it’s done. The truth is that the materials are not fully polymerized, often leading to inflammation in the tubules, microleakage, and many additional issues that ultimately lead to bond failures. Often, curing times are variable. Most dentists don’t realize this. They are variable based on distance, type of material, the size of the restoration, the orifice of the tip of the light, the color of the material—all of these things can affect bonding. Bond failures will occur if materials are not cured enough.
Why do I bring this up? Coming next year will be a light that analyzes much of this data by actually auto-focusing the light itself with the touch of a button. So, basically the light turns itself off once it knows the material is cured. It’s called an Auto-Focus 2 light and it has more than 2,000 mW of power. It will be launched soon by ACTEON. For you to have a light that tells you when a material is cured layer after layer, that’s going to take a lot of the variability out of the equation and whether or not a material is actually completely cured.
Dr. Adams: What is another example of a “mainstay” technology?
Dr. Graham: In each area of dentistry, technological advancements have enabled us to broaden our approach over past eras. The most obvious area in my opinion is oral cancer prevention, and yes, I said prevention. I’ve done the rounds many times at the university hospital I’m affiliated with, and one thing becomes very clear. The message screams out to me that medical doctors are trained for years and years, but routinely their training does not include the oral cavity—which is amazing! They treat patients as if the body is not connected to the oral cavity. So, whose job is it to prevent oral cancer? The answer is the dental profession.
Over the last 18 months in our practice we’ve incorporated a mandatory 2 step screening process for our hygiene and initial exams. The first step is what we have always been doing—a comprehensive visual exam which should take no more than one to 2 minutes to look at all the oral tissues. In our office, this is followed by a $26 test that is mandatory utilizing the VELscope. It is so easy to implement and use that it does not interrupt the flow of hygiene at all, which is absolutely essential. Using fluorescence technology, it can identify cellular changes in the epithelium and basement membrane that are often overlooked on a visual exam. If a positive finding is noted, we often bring the patient back 2 weeks later to rule out any inflammatory causes and if needed we perform a brush biopsy. Again, this is yet another technology that should be standard in our practices. With the OralCDx’s brush (Figures 1a and 1b), you simply remove some epithelium tissue and penetrate the basement membrane (a sign of penetration would be bleeding), scraping the cells on a slide. It is sent off for computer analysis and is confirmed and reread by a histopathologist. This all takes place at OralCDx. The doctor then receives the report and can then talk with one of the OralCDx oral histopathologists. This, to me, is a 1-2-3 approach to oral cancer prevention. In the last 18 months we have unfortunately diagnosed one mucoepidermoid carcinoma which is very unusual through a traditional biopsy. We have also diagnosed 3 dysplastic lesions. Again, there is so much here to discuss, but if this article can drive home one message: technologies such as VELscope and brush biopsies can save lives! This should be a major focus in all of our practices.
Dr. Adams: Are there technologies that you have found that not only help you, but can benefit your practice by creating a better patient experience?
Dr. Graham: One such technology that I would consider is the Single Tooth Anesthesia (STA). It is manufactured by Milestone Scientific. Personally, I became aware of this only in the last 6 or 8 months, but I have to tell you it’s a must! For routine dentistry this replaces traditional injections with a Dynamic Pressure Sensing technology. It literally anesthetizes mandibular molars within 2 minutes, and routinely I find that the numbness is more profound than a block. It lasts about 45 minutes or maybe an hour—no more. So, for my practice, gone are the days of waiting for a block to take affect and then reinjecting. This allows predictability, and it saves me a ton of time so I can get to work immediately. I ask my lecture audiences how many times does the patient ask, “Can you just give me a little anesthetic?” Well, now you can satisfy your patients’ requests because with the STA you’re getting just the tooth numb, not the whole face. There are many ways to use this, but for me getting mandibular molars numb in one to 2 minutes is something I couldn’t even imagine ever doing without again.
Another “must have” in new technologies are the new topical anesthetics that are far more effective than the traditional benzocaine derivatives. For me, watching a patient not feel the initial entry via a traditional anesthetic injection is one of my “highs” each day. Don’t you love it when the patient says, “Wow!” or “I have never had such a great shot!” Such products are mixtures of different “caine” families and the 2 that we use in our practice are TAC and a new one called Xtra Numb. One to 2 minutes prior to an injection and you’re off to patient happiness.
Dr. Adams: What are some examples of other technological advancements that can be implemented into a general practice when doing restorative dentistry?
Dr. Graham: There are some restorative-related technologies that come to mind which are often overlooked in many practices today. One such product line is glass ionomers. I hear that this technology is “30-years-old and outdated,” but actually the opposite holds true. These materials continue to grow in market share around the world and they continue to get far better in quality. The reason is that they act as dentin “replacements.” They create a chemical seal that far surpasses those of bonding agents employed today. Companies like GC America, 3M ESPE, SDI, and others, have invested decades of research into advancing these materials. There are so many current uses for these that they’ve become an every day staple in my restorative armamentarium. Imagine placing these over dentin and 30 years later seeing minimal recurrent decay based on the chemical reaction that occurs. This is what myself and many others have seen. Why these aren’t routinely used under composites simply doesn’t follow the research that shows that resin bond strengths over time decrease and that microleakage is an accepted fact for adhesive dentistry.
With regard to composites and bonding agents, there is no doubt that these have become “mainstay” technological advancements within our practices. However, I am often very cautious with these because many “advancements” may not in fact improve overall outcomes. Take a fourth generation product like OptiBond Fl: it is a product that has been around for almost a decade, yet in my opinion, succeeding generations of products may not have improved long-term outcomes. However, this is not to say other products in this category do not have merit. I simply am stating that it is important to know what you are using, and what a particular material’s indications are, for you to have the most beneficial outcomes.
Since I try to approach dentistry in a conservative manner, 2 new and very cost effective technology advancements are KOMET USA’s Ceraburs and CeraTorque. Ceraburs are new ceramic burs that remove only infected dentin while creating no heat and protecting healthy dentin—which is essential to long-term pulpal health. The only issue is that you have to use these burs at 1,000 to 1,250 rpm and most of us do not have handpieces that operate at these low speeds. Enter the CeraTorque technology. This advancement may not be “cutting edge,” but it makes so much sense because the handpiece comes with only 2 speeds: 1,250 and 5,000 rpm. These have replaced my traditional slow-speed 20,000 rpm handpieces in my practice. This is exactly what you need routinely in restorative dentistry, because it allows you to have control when carefully removing caries, performing post space preparations, and placing pins.
Other “must haves” that I could not imagine practicing without are products such as RECALDENT (CPP-ACP) (PROSPEC MI Paste [GC America]). It is indispensable when you are dealing with geriatric patients who have ongoing decay issues, often from xerostomia; when you have teenage patients in braces and you are dealing with hypocalcification issues (Figure 2); or when you deal with patients that have decay issues simply from diet. We recommend that the patients who we prescribe it for use it 4 times a day. Its usage just continues to grow with different levels of the kind of care that we provide in our office. For patients with diet issues, we often will try and alter their intake of high cariogenic foods and drinks, but often additional supplements such as MI Paste are very important. In addition to MI Paste you may want a xylitol substitute such as Theramints or a new time-release self-adhering xylitol patch that goes intraorally prior to bed.
Another material that many do not know about is mineral trioxide aggregate. Let’s say you are doing a procedure, and all of a sudden you have drilled too much on an asymptomatic tooth and you see a bleeding pulp. Normally you would do endo. The “must have” product in this category is made by DENTSPLY Tulsa Dental Specialties called ProRoot MTA. Our follow up with direct pulp caps over the last 8 years has shown over a 90% success rate. Routinely, all you have to do is stop the bleeding, sterilize the area, and place ProRoot MTA on. It’s a little superoxol for a minute, followed by sodium hyperchlorite for a minute, and then ProRoot MTA. It’s amazing how many pulps you will save! There are many other uses for ProRoot MTA that we do not have the time to go into now.
|Figure 3. Two examples showing how GURU (DENTRIX/Henry Schein Practice Solutions) can be used daily to improve communication with patients and insurance companies.|
Lastly, case presentation, patient communication, insurance communication, and doctor-technician (laboratory) communication are within a simple reach on your computer via a software product called GURU (DENTRIX/Henry Schein Practice Solutions) (Figures 3a and 3b). From traditional audio animations, this software allows you to import pictures, draw on the pictures, put notations onto the pictures, save such in patient folders, and far more. You can create your own customized presentation within minutes by blending in their animations with your own audio and your own pictures. Hygienists can create their own homecare presentations and all can be emailed directly to the patient. Imagine taking pictures, utilizing arrows to highlight issues to your dental technician, and then simply hitting send and off they go. No question, there are many wonderful software systems out there that can compliment your practice and without hesitation, my entire team would recommend such a tool.
Dr. Adams: Would you like to leave us with a concluding statement?
|Figure 4. This case was fabricated using digital impressions (Lava COS [3M ESPE]). The buccal margin of the molar in this 4 unit bridge case was literally tucked under the external oblique ridge of the mandible and a conventional impression would have been nearly impossible.|
Dr. Graham: This article can only touch on a few of the wonderful technological advancements available to us today. Technologies that I have incorporated into my own practice include digital impression scanning with Lava C.O.S. (3M ESPE) (Figures 4a to 4c) and iTero (Cadent), digital x-rays, piezo-electrics built into my operatory equipment for conservative procedures in many areas, and tissue lasers in both the CO2 and 980 wavelengths. For me, it’s essential to understand how each such technology can add to long-term outcomes, while building my practice and creating a better patient experience.
Disclosure: Dr. Graham has received sponsorship for his lectures from numerous companies. These are products and materials he utilizes in his practice, they include DENTSPLY, 3M ESPE, Kerr, KaVo, GC America, South Dental Industries, Medidenta, ACTEON, Milestone, Triodent.
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