As we strive to create new-age, high-tech offices, the permutations of the equipment are getting more and more confusing. We are being pushed to get the latest digital x-ray sensors (the “new and improved” models, of course), implying that the ones we have been using the past 10 years are no good. And let’s get rid of impression material and get the latest and greatest intraoral scanning systems. The older models were good for their time, but the new ones are much better.
In this past August’s CLINICIAN’S REPORT (cliniciansreport.org), Dr. Christensen offered this observation, based on the evaluators’ reviews: “Digital impression scanning and in-office milling provide alternative treatment options not possible with conventional techniques. The newest scanner models and upgrades are faster and easier to use. The greatest advantage of in-office milling is elimination of the second appointment. Use of digital impressions will increase, while in-office milling will continue to grow slowly.
“Major limitations continue to be cost and complexity of integrating new technology and digital workflow into clinical practice. The majority of users and patients are satisfied with performance.”
So what are we to do now? Ditch the old technology and get the new one? Pay an upgrade (usually a trade-in) of $10,000 or more? With the current models in the marketplace, they are all accurate; differences are in design, software, speed of acquisition, color, and more. But how important is it to have the fastest, slickest unit if the endpoint/accuracy is the same? We are now trying to build our “system” in the same manner we would build a stereo system or buy a new car while comparing features that may or may not make any difference in the end. And who can you turn to for help with these “what do I buy” decisions? Surely my reviews and those of my colleagues will give you some guidance, but my needs and visions may not match yours.
Let’s confuse this even further with the addition of cone beam units. We are being told that we cannot practice without these units. And looking at some of the manufacturers’ models, we are faced with choosing one of the 8 or so models they are showing! In fact, we are being told that we need both the intraoral scanner and the cone beam together. Sure! Why not spend $75,000 to $250,000 to get up to speed. Of course, the “experts” show us how this “modest” investment will provide a return far beyond the initial costs. But is it believable? If you read Dentistry Today’s clinical articles or go to seminars, it actually seems to make sense. Dr. Michael Tischler, Dentistry Today’s implant editor, presents cases and situations monthly in the magazine that seem to validate this upward move. But still, this question lingers: How do you make such a decision?
There are 2 strong forces now in our industry that are actually trying to be helpful. Their ultimate motive, of course, is to sell equipment—or in these cases, systems—to practitioners. I am talking about Dentsply Sirona and Henry Schein. CEREC is almost a household name now. When I talked with Michael Augins, Dentsply Sirona’s senior vice president and regional commercial officer, I said that there are many new scanners that are faster and perhaps slicker than the current Omnicam. Michael said that Dentsply Sirona knows this but is more focused on the entire system and workflow. It is teaching a system that includes cone beam integration that is a turnkey operation; you can purchase and install these newer, faster “components,” but there is no thought about how to make the parts talk to each other and create the restorations for the patients. Its system enables the practitioner to decide what he or she is looking to do clinically, then let Dentsply Sirona guide him or her to that path. Because all of the components are from the same source, it has total control over integration and solutions.
Not standing idly by, Henry Schein has launched ConnectDental. Unlike Dentsply Sirona, it has an enormous array of products and manufacturers. In addition to intraoral scanners, cone beams, and digital x-ray sensors, there are also several other products that can be integrated into the workflow. Schein representatives help practitioners determine what path they are taking, then mix and match the components and integrate them, taking that headache away from the office. Again, the practice establishes a goal. What Schein is doing is taking away the responsibility and tedious comparative research from the practitioner and choosing/integrating the components that will best get to that end. Additionally, it is coordinated under one supplier/installer, so there are not multiple calls to individual manufacturers for any troubleshooting. Benco, Burkhart, and others are also assembling packages of components in the intraoral scanning/design and milling arena. By the way, Carestream has just launched an integrated system with its CS 3600 scanner and cone beam systems that is called PDIP (prosthetic-driven implant planning). I will be getting more information on this shortly.
Another issue is post-installation training. Patterson Dental (cereconline.com) and Henry Schein (planmecauniversity.com) include the basics and also offer advanced training, either live or virtual. There are also courses being offered in the branches as well as at dental meetings for honing this craft. Additionally, there are several excellent practition-ers and websites that offer advanced training, with or without the blessings of the motherships. Among them are Mark Morin (drmarkmorin.com), Samir Puri (cerecdoctors.com), Tarun Argurwal (3d-dentists.com and asktbone.com), Todd Erlich (digitalenamel.com), Armen Mizaryun (cad-ray.com), James Klim (cadstar.com), and the website located at learndigitaldentistry.com.
The bottom line is this: if you’re comfortable putting together a system and setting things up, go right ahead. Others may want to spend time with patients and won’t want to deal with how these things work. Just head in with your eyes open.
Also by Dr. Paul Feuerstein
It has become apparent today that a lot of research must be done to help you find “the one”—that company/service ideally suited to help you grow your practice.
Today, we are interacting with our patients very differently than in years past. I can safely say that flipping through the Yellow Pages and finding a new dentist is not happening. Although the Yellow Pages is now online, it has been replaced by Google, Yelp, Facebook, Angie’s List, Healthgrades, and other search methods. Personal recommendations and referrals still represent a large percentage of new patient generation, but online reviews have now added a new dimension to things. Websites are being built for dental practices with software featuring search engine optimization (SEO) designed to prioritize a company’s search results, and the buzzwords “social media” represent yet other sources of patient referral, using Facebook, Twitter, Google Plus, Instagram, and others. Many dentistry-specific Web designers promise that your practice will be at the top of a search list; they all say they can do this, but there is only one top spot. Office reviews and videos can help boost your position, and although reviews are helpful, reputation management is also an important consideration. Even if you are in that top search spot, if there are a lot of negative reviews, it negates the efforts you’ve made to be there.
As you walk the aisles of dental shows meeting exhibitors while also perusing Dentistry Today and other dental magazines, it becomes apparent that a lot of research must be done to help you find “the one”—that company/service ideally suited to help you grow your practice. Dentistry Today has been totally focused on the clinical aspects of a practice, but we on its staff realize that you cannot perform procedures without patients. I hope to expand our prowess in this area in future columns and articles, and since this is about Internet communication, the initial focus will be online.
Now, once you have obtained new patients, how do you retain them? Many companies now offer services to keep in touch with existing patients with things as simple as sending birthday greetings, alerting them about new procedures, and even “specials.” An office that really takes charge can use these services to send congratulaions to patients for various acheivments or family landmarks. These communications help to generate new patient referrals the old fashioned way—by word of mouth. These services also assume many of the manual tasks that your staff has been doing and links them in a logical and coordinated effort with methods to monitor your success (or failure). Basic communication utilizing the time-consuming and often ineffective appointment reminder/confirmation phone call has changed due to society’s changes. Text, email, and the use of mobile devices are now the front lines of communication, and using this method to let patients know there is an upcoming appointment and offer them a simple one-click method to respond is desirable. And contacting them about a schedule change or a “short notice” opening can keep the appointment book full. Also, consider this: research has shown that your practice will receive a response within 5 to 8 minutes. And what about missed appointments? Here is where this slightly impersonal system might save a practice from an embarrassing phone call—we have all had that experience of calling a patient who missed an appointment only to hear about a critical personal emergency.
Similarly, we all have had patients who quietly “disappeared.” They didn’t complain, they just never came back. Something unpleasant may have happened that no one was aware of, and a practice might get an email or text from the patient reluctant to discuss this occurrence if he or she had gotten a phone call. A simple questionnaire could provide answers, usually right away. Of course, many of these lost patients have no idea that it perhaps has been such a long time since they were last in the office. (“Two years ago? Really?”)
One communication method that some companies provide with their systems is to email a short “survey” asking how the appointment was handled. Some send these follow-ups later in the day, while others generate the request before the patient gets from the dental chair to the front desk. These surveys can turn into reviews. And usually if patients are willing to spend the time answering the survey, they might be willing to write a review. Some systems allow the practice to publish the surveys either on the doctor’s website or in public forums. In this situation, the practice has a chance to filter what goes out there and where it goes. Keep in mind that if a patient does post a negative review on a commercial forum such as Yelp, there is little the practice can do.
Responding to a negative review can often lead to disaster, although there are times when an explanation is due. Of course, if the patient was hostile enough to spend the time for the initial review, it can get a bit ugly. The best response, of course, is overwhelming the review with many positive comments. We all have “premium” patients who just love us—have them show us the love (online). Once again, there are many services that will help you monitor the online reviews for you, saving a lot of staff time surfing the various sites. The point here is that we are all doing what we can within the resources of our individual staffs, but with technology we can leave several tasks to outside companies who are more efficient than we are, and free up the staff for the internal workings of the practice.
The patient finder/retainer concept is not new. Several companies have long occupied this business niche, and I will discuss a few of them here. (I hope to mention other companies in a later column.) One of the oldest companies is Smile Reminders, now Solutionreach (solutionreach.com), and Mike Buckner has been a great resource. Fred Joyal of 1-800-DENTIST and its many subsidiaries (including Futuredontics) has been a notable resource, and Dr. Lenny Tau (birdeye.com) has given me insight into reputation management. WEO Media (weodental.com) has also helped me considerably, but I save the best for last: Rita Zamora (ritazamora.com), whose lectures, website, blogs, Facebook posts, and more have been an invaluable resource to me in this realm. All these companies are accessible and actually impartial and honest despite direct affiliations with their products. In the meantime, examine your practice’s marketing methods, ask questions, and get started in this quest to “let it grow.”
Another term we are seeing is 3-D printing. This technology is improving rapidly, and it has expanded into the medical profession, as we have seen with artificial body parts. So far in dentistry, there are no FDA-approved materials for our final restorations, with one minor exception—metal.
|Figure 1. Roland’s DWX-4W.|
|Figure 2. Formlabs’ Form2 printer.|
By now, we are familiar with the term one-visit dentistry. Dentsply Sirona and Planmeca have promoted this concept for years, with the former focusing directly on consumers. One of the term’s core components is the existence of in-office design software and a milling unit that can create in-office crowns and small bridges. This technology also allows for fabrication of small appliances such as surgical guides using what is called in CAD/CAM as “subtractive” creation. In other words, a block of material is milled with burs—or in the future, with lasers (dentalwings.com)—to create restorations or appliances. New milling units have entered the marketplace, and they’ll be detailed in a future column. Glidewell introduced the TS150, and Roland (rolanddga.com) has 2 low-cost mills: DWX-4 and DWX-4W (Figure 1), coming in at $18,000 and $25,000 respectively.
As we have seen in the explosion of new materials currently being milled, they have become much stronger, and now some systems can create in-office zirconia restorations. Note that when we tell patients we are making metal-free restorations, zirconia could be perceived as being a metal. Zirconium is a chemical element with atomic No. 40 in the periodic chart of elements. Its symbol is Zr. It is a hard metal, resistant to corrosion and similar to steel. The material we use is ZrO2–zirconium oxide. According to experts, “zirconium and zirconia are distinctly different in terms of crystal structure, stability, reactivity, density, hardness, strength, toughness, etc. Every ceramic has a crystal structure containing both metallic and nonmetallic atoms, but the combination is never referred to as—nor does it behave like—a metal.” I know, I am indeed splitting hairs, but be careful what you tell your patients.
Another term we are seeing is 3-D printing, or “additive” fabrication. This technology is improving rapidly, and it has expanded into the medical profession, as we have seen with artificial body parts. So far in dentistry, there are no FDA-approved materials for our final restorations, with one minor exception (metal), detailed later in this column. So as of right now, to create a final restoration in the office, we still have to resort to the mills.
3-D printers are appearing everywhere, and the cost is plummeting. Dental labs have been using units from Stratasys, Envisiontec, 3D Systems, and others for a long time. Some of these units are fairly large and quite expensive. They originally were used to print models from digital scans, saving orthodontists volumes of storage space, and they are now used to print just about anything we can make out of acrylic. The resolution is in microns, and the fit is excellent. Temporary crowns can be printed, but at least right now, if we are not premaking the temps, the process takes too long. Adjusting your workflow could make it work, although if an office is invested in scanning technology, it might be better off investing in the milling concept, where no temporary is necessary. It should be noted that if a patient needs an appliance such as a night guard, orthodontic appliance, or partial denture, the cases that come from a full-arch digital scan fit better. This is due to the fact that the appliances can be printed, or in more situations right now, the models are printed, and the appliances made on these. Think about printed hard-acrylic models versus those of plaster. As the appliance is being fabricated, small bits of plaster are removed, not to mention the inaccuracies of plaster, especially if it’s not mixed by measuring the water and powder according to specifications. Also, a digital scan is much more accurate in the area of the papilla and interproximal areas, where a full-arch impression, even VPS, “melts” into those areas. This has been well demonstrated by Align Technologies when creating aligners from digital impressions. They fit better at the gingival areas.
Will we see in-office printers? Somerville, Mass-based Formlabs (formlabs.com) has introduced the Form2 printer at the remarkable cost of $3,500. This a robust unit, and Formlabs now has “Dental SG Resin,” which has been approved as biocompatible and can be used to create surgical guides. Its standard resin can be used for models, retainers, and more.
Argen Corp (argen.com) is currently using “Concept Lasers for 3-D metal printing of high noble, noble, and nonprecious alloys. Utilizing 3-D metal printing—also known as metal additive manufacturing—Argen manufactures its portfolio of digitally fabricated dental restorations from single-unit to long-span bridges with LaserCUSING, which builds these products layer by layer directly from 3-D CAD data. The metal powder is melted entirely to provide a fully dense, homogenous structure. The end result is high-detail resolution and exceptional surface finish.” Other possibilities are printing precise wax patterns that can be cast traditionally. Using software, a technician can scan a model or impression and quickly create the wax patterns on the computer screen, setting up several cases at a time and then sending them to the wax printer.
This is just a simple introduction to get you thinking. As the year progresses, I will highlight a number of new products and processes in this exciting area of dentistry.
In our connected, fast-paced world, we are seeing a true evolution of healthcare products. Data gathered should be helpful in creating healthier mouths for both the users and the professionals who are analyzing it.
Toothbrushes are the primary home care products our patients use. Ever since Bucky Beaver appeared in Ipana toothpaste TV commercials, we’ve encouraged our patients to brush twice a day and see the dentist twice a year (a proposal created by the commercials, not the dental profession; thus the foundation of our 6-month recalls). We have seen toothbrushes evolve with a variety of bristle and handle designs and the next-generation “power toothbrushes.” In the 1950s, the Squibb Broxodent toothbrush hit the marketplace, and the Interplak made a splash as the first rotary-powered toothbrush, offered in the Sharper Image catalog. Braun/OralB came in with new models, Interplak evolved into Rotadent, and Philips developed the Sonicare line. There are many other companies in this market niche with a variety of designs and claims that we have to carefully examine and evaluate. All make claims of helping patients do the most efficient job of removing plaque and cleaning teeth, but how do we know if they are actually brushing, and if they are, how efficiently?
In our electronic info-world, engineers have added features to existing toothbrushes and created new models. We first saw timers on toothbrushes—especially pediatric models—to make sure users brushed for a specified amount of time. Flashing LEDs and/or sounds guided the brushing, and a few companies added music to accompany the brushing with timed songs. Arm & Hammer Tooth Tunes (armandhammer.com) features music from Kiss and Queen, while BrushBuddies (brushbuddies.com) (Figure 1) features Justin Bieber- and Lady Gaga-voiced singing brushes, and also Shopkins! This at least keeps children in the bathroom for the correct amount of time, but of course they could just be in there being entertained.
Today, Bluetooth as well as GPS have been added to many toothbrushes. They connect to a smartphone or tablet and guide you through an efficient, full-mouth cleaning. These toothbrushes have downloadable apps that vary in the information given and collected, and the variety is quite interesting. Some apps are actually just a timer connected to the toothbrush with a video game guiding the child through the quadrants. Various characters talk to the child and give him or her encouragement as well as incentives to achieve a high score. However, some apps also record the time of day and other information for the parents (or dentist) to review, and the more sophisticated apps can actually sense where in the mouth the toothbrush is and alert the user if too much pressure is being used. In these apps, the user can personally program problem areas, and the dentist—who can be allowed access to the user’s data—can keep tabs on the patient and be sure there is compliance. My question: Has Big Brother now invaded the bathroom?
So we now have another dimension that’s been added to the bathroom brushing routine—bringing your smartphone or tablet in there with you. Companies have responded to this by issuing a variety of devices that hold your smartphone or tablet on the mirror with suction cup holders or pockets. A short list of companies and toothbrushes follows, but note that toothbrush features are changing rapidly, so it is important to check websites not only to see the newest features but also to preview apps. Keep in mind that some of these toothbrushes are more focused on technology and the app than on design and research, so be sure to question manufacturers as you start using and recommending them.
|Figure 1. BrushBuddies, featuring Lada Gaga’s voice.||Figure 2. The Philips Sonicare FlexCare Platinum Connected.|
|Figure 3. The Oral B Bluetooth Toothbrush.||Figure 4. Kolibree’s app.|
|Figure 5. The Grush Connected Toothbrush.|
A. Philips (sonicare.com) started with the clinically proven Sonicare for Kids with an interactive BT video game app that gives users a sequence to follow and keeps track of the date, time, and time spent brushing. Recently, the company launched the Philips Sonicare FlexCare Platinum Connected (Figure 2), which not only tracks brushing but also alerts users if they are brushing too fast or too hard. It also gives an map of areas the user has missed. Dental professionals can advise users based on this data.
B. Oral B Bluetooth toothbrushes (oralb.com) (Figure 3) are based on the company’s well-documented power toothbrush designs and also show a sequence directing the user where to brush. The toothbrushes also have a pressure sensor that alerts users who are brushing too hard. The upcoming Genius toothbrush will add even more features, including a camera and position detection using sensors.
C. From Paris comes the Kolibree toothbrush (kolibree.com) (Figure 4), which was one of the first to use a GPS-like device to show where the toothbrush is in the mouth while also tracking progress. The company has just teamed up with the game maker Ubisoft to create a spectacular new app called Rabbids Smart Brush.
D. Beam (beam.dental) takes things a step further; it has partnered with a dental insurance company, and recorded data helps more compliant patients get a better rate on their premiums. The company also offers free brush heads, paste, and floss via an automatic delivery system for insurance subscribers.
E. From Switzerland comes the Rainbow (vigilant.com), a toothbrush that has a gyroscope and “accelerometer” in it to show where the brush is in the mouth. It records areas of the mouth that a child has covered and uses a game app for encouragement.
F. Grush (grushgamer.com) offers a connected toothbrush (Figure 5) with “tooth-to-tooth navigation.” It is accurate with a resolution of up to one tooth and uses advanced, pattern-matching algorithms to achieve this. Grush has the support of Intel, IBM, Unity, and more, and is currently running clinical trials at Harvard to prove its toothbrush’s efficacy.
G. The app for Lifebrush (lifebrush.net) has virtual disclosing solution; users have to remove the red areas to be sure their teeth are clean.
H. A unique item is Playbrush (playbrush.com), which is merely a handle that slips on to the end of a standard toothbrush and transforms it into a Bluetooth device. The accompanying Toothtopia game encourages brushing.
I. A power toothbrush that has recently appeared is the “bare bones” Quip (getquip.com). When you buy this toothbrush, you have the option to include the company’s toothpaste and brush head in addition to toothpaste refills every 3 months at little or no cost depending on the purchase plan.
J. ONVI’s prophix brush (getprophix.com), to be shipped in early 2017, has an intraoral camera in the handle, allowing patients to see and take images of areas of concern.
In our connected, fast-paced world, we are seeing a true evolution of healthcare products. Data gathered should be helpful in creating healthier mouths for both the users and the professionals who are analyzing it. It will also be a lot tougher for children to just stand in the bathroom and run the water for a few minutes, stating they’ve brushed their teeth. Time will tell, but for now, we should take advantage of these technological advances.
“The message here is don’t take your curing light for granted; test it periodically for light output, and if it is being held together with duct tape, as one of your basic tools, do the right thing—spring for a new one.”
|The frequencies of the 4 LEDs in Ultradent’s VALO.|
|The Bluephase 20i Curing Light and Bluephase Meter II.|
Every dentist owns one or more curing lights. We have new ones and old ones that we hate to throw out in case we need them for use or for parts. The reasons we get new ones are that the latest models are smaller, maybe cordless, and use LEDs, either directly in a wand shape or through some type of fiber-optic pipe. Also, these LEDs are lighter in weight, have a full spectrum for curing, and “last forever.”
Some of this, of course, is a stretch and can lead us into a false sense of security. When a composite fails, most of us assume there was an issue with the material or technique. But what if for some reason the material was not cured completely? We assume that you just fire the light for 20 seconds or so, and it is all set. There are also many studies on depth of cure as well as on the pluses and minuses of bulk fill. And incidentally, a few new composites are appearing that are self- and/or dual-cure, so the light may not be necessary at all! And just to confuse things further, if you have a dual-cure, and you light it too soon, you could end up with problems. Let’s examine a few basic facts about composites and curing.
Composites have photo-sensitive catalysts (initiators) that make this all happen. Gary DeWood, DDS, wrote a summary of them in the Spear Institute Journal, stating, “The 3 light-sensitive initiators—camphorquinone (CQ), phenyl-propanedione (PPD), and trimethylbenzoyl-diphenyl-phosphine oxide (TPO)—acted as the triggers that set off polymerization in all of the available products when light was applied. CQ was the most commonly used initiator in all applications. The color of the initiators is quite different—CQ being quite yellow before it’s cured—and it represented a problem with color-matching composites to teeth prior to the cure.”
TPO is the least “colored” of the initiators and made possible clear flowable resins that could be used to seal things. Clear sealants use TPO as an initiator. Dr. DeWood explains: “The spectrum of absorption by these initiators was not a problem when quartz-halogen was the only available source. However, with the introduction of the LED light, the initiator became a factor in the cure as single-wave LED lights, most of which emitted in the 430 to 500 nm range, did not interact well with TPO, which absorbs in the 350 to 430 nm range.”
What this translates to is that you have to know a bit about the frequency range of the light you are using as well as the composition of your composite. Some of the single-wave LEDs have a range of 430 or 450 nm to 480 nm. This cuts off the ability to cure TPO. Other companies use a couple of LEDs with different frequencies, using names like polywave (Ivoclar Vivadent [ivoclarvivadent.com]) or multiwave (Ultradent [ultradent.com]) that extend the range to as wide as 380 to 515 nm. It may seem like we are splitting hairs, but the chemicals are quite specific in their sensitivity.
Light intensity is also critical, and here is where things can really go wrong. The standard output seems to be 1,000 mw/cm2 for “normal” composite restorations. Keep in mind that there are many factors that determine the amount of light and the time of cure. Darker colors, for example, may require longer cure times. DentLight’s new Fusion 5 (dentlight.com) claims to be 2,700 mWcm2 or more, which should cure anything in its path. The distance of the light tip to the surface of the composite is certainly a factor, and it is recommended that you not only cure from the occlusal but also the buccal and lingual. I have seen some interesting techniques—for example, if you are using a sectional band, you can get the light down to the gingival once you remove the ring and before you actually remove the band. This will ensure you’ve gotten to the bottom of the box. With a full-metal band, the light tip can be slipped between the band and the tooth as it is peeled back both buccally and lingually. Even the reflection off of the band will ensure that gingival cure. It takes more time (but less than needed to replace a failed composite).
Despite the longevity of the LEDs themselves, light output can degrade with time. Some causes are physical—material buildup on the light’s tip, scratches on the lens, etc. Also, despite the assumption that LEDs emit no heat, there may be enough at the component level to disrupt the actual LED and cause it to receive less electrical current, thus reducing the output.
There are many ways to measure the light output. Some lights come with a built-in radiometer, and since it is usually calibrated to that specific light in terms of the diameter of the spot and frequency of the unit, it is best used with that device only. There is a service (Blue Light Analytics [curingresin.com]) that your local supplier can contact that can dispatch a representative to your practice with a more robust radiometer and examine all your lights. There are also radiometers that you can purchase that offer various price points and features. Kerr has the compact Demetron LED Radiometer, and SDI has a nice in-office unit. The newest one is the Ivoclar Bluephase Meter II, which can accommodate any size light tip, is full spectrum, and has a digital display. Note that some of the light manufacturers claim the accuracy of these in-office devices is not as accurate as larger, more expensive units used by testing labs. While true, with an in-office meter, you can test your lights when they first arrive (or at a start date) and monitor them from that point on to see the relative degradation and realize when the light has to be repaired or replaced. To further clarify the use of radiometers, Ultradent Products recently posted a PDF online entitled “An Explanation of Dental Radiometers.”
The message here is don’t take your curing light for granted; test it periodically for light output, and if it is being held together with duct tape, as one of your basic tools, do the right thing—spring for a new one.
Years of playing in rock bands as well as attending concerts have put a strain on my hearing, which is often a good excuse for not hearing orders from my wife or coworkers. Auditory damage is well documented, and OSHA requires hearing protection for people working in loud noise environments. In its literature, it clearly states this: “Exposure to high levels of noise can cause permanent hearing loss.” And neither surgery nor a hearing aid can help to correct this type of hearing loss.
|The DI15 Electronic Earplug.|
Short-term exposure to loud noise can also cause a temporary change in hearing or tinnitus. OSHA sets a permissible exposure limit on workplace noise, which is 90 dB during an 8-hour day. The National Institute for Occupational Safety and Health recommends that “all worker exposure to noise be controlled below a level equivalent to 85 dB for 8 hours to minimize occupational, noise-induced hearing loss.” It suggests that noise levels be controlled or if not possible that “hearing protection devices such as earmuffs and plugs be considered as an acceptable but a less desirable option.”
How does this relate to the dental practice? For one thing, the noise of the handpiece (the greatest offender) is not continuous for 8 hours a day, so there is no real requirement; however, studies do point to dental professionals being affected. I have been talking with Sam Shamardi, a Boston-based periodontist who has been studying this issue for several years. He states, “Noise-induced hearing loss is permanent and irreversible and nearly a guarantee to some degree for all dental professionals. Noise, like smoking or sun exposure, is a cumulative and additive process, so even shorter exposures below industry standards during our workdays will accumulate during time to cause serious damage.
“The dental literature and the ADA as early as 1974 clearly show our environment causes damage—handpieces, suctions, ultrasonics, lab equipment, and even solvents can contribute to hearing loss and other significant systemic health issues. And we are doing nothing to protect ourselves.
“Noises we are exposed to at work each day are louder than we perceive. The shrill of the suction and high pitch make us cringe, and we all directly or indirectly know colleagues with tinnitus and hearing damage, yet we have never thought to ask why.
“The dental literature is saturated with disturbing statistics. Dental professionals consistently are found to have poorer hearing at the standard 3- and 4-kHz levels compared to other health professionals of similar age/gender (source: Ahmed, Tolentino, and Gurbuz). Rytkonen and Baren found that ultrasonic noise levels for the high-speed handpiece reach can 89 dB, with ultrasonic scalers and high-speed air turbines reaching 107 dB and 115 dB respectively. Folmer showed different high-speed handpiece brands reaching ranges of 90 dB to 115 dB, while Wilson showed hygienists utilizing ultrasonic instruments having ‘significantly worse hearing thresholds compared to non-users.’ And Lehto’s 15-year follow-up study showed significant high frequency hearing loss in both ears for both genders across all age groups.”
One might think that simple devices such as small sponges placed in the ears should reduce noise levels. There are also several products in the marketplace that act as baffles, which reduce the amount of sound that comes into the ear. However, this also comes with the muffling of sounds, and this is not really desirable, for example, when speaking to the chairside assistant or listening to a patient. Some may think that noise cancelling headphones could be an answer. There are a number of negatives. They cancel all external sounds including familiar noises of instruments being used as well as some outside voices—not a good thing for inter-office communication. Also, the better devices are oversized ear-covering headphones, which would surely be in the way. Dr. Shamardi has devised a better, more high-tech solution—he has developed the DI15 Electronic Earplug. He explains: “The DI15 is revolutionary for our field and the only product of its kind. Unlike foam or filters, which significantly muffle sounds and compromise communication with patients and staff, the DI15 uses a high-tech microcircuit developed in the United States that allows for all sounds to be heard 100% naturally, with no distortion, despite having a sealed, plugged ear. At the same time, noises in the high frequency/decibel range are specifically targeted and instantly compressed to safe levels. The result is an environment where communication is not compromised, and hearing damage is prevented.”
Since the beginning of the year, I have been to several meetings. I am still reviewing many products and services, but I will present a few of the interesting ones here in no particular order and with no bias.
|Figure 1. Carestream’s CS 3600.|
|Figure 2. Air Techniques’ ScanX Swift.|
|Figure 3. VOCO’s Admira Fusion.|
As I run up and down the aisles of dental meetings, I am constantly stopped by people at booths who say, “You have to see this!” Being the accommodating person that I am, I give a cursory look, make notes, then return later to fill in the blanks with additional information, which you will see here in this column. Since the beginning of the year, I have been to several meetings, including the Star of the South, Yankee, Chicago Midwinter, and Hinman. I am still reviewing many products and services, but I will present a few of the interesting ones here in no particular order and with no bias.
In the digital impression world, Dental Wings launched a new scanner as did Carestream and Align. The Carestream CS 3600 (Figure 1) is much faster than the 3500, the software is better, and the color resolution is HD. Carestream will continue to sell and support the CS 3500, which is still a nice, lower-priced option. The Align iTero has been totally redesigned, and Align was showcasing its “blinding speed” of acquisition at the meetings. The Dental Wings scanner uses a different-shaped wand and has innovative software and hardware as the interface. The others continue with upgrades and improvements, and the good news is that all are totally accurate and predictable, and offices should look hard at this alternative to the traditional impressions. Also, you should not focus totally on which one is the slickest unit; focus on how the unit integrates into your patient workflow. We will get further into this at the year progresses.
In digital radiography, there seems to be a resurgence of phosphor plates. These film-like sensors are used in the office like “the old days,” except the plates are developed in a digital box in less than 10 seconds. The images have vastly improved, and they come in all sizes at a very low cost. It is notable that the entire surface area of the plates captures the image, whereas the sensors have to leave room for the electronics and cases, so there is a slightly smaller capture in each image. Air Techniques now has the ScanX Swift (Figure 2), Acteon the PSPIX, and Carestream the CS 7200. Take another look at this category.
Hard-tissue lasers were prevalent at the meetings. BIOLASE continues to upgrade its system and add to its existing line of lasers. Convergent, with its Solea, is turning a lot of heads. Its CO2-based system gets faster and more accurate every time I see it at the shows. Competition in this area is fierce, with Fotona’s LightWalker and the newest LiteTouch, introduced in Chicago by AMD, which is continuing its quest to keep lasers of all types very affordable.
Speaking of affordability, the new Bien-Air Optima electric handpiece system is compact, inexpensive, and easy to install—just connect a standard hose and plug it into an electrical outlet. It is compatible with the company’s entire line of contra-angles and other attachments, and it comes in several colors.
Although tech products are my main focus, as a GP, I of course use various restorative materials, and 3 companies have pushed chemistry to another level. Pulpdent has its bioactive Activa base and restorative material. According to Pulpdent, there is a formation of hydroxyapatite-like crystals at the etched enamel interface. Doxa’s Ceramir cement has similar properties at the crown margins. VOCO showcased its new Admira Fusion (Figure 3), which is a unique restorative material that is not a composite but a ceramic-based restorative, and it does not contain traditional monomers or BIS-GMA, BPA, or other chemicals that are undergoing public scrutiny.
One of the most interesting products I’ve seen at the past few meetings has been a little robot named MEDi. Its manufacturer, Calgary-based RxRobots, has developed this sophisticated little guy to be programmed to talk to young children undergoing dental procedures. It calls them by name and acts as a compassionate coach while entertaining by singing and dancing. It is not unlike offices that use a lap dog with some patients. There are videos on the company’s website (rxrobots.com) and YouTube. People have become quite enamored with this little guy.
I have been to several meetings and have visited hundreds of booths, and this is only a small sample of the items that I have seen. I did not leave anything out intentionally, and to be honest, I have enough information for at least a year of Technology Today. As they say, stay tuned.
With patients downplaying fractured tooth treatment, your final statement usually is this: “Don’t call me in the middle of your sister’s wedding and tell me that the almond you bit into broke your tooth in half.”
|Figure 1. Transillumination with AdDent’s Microlux unit.|
|Figure 2. View using DEXIS’s CariVu unit.|
|Figure 3a. Direct view using ACTEON’S SoproCare unit.|
|Figure 3b. Fluorescence view using SoproCare.|
We as dentists have often heard this from a patient: “I have a tooth that hurts sometimes on the left side.” The patient—let’s call him Dave—points to the cheek (not inside the mouth) and says “somewhere around here.” On questioning, Dave is often unsure if it is top or bottom or what triggers the pain. He further states that the tooth is not consistently sensitive and really doesn’t react to hot or cold, but he refrains from chewing on that side.
The suspicion here is that we are dealing with a tooth fracture. Using low-tech tests like having the patient bite on cotton or soft wooden sticks or using instruments such as the Tooth Sleuth sometimes helps us locate the source and in fact helps the patient duplicate the source of the pain. Once we have identified the tooth or teeth, a simple high-intensity light such as the Microlux Transillluminator (addent.com) placed on the tooth can identify a fracture. Thinking of enamel as a fiberoptic “pipe.” If there is a break, the light stops. You can see this in Figure 1. The CariVu (dexis.com) allows you to see this fracture and take a photo of it (Figure 2). (This device is also quite helpful in caries detection, as I noted in one of my earlier columns). Of course, a good high-resolution intraoral camera with good lighting is also not only helpful to the practitioner’s diagnosis but also for patient education. The use of fluorescence with some of the cameras can also enhance the view of a fracture (Figures 3a and 3b).
This brings up 2 “must-haves” that will define your practice as a high-tech operation: an intraoral camera and digital radiography. Of course, these technologies assume that you have access to a computer and monitor in the treatment room so you can see an image and have the ability to show it to the patient. Most of my readers already have networked systems, while some are using laptops or mobile devices. Also, the advent of excellent tablets has opened new possibilities for show and tell.
Once you have located the pain-causing culprit, the discussion begins with the patient. One problem even at this point is the extent of the fracture. The American Academy of Endodontics has actually classified fractures. And there is an excellent article, “The Cracked Tooth Syndrome,” written by Dr. John West from The Center for Endodontics in Tacoma, Wash, that appeared in Dentistry Today 14 years ago (May, 2002) that explains this well. (Editor’s note: This article can be accessed online at dentistrytoday.com.) At this point, the real discussion begins. The problem is explained to the patient, and many times the treatment plan is to propose a crown. There is usually a necessary disclaimer here, implying that the crown may in fact stop the symptom, but depending on the path of the fracture, it could continue like a crack in glass, with future endodontics required and even the chance of tooth loss. With new 3-D radiographic imaging, you can get a better view of the extent of the fracture. Or in a more conservative approach, a bonded restoration—either direct or indirect—can be placed. In a recent report, Dr. Gordon Christensen stated that cuspal coverage with an onlay makes the tooth less susceptible to fracture than in its natural state.
The conversation with the patient then continues and often goes like this: “You know doc, it’s not that bad. It only happens once in a while. I don’t really have to do anything right now.” And then the infamous “if it ain’t broke, don’t fix it” comment emerges. You can argue all you want, but your final statement is usually this: “Well, don’t call me in the middle of your sister’s wedding and tell me that the almond you bit into broke your tooth in half.”
I was talking recently with a well-known dental consultant, Dr. Rhonda Savage, CEO of Miles Global, and asked her how she handles this situation. She said that using the term fracture conjures up an image of a broken bone—something that can be repaired. Why not just say “your tooth is broken,” and tell the patient that it has to be fixed before he or she utters the “ain’t broke” phrase? That simple change of terminology has had a change in my patients’ perceptions. (That is why Dr. Savage is the consultant, and I am the tech guy.) She continued by saying this: “Add the word ‘yet’ to the ‘not broken’ phrase, This is more forceful and tells the patient it will happen.”
Of course, if we do a careful exam with the cameras or high-intensity lighting and magnification, we will see fractures in almost every tooth. Many are asymptomatic and could be craze lines stemming from the actual operative procedure with a handpiece, a prematurity in a virgin tooth, or as even some say, thermocycling. These should be noted, and images stored in the patient record. Then perhaps address occlusion and discuss with the patient how proactive you want to be. Of course, always use your own clinical judgment and these tools as diagnostic aids.
Data breach protection has to be handled with tools such as firewalls and encryption, but what chance does a small dental office have of protecting itself when giant corporations, government agencies, and banks can be been affected? This is where professional help comes in.
“Hello, This is Rick from your computer monitoring center, and we just detected a virus in your system. Follow my instructions as fast as possible so your whole system won’t crash.”
The unsuspecting staff member on the phone is put into a panic by this professionally trained caller.
“Just open a browser and type in this code and then relog into your practice management system,” Rick says.
The staff member replies, “It didn’t work. I can’t log in.”
“No problem,” Rick says. “Just give me a credit card and for $500 we can fix it.”
Or…a popup box appears on the computer screen saying something like “Your files are encrypted; click here to reset,” and the scam begins, with onscreen messages instructing how to pay for the “fix.”
|DDS Rescue’s backup unit.|
What “Rick” is doing in the dialogue above is engaging in “ransomware,” and there are several similar methods of hitting your office with this scam. It has many incarnations, from phone calls and emails to tricky techniques, and it is worse than a virus. Your system will be corrupted, file names will change, and nothing will seem to work. This can also come into your system with fake emails that look official—company logos, etc—which is called phishing. When this “program” is installed on your computer, it often takes over the main screen and has a voice stating that your computer has been infected and to call the number on the screen to get it fixed. This voice message may repeat indefinitely, locking up the system, and sometimes you may just have to literally pull the plug.
In the above ransomware example, why only $500? These scammers work on volume; 10,000 systems will yield a quick $5 million, and that is being conservative. And this is not just a dental office issue; these scammers target homes, businesses, and in the town near me, the police department. They also prey on senior citizens who may not be too computer savvy and just go along with the script being read to them.
There are scammer programs with names like Cryptolocker and Cryptowall, and according to Bloomberg, they can now disable your cell phone. And antivirus/malware/spam programs of some firewalls do not protect you from this since the user is entering the data “voluntarily.”
I spoke with Jim Flynne, chief security officer and vice president of Carbonite (carbonite.com), a wellknown cloud backup company, and he explained that Carbonite’s service notices when a client suddenly begins rapidly backing up hundreds of files. (Carbonite is a realtime file backup service.) This is the malware program changing file content (through encryption). Carbonite’s staff works with users to identify the exact instant of infection so files can be restored from a clean version prior to encryption.
Keep in mind that ransomware is not necessarily interested in stealing your data —ransomware scammers make their living through disruption and their “fix” fees.
We also have to watch for data breaches. According to Steve White of DDS Rescue (ddsrescue.com), we have to be concerned with viruses and ransomware, but there are other hackers working in synergy with these ransom scammers that can cause even more havoc. HIPAA rules and fines can close your office down, and remember this—we store birthdates and Social Security numbers. Think of the recent IRS fake refund scams and the Target retail chain breach to see where that can go. Data breach protection has to be handled with tools such as firewalls and encryption, but what chance does a small dental office have protecting itself when giant corporations, government agencies, and banks can be affected?
This is where professional help comes in.
Backups are partly an answer, but keep in mind that without a proper strategy, you may be backing up data already containing a virus. Also, if your computer is totally disabled, what’s needed is more than just reentering the data—the computer/disk has to be totally wiped clean (reformatted), and all the programs (including operating systems like Windows) have to be reinstalled from scratch, which is not an easy task.
And with regard to your practice management system, it will have to be reinstalled from scratch. One proactive solution is a backup system that takes a snapshot (image) of your hard drive at various intervals and keeps several copies dating back weeks. This way, you can go to a backup dated before the trouble started. A backup service like this is offered by Carbonite, which—in the consumer version—simply backs up any data that you choose automatically and dynamically as soon as a file is added or changed. It also keeps copies of the old files.
For a business, however, Carbonite offers better options that include taking the aforementioned image of your server or workstation(s), allowing damaged hard drives to be correctly reformatted. A new option even includes putting an actual device in the office that keeps copies of the backups. Details are on Carbonite’s website.
A more robust solution for business continuity comes from DDS Rescue, which uses constant data and image backups, firewalls, onsite hardware backup, and cloud versions as well as remote monitoring. The company proved to be a true practice saver when office systems were recently totally destroyed in floods, hurricanes, and even thefts. More information is available on DDS Rescue’s website.
These are just 2 examples of products in the marketplace. Many dental IT companies offer more personalized solutions, including remote monitoring. Savvy practitioners might think about creating this system on their own, but in this day and age, I believe pros should handle this, and you should stick to teeth. The bottom line is this: none of these companies are as expensive as data loss, recreation of a server, possible fines, and loss of business. Meet with your staff, discuss this topic, and make them more diligent.
|Figure 1. The Wand (Aseptico).|
|Figure 2. VibraJect (Golden Dental Solutions).|
|Figure 3. The Anutra System (Anutra Medical).|
There are several anesthesia products and techniques available today, but our number one objective must be to remove our patients’ fears.
Dentist: “Why are you afraid of me?”
Patient: “I hate the shots.”
This all-too-common answer needs a lot of TLC and comforting responses from a practitioner. Of course, empathy goes a long way, but it is also reassuring to respond to an “I am afraid” statement with this: “Well, that was the old days; things have changed.”
So, what has changed to help these fearful souls? First and foremost is technique. Slow insertion and injection are always key. And do I mean SLOW. Infiltration does not mean blasting a bolus of liquid into a small tissue area of the mouth, unlike what you would do in the gluteus maximus. Topical in my hands works, although many experts state that it is more psychological for the patient. So what? You are doing something to combat the patient’s previously poor experience. Also, technology and chemistry have now entered into this discussion. The word slow has led us to the Wand (aseptico.com [Figure 1]), a product that has gone through a few transformations throughout the years, including name changes. It was once called STA (Single Tooth Anesthesia), emphasizing its strong point, but its manufacturer went back to the Wand since it is a substitute for all injections and supplies the anesthetic slowly and evenly. The Wand also provides practitioner feedback, letting you know visually and/or with sound cues if you have the correct placement and when the correct amount of anesthetic is delivered. Once you are familiar with the Wand technique, your patients will marvel at their very small amount of soft-tissue numbness, and you will easily be able to work bilaterally on the lower arch.
There are also times when there is a small lesion at the gingival margin, and giving a full block for less than 2 minutes of drilling seems to be overkill. In this situation, the Wand is great. Of course, there are patients who don’t believe they are numb without that feeling, so it is not imprudent to give a few drops of anesthetic in the buccal fold prior to the Wand, and of course you can get supplemental anesthesia from that. The numbness with a periodontal ligament injection lasts 30 to 40 minutes, so choose your cases selectively.
When using lip wiggling, pressure, cotton roll biting, and others, you are creating a distraction. The Gate Theory of Pain states that loading the sensory input with one stimulus can reduce (“close the gate”) the pain impulses going to the central nervous system. Some studies have shown that vibration applied to the area being injected is a great (albeit annoying) stimulus and can distract the patient from feeling the injection. One of the first devices to use vibration as a distraction was VibraJect (goldendentalsolutions.com [Figure 2]), a battery-operated device that clips onto a syringe. Not only does the syringe vibrate, but the operator’s fingers do also as the patient’s lips or cheeks are stimulated. Even the syringe tip is vibrating, causing a great distraction.
This concept is carried further by the DentalVibe (dentalvibe.com), which is actually a lighted retractor that vibrates the injection area with a distracting on/off tempo. The device’s disposable tips are also strong enough to deliver pressure on the palate in a combination with the vibration to additionally ease that injection.
Finally, part of injection discomfort is from the actual “burn” of the injection, since the anesthetic is acidic. By buffering it with sodium bicarbonate, its pH can be neutralized, thus further reducing the injection sensation. As a “side effect” of this buffering, anesthesia occurs more rapidly for the patient, usually in less than 2 minutes. This could be very effective in reducing chair time for a patient and doctor since there is no long wait for the anesthetic to take effect. And in the case of a mandibular block, which I am sure all practitioners have “missed” in their careers, you will know in 2 minutes if the block is effective. Two anesthesia buffering systems are Onset (onpharma.com) and Anutra (anutramedical.com [Figure 3]). Onset features a device that loads a standard carpule along with a cartridge of bicarbonate, then practitioners utilize its dial system to add the precise amount into the carpule. Anutra uses a bicarbonate with a longer active life and an interesting mixing unit. It lets you to fill a larger proprietary syringe (5 mL), allowing you to give multiple injections without changing carpules after each one. This, added to the rapid anesthesia, can cut treatment time.
There are several anesthesia products and techniques available today, but our number one objective must be to remove our patients’ fears.
"All I Want for Christmas..."
Companies today are promising "digital dentures." Two that are quite visible are Avadent (Global Dental Science) and Mitsui/Heraeus Kulzer, based on the DENTCA System, which is now used in Whole You's Nexteeth System.
|Milled monolithic denture properties from Avadent.|
|A virtual try-in screen shot from Avadent.|
|Digital denture process from Whole You.|
Digital impressions have been a popular topic of discussion during the past few years. The focus has gone from single crowns to multiple units to implants and beyond into complex cases. One area that has been lacking is fully edentulous impressions. We still have many patients who have or need dentures and are not interested in more than just that. Capturing soft tissue itself with a digital impression can of course be performed since we are constantly restoring edentulous areas, but most of these cases are tooth- or implant-borne. They do not take the periphery into consideration, and if the impression does capture that area, it is static, uncompressed tissue in the fold. Also, due to the limited field of view of the current scanners, in order to get the palate, there would be many passes back and forth. Without a reference point, it is unlikely the images could be stitched together. I have seen it done for an upper retainer using light powder, but the accuracy is questionable. There is at least one intraoral scanner in development that captures the entire arch all at once, but it is still in its infancy. (I cannot publish details, but I can answer individual inquiries.) A model of course can be scanned, but this means a traditional impression at the outset. This allows laboratories to digitally create retainers, partials, and other full-arch restorations, including the palate or flanges.
In creating well-fitting dentures, we have all learned various impression techniques to displace peripheral tissue. The term border molding comes to mind, as well as static, functional, or compression impressions. These techniques are for the stability and "suction" of the denture and require the patient to make facial movements during the impression. There is a reported idea of using compressed air in the periphery for tissue displacement, but I have not found any details. Having said this, we are seeing companies promising "digital dentures." Two that are quite visible are Avadent (Global Dental Science) and Mitsui/Heraeus Kulzer, based on the DENTCA System. The DENTCA System is now used in the Nexteeth System, a product of the Whole You company.
Both of these systems require dentists to take traditional denture impressions but ask that they use their proprietary trays, which are quite different. In addition, each company includes with its trays a method to obtain a bite relationship, lip-line, vertical dimension, and centric and also to create a gothic arch type tracing at that first impression visit. These impressions and records are then sent to participating laboratories, scanned, and put into a digital workflow. This is where the digital system begins. Teeth are set up on the screen with software, and the try-in can be emailed to the dentist with 3-D images. This is a virtual try-in, and changes can be addressed, sent back digitally, and quickly returned. Even the lips are superimposed on the screen. If acceptable, the completed denture can be returned to the office, making this whole process a 2-visit procedure. Both companies have extensive information and clinical procedure videos on their websites: avadent.com and wholeyou.com.
Of course, those of us who are not totally trusting can request an actual try-in. Both systems will send back a denture prototype (Avadent, milled; Whole You, 3-D printed) for try-in. It is all one color, but you can see the teeth setup as well as check the vertical, centric, and fit. Modifications can be made on the trial denture, or they can simply be marked (for example, if the midline is off). Note that the tooth color is not in this try-in denture. The denture base is exactly the same fit as the final, so adjustments and even relines can be done and returned to the company. Again, you will get the virtual images sent prior to final finish for your approval. Initially, these systems were for full upper and lower dentures, but now the processes can do single-arch and immediate dentures. There are also protocols for overdentures and screw-retained dentures.
The companies' denture processes are quite different. The Whole You System uses a milled Lucitone base with standard acrylic and composite teeth; the Avadent System uses CAD/CAM to create the final denture and mills the final denture from a block of preprocessed base material that is much stronger and lighter than traditional lab-processed materials. Additionally, Avadent recently introduced a fully milled denture where the base and teeth comprise one unit (monolithic); there are no teeth to fall out, and no seams to harbor bacteria.
There are also digital denture design software programs from 3Shape, DentalWings, and others in use by laboratories, but for now, it is still an old-fashioned impression that gets it all started.