|Figure 1. EasyShade V in action.|
|Figure 2. EasyShade V LCD screen information.|
|Figure 3. EyeSpecial C-II Isolate Shade mode.|
|Figure 4. Taking a shade for ShadeWave.|
|Figure 5. ShadeWave shade map.|
During the years, many shade-matching devices have come and gone. Issues are that with even the most sophisticated spectrophotometers, the tooth surface is not opaque like paint on a wall.
Shade matching of teeth is an art form more than an exact science. We have all sat there for a long time placing shade tabs next to a tooth and mumbling “too yellow/too dark/too light!” many times. And if there is a laboratory nearby, a patient may be sent off to let the technician figure it out. (Some labs actually come to the office.) Variations in color are affected by office lighting such as fluorescent, LED, incandescent, natural light, and more. Also, wall colors and even lipstick colors enter in to the shade-match game.
One simple idea is making sure that the lighting is uniform and correct. AdDent (addent.com) has the Rite-Lite 2 HI CRI Shade-Matching Unit, a device that “incorporates diffused LED technology to simulate various lighting conditions to aid in the matching of teeth.” A portable device, it illuminates the mouth with 3 lighting situations—5500°K, 3200°K, and 3900°K—that remove ambient light discrepancies. You simply shine the device on the area of interest and take the shade under these 3 lighting conditions with or without a polarizing filter.
During the years, many shade-matching devices have come and gone. Issues are that with even the most sophisticated spectrophotometers, the tooth surface is not opaque like paint on a wall. Montreal-based Cynovad had a great one, and Olympus had probably the best, allowing mapping, printouts, photos, and more. Alas, at a cost of about $7,000, it did not survive. XRite, the company that makes the devices for Home Depot, auto manufacturers, and others also seems to have dropped out.
VITA North America (vitanorthamerica.com) introduced the EasyShade in 2004, and it just keeps improving the product. Originally using the 16-shade A1 to D4, it now includes all these and the 3D-MASTER shade system. A simple design with a portable device, EasyShade allows you to map the tooth in as many areas as you care to, although typically it would be gingival, middle, and incisal using the 3-mm tip (Figures 1 and 2). With the latest configuration, the data can be sent wirelessly to an app and off to the dental lab. It is fast and simple to use.
Another popular method of shade communication with the lab is simply taking a photograph of the case with a shade guide in the photo. Even if you are sure of the color, it is best to send 3 images: one with the shade you chose, one with the tab just below, and one with the shade just above the one you picked. This is because cameras, computers, and monitors may not be exactly color-calibrated. In other words, the color on your screen might not exactly match the lab’s. This gives a guide as to how close the tab is to the actual tooth you are matching. Photographic shade matching is even better if you are using Shofu’s EyeSpecial C-II camera (shofu.com). In addition to its menu of settings for closeups, mirror shots, full face, and others, it has an amazing shade-matching setting. As you see in Figure 3, it grays out the soft tissue, highlighting the area you are looking at. I have personally found this to be a great function, and here is a quote from one of the labs I use: “We find the filtered photo to be helpful because we can see the shade and characteristics of the teeth better.”
But, as they say, that’s not all, folks. Dennis Braunston has been teaching dental photography for years. Additionally, his company Dental Learning Centers (dlcenters.com) has put together a dental camera kit that allows you to take images right out of the box (manual included). In the past few years, though, he has taken an old idea and now has software that will actually read the digital image of the teeth and figure out the shades. Even if the color of the camera or monitor is off, this works because you are taking a photo of the shade guide as well as a black, gray, and white tab with an A2 shade tab. The software can easily calibrate the shade since it “knows” black and white and A2 and can then extrapolate the colors. Here are some examples, shown in Figures 4 and 5. For more information, visit shadewave.com.
Also in Technology Today
My colleagues have consistently told me that I owe it to my readers to add magnification to my technology repertoire; that there is, well, a lot that I am not seeing...
|A clear view of pinpoint pulp exposure.|
|A Global Surgical A-Series microscope in use.|
|Dr. DeWeirdt operating with no neck or back strain using a ZEISS OPMI pico microscope.|
In my years of practice, I have never performed clinical dentistry with a microscope. I have worked with various magnifying loupes but stopped my journey at 3.5x magnification. Colleagues have tried to push me to 4x-plus or acquire the Orascoptics EyeZoom (orascoptic.com), which allows a range from 3.5x. I have also worked with indirect vision, using products like MagnaVu that project the working field on a screen, showing your operating area over 20x, but the image is coming from a camera mounted away from the mouth. And as I have stated many times, the use of digital impressions and seeing my work on a large screen has improved my preparations. As I stroll the aisles of dental meetings, I see these seemingly giant pieces of magnification equipment, glance over and say hello to friends performing product demonstrations, and then pass on by. My perception is that this equipment is a great tool for performing endodontics, noting that specialists I work with use them. But since endo is not in my main repertoire, I see no reason to pursue this. My colleagues, however, have consistently told me that I owe it to my readers to add magnification to my technology repertoire; that there is, well, a lot that I am not seeing. Drs. Glenn van As, Glenn DeWeirdt, and David Clark have been leading this charge. I have now personally looked at ZEISS (zeiss.com/meditec), Global Surgical (globalsurgical.com), and Seiler (seilermicro.com) microscopes and soon intend to cover them in detail, but in concept, they all perform the same function. Like automobile brands, they get you there slightly differently and have several options. As I polled the owners of these microscopes, each one responded passionately about the brand they were using, so I dare not compare brands at this early stage of my education.
Drs. van As and Clark, who you have seen in Dentistry Today, use Global Surgical microscopes. Dr. DeWeirdt, an up-and-coming leader, is a ZEISS microscope user, and he has spent the last 2 months showing me cases and explaining to me why he uses magnification for most of his procedures. Specifically he’s stated this: “Since incorporating the dental operating microscope into my daily practice, I have reduced neck, back, and eye strain; increased patient satisfaction; improved my quality of care; and also improved my bottom line.” A strong statement indeed!
In endodontics, Dr. DeWeirdt can easily spot extra canals, see intracanal debris, and in many situations, see the apex. In operative dentistry, the subtle texture and color of caries are clearly visible. And of course, locating fractures and seeing their extent is quite remarkable and a bit unnerving since he sees issues that would normally go unnoticed. With the microscope’s camera, lighting, and video capabilities, this information can be archived as well and shown to patients for better understanding of the procedures. Dr. DeWeirdt notes that this feature is also quite useful for over-the-shoulder staff training as well as practitioner training. With this simple technology, images and videos can be shown on a large screen for groups or classes.
Utilizing magnification, Dr. DeWeirdt also notes that crown (and all) preps are better, smoother, and more accurate. Caries looks quite different when magnified, in both color and texture. When checking the fit of crowns, there is a more critical eye, putting the lab on notice, and with his in-office CEREC restorations, he can see a better fit. And of course, things like polishing and bonded margins of crowns and composites can be greatly scrutinized.
Magnification’s biggest advantage, however, may be improved operator comfort; the use of microscopes has prolonged many dental careers. Many of us experience back and neck pain, unfortunately to the point where some of our colleagues have had to stop practicing. Even though loupes, if properly measured, force us to sit more erectly, we all like to twist and turn to get a better view. This does not happen when working through a microscope; thus, there is less strain on the neck and lower back. There is also less eye strain, with somewhat fixed focal length and uniform illumination.
Also in Technology Today
|Figure 1. The Owandy I-Max 3D.|
|Figure 2. The MyRay Hyperion X5.|
My quest at dental meetings is to run up and down exhibitor aisles researching products (so you don’t have to). My Fitbit averages more than 50,000 steps during these meetings!
At the end of last year, there was a flurry of meetings such as the ADA Annual Session and the Greater New York Dental Meeting, and a number of new products appeared on their exhibit floors. Throughout the year, I report on these products. Some I’ve had a hands-on chance to use; others I just found interesting. Here are a few that are not mainstream (yet) that caught my eye.
While 3-D imaging and cone-beam units continue to proliferate, many practices do just fine with results they get from panoramic systems. Companies continue to improve existing systems and introduce new ones. In the past, Air Techniques (the Provecta S-Pan Panoramic X-Ray system [airtechniques.com]) and Sirona (ORTHOPHOS SL DCS [sirona.com]) enhanced images by using multiple layers, getting an extremely sharp final result. New units from Owandy (owandy.com) and Cefla (cefladental.com)address the physical footprint of the existing units and offer a unique alternative: wall-mounted panoramic units that are compact and obviously take up less real estate in the office. If these last 2 names are unfamiliar to you, they have been around for a long time in the international marketplace but are lesser known here. Their products are all top of the line and certainly competitive with others that are more visible in the United States.
The Owandy I-Max 2D wall-mounted system is not only sleek and compact, but it is also able to deliver 12 modes, including extraoral bite-wings, TMJ closeups, and more. It offers other features like low-dose setting, Internet connectivity (eliminating the need for a dedicated computer), layering technology, and more. And of course, the wall mounting is very space-efficient. Owandy also has 3-D systems both traditional floor-mounted and wall-mounted (I-Max 3D [Figure 1]) versions as well.
The MyRay Hyperion X5 (Figure 2) from Cefla also boasts a wall-mounted pan with multiple settings, and it also has a low-dose setting and Internet connectivity, which allows connectivity to tablet devices, making images portable and easy for patients to view. The interface is a very slick touchscreen, making image setup easy to do. In Cefla’s 3-D division is the NewTom, which has one of the very first cone-beam systems in the marketplace.
There are differences in de-sign and patient positioning between these 2 units, giving an office more options to choose from. If you are in the marketplace for any digital radiography—from sensors on up—you owe it to yourself to look at these companies.
A company that generated lot of buzz at the recent meetings was St. Renatus (st-renatus.com), with its product Kovanaze, the first nasal oral anesthetic. Using a small syringe (no needle), the patient sniffs the solution tetracaine HCl and oxymetazoline HCl into one nostril, waits a short period of time, and then sniffs in the other nostril. This creates profound tooth anesthesia to the 8 upper anterior teeth—first premolar to premolar. Some studies show second premolars affected also. And there is no soft-tissue numbness, so you can keep control of the smile-line in anterior cosmetic cases. This item is primarily designed for needle-phobic patients and those who are very sensitive to anterior injections. One of its uses is the insertion visit of anterior crowns or veneers where you might want to use a lot of air and water on those sensitive teeth and want to see the natural smile results right away.
Another niche product I noted was from TAUB Products (taubdental.com). Since the 1930s, it has always had innovative dental materials for dentists and labs, and it is constantly looking for products to solve common problems that are not addressed by other larger manufacturers. Several highly visible practitioners such as Ross Nash use its products and provide feedback for improvement and new ideas. Although Fusion ZR, its new crown and bridge cement (which comes in “clear” ), and Zero-G, its new implant cement, look intriguing, its new Liquid Magic provides a great solution to a common issue. Before cementing a crown on a screw-retained implant abutment, dentists use all sorts of things to fill in the screw hole; a cotton pellet is quite common as is a little squirt of impression material. At a recent course, I learned about packing in plumbers’ white Teflon tape into the screw sleeve. All of these are used because they are easy to remove in case you have to get back and tighten a screw later on. Liquid Magic is the easiest of all solutions. It comes in a small syringe and acts like a flowable composite, injected into the hole and light-cured. It turns into a rubbery, nonsticky material that can easily be removed with the flick of an explorer.
As you might have surmised, my quest at dental meetings is to run up and down exhibitor aisles researching products (so you don’t have to). My Fitbit averages more than 50,000 steps during these meetings! As I have said before, just like the old Yellow Pages ad advocates: “Let Paul do the walking.” I’ll see you in Boston, and Chicago, and Atlanta, and….
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.