Technology Today

"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.

SciCan’s STATIM G4 Sterilizers.
Planmeca’s Sovereign Chair.
Monitoring water quality with Romexis software.

This month, I offer a glimpse of the future as more companies develop software-controlled and Internet-enabled dental equipment.

In the days before caller ID, you might have received a prank call asking the question “Is your refrigerator running?” “Well, yes,” you’d respond. And then, of course, you’d get hit with this: “Then you better go catch it.”

Today, your practice might get a call from the SciCan Corporation, asking “Is your STATIM G4 Sterilizer running?” You might say yes, but the voice on the other end of the phone line might disagree. The STATIM G4—as well as SciCan’s HYDRIM Instrument Washer—is connected to the Internet and sends a message to a central service center if something has gone wrong. SciCan led the industry with this remote monitoring of dental equipment 2 years ago. There is a small computer inside each unit that monitors every cycle and records it. Some states require this record, so all you need to do is plug a USB drive into the unit and get a copy of the log. If there is a failure, not only does the service center get notified, but you get an email, text, or phone call (based on your preference). The service technician can then log into your unit, run diagnostics, and determine what’s wrong. When the service technician arrives at the practice, he or she can bring the needed parts, hopefully preventing the all-too-common second visit.

This is also happening in our everyday lives. There are home appliances and home security systems that use this technology to monitor everything from our heating and cooling habits (nest.com) to how old the milk is in our refrigerator. If you want to see one group of current home products that can be controlled remotely, visit wemo.com.

As an aside, there is a common scam whereby you receive a phone call from an alleged computer service technician telling you that your computer has a problem. If you give this person access to your computer, he or she can either infect your computer and make it inoperable until you pay a fee (ransom?) or “fix” the problem and bill you an extraordinary amount of money. Unfortunately, there are still gullible and nontechnical people who fall for this ploy.

Another company that is using a great deal of technology today in its equipment is Planmeca. We know of its top-of-the-line radiography products from the ProSensors to the ProMax 3D Cone Beam to the E4D, now renamed PlanScan, which is part of the Planmeca FIT integration. But you might not be as familiar with the Planmeca Sovereign line, an entire line of dental units, chairs, lights, etc, that are not only beautifully designed but have many ergonomic and functional features that are unique and integrated with software control and monitoring.

Planmeca’s chair design differs from most chair designs because its footrest area drops down to 90° so the patient is sitting upright as if in a comfortable chair. Aside from this being a better position in which to talk with the patient about treatment, it makes the chair extremely accessible for patients with ambulatory problems. The big thing though, from the technology standpoint, is connection to the Planmeca Romexis Clinic Management Software. It can be programmed to remember an operator’s chair setting for various procedures, and each operator has his or her own settings. It also monitors the unit’s functions in terms of use and wear; for example, the number of times it has moved, how long the lights have been on, and more. This information is displayed, and the software gives alerts not only of malfunctions but also to let the operator know the unit needs routine service. Also, since these units have self-contained water, treatment protocols and biologic monitoring are also being checked. In addition, all waterlines are monitored for proper biologic standards. And, as to be expected, there are multiple configurations for an office designer to choose from as well as other features too numerous to cover. More information is available at planmeca.com.

This is just a glimpse of the future as more companies develop software-controlled and Internet-enabled dental equipment. I should also note that Sirona Dental recently introduced its Transcendental Treatment Centers at the CEREC 30 event in held in Las Vegas this past September, including the TENEO and INTEGO systems with state-of-the-art integration and Kappler cabinetry. This should lead to centralized monitoring centers at both manufacturer and distributor facilities, which will ultimately lead to better maintenance and cost savings for servicing the practitioners. It also means that when designing new practices, be sure to have extra network inputs in treatment rooms, sterilization areas, labs, and more.

No matter how much technology a practitioner uses, there is one common instrument that everyone uses, and the majority of them use one with a 50-year-old design: the air- turbine handpiece, a staple in the armamentarium of almost every office. Most practitioners make their purchasing decisions based on the model they used in school or perhaps the ones that were used in a former or associated office. You step on the pedal and get to work. When a turbine fails, either you pop in a new one or send it out for repair. Some offices have the turbine repair unit and kit and keep the handpieces running for more than 20 years, so there does not seem to be much need to buy a new handpiece. Of course, the glamour of electrics is out there, with many amazing benefits, but there are many frugal offices that don’t want to “get into that expense” just yet. Plus, to keep up with sterilization protocols, you probably have already invested in several handpieces, usually the same model.

Figure 1. J. Morita’s TwinPower turbine. It looks and feels like all other turbines, but when in use, its power is immeditely noticeable.
Figure 2. Bien Air’s Tornado. Using ceramic ball bearings and a new turbine design, not only is it the most powerful handpiece in the class but perhaps also the quietest.

There seem to be some new sleek designs and lighter materials (titanium), but if asked, how many of you would know the torque power rating of the one you are using? We are aware that with too much pressure on a tooth, many handpieces will stall or slow down. When cutting through large amalgams or crowns, we seem to apply more pressure and can manipulate the bur so it won’t stall, but you know it is generating more heat. The answer to the torque is that a typical air handpiece cuts at about 16 to 18W. Electrics maintain 35W or more and don’t usually stall due to the drive system. Aside from cost, a disadvantage of electrics was the size and weight of both the motors and the hoses. This has changed dramatically during the past few years, with smaller, lighter motors and better balance.

Handpiece companies, even those who manufacture state-of-the-art electric handpieces, have taken a cue from dentists and realize that most still prefer air turbines. They are easy to connect and disconnect, and despite the advances lowering the size and weight of electrics, air turbines are lighter, thinner, and less expensive. No matter what, electrics have to be a bit more robust to accommodate the gears and shafts instead of an air hose with a small spinning top at the end.

Several years ago, J. Morita reinvented the turbine by creating a “TwinPower” turbine (Figure 1), increasing power from the typical 16W to 22W. Unfortunately, this was almost unnoticed since J. Morita is not a name most associate with equipment. (Incidentally, J. Morita has an excellent cone beam unit). The TwinPower turbine handpiece looks and feels like all others, but when in use, its power is immediately noticeable.

KaVo recently introduced the Mastertorque lux. The company has increased its already robust handpiece to 23W and reduced the noise level. It has also introduced “Direct Stop Technology,” which is like ABS brakes on your car. The bur stops in 0.8 seconds, reducing injury to an aberrant soft tissue or a cotton roll. (We all know that sound.)

Another interesting innovation in air handpieces is Medidenta’s surgical unit, the Air King Surgical (45°). Medidenta has changed the entire airflow through the handpiece, exhausting through the back, thus eliminating the possibility of air embolism. At the same time, it has pushed the torque to 22W.
Continuing with improvements in power, NSK introduced the Ti-Max Z900L , offering a whopping 26W of power (as well as a 30-month warranty). NSK has created a formidable competitor to its own line of electric models.

The newest and highest power air handpiece comes from Bien Air, with its new Tornado (Figure 2). Its power tops out at a remarkable 30W, closer to the 35W of an electric. Using ceramic ball bearings and a new turbine design, not only is this the most powerful handpiece in the class but perhaps also the quietest. It offers many more advanced features, including a heat shield like the space capsules, ensuring patient safety.

One notable handpiece from Toronto-based Beyes, the AirLight M800, gives you fiber-optic light without a cable, and there is a generator turbine in the handpiece that powers the LED.

Finally, Midwest introduced a handpiece priced between air and electric models, the Stylus ATC. Although it is only reporting 20W, this power does not diminish unless you are pushing against the tooth with 2 hands.

There are other new air handpieces that have had similar advances that we’ll highlight in a later issue of Dentistry Today. In the meantime, take a hard look around your office because it might be time to retire that Borden AirRotor.

Fools Rush In

10 Aug 2015 Written by

There are patients who have low caries susceptibility. Commonly, there are small lesions found on radiographs, especially interproximally, that started and then—for whatever reason—were arrested. There is no greater thrill for a hygienist to report on a newfound “stick.” With all patients, it behooves the practitioner to check the prior notes and images before rushing to the restoration. The digital radiographs and software allow for easy side-by-side comparisons to see the progression of a lesion. Years ago, there was actually a program that did x-ray comparison by “digital subtraction.” (If anyone knows what happened to this idea, let me know.) It is not harmful to watch something as long as there is follow-up. Even with minimally invasive dentistry, the preparation can be much larger than the caries. Caries detection using fluoroscopy (eg, Spectra [Air Techniques—Fig- ure 1], SoproLife/SoproCare [ACTEON]), laser reflection (eg, Diagnodent [KaVo]), transillumination (eg, CariVu [DEXIS]), laser photothermal and luminescence imaging (eg, The Canary System [Quantum Dental Technologies—Figure 2]), digital radiograph analysis (eg, Logicon [Carestream]), and others give us a quantitative method of “watching.” Other than myself, for teaching purposes, there is no reason to have many or all of these. Studying each of them will give you a sense of what system (or systems) fit into your practice style and philosophy. The start of the process is thinking about what you have been seeing and doing for many years of practice.

Figure 1. Air Techniques’ Spectra Caries Detection Aid.
Figure 2. Quantum Dental Technologies’ Canary System.

Looking at the clinical exam, it starts with physical examination, use of excellent lighting, and perhaps an intraoral camera and/or optical magnification. Once you start moving up the loupe chain, you will see more and more detail of what used to be determined by just the eyes and an explorer. (As an aside, Orascoptic recently introduced loupes that actually can zoom in: EyeZoom, which goes from 3x to 5x.) Radiography (hopefully digital) is the next step to determining a course of action. New 3-D imaging is also wonderful, although not necessary at this time for a routine exam. However, this will change as technology and current thinking evolves. When performing this exam, there is a buzzword: CAMBRA—Caries Management By Risk Assessment. It should really be called TAMBO—Think A Minute Before Operating. Don’t rush to pick up that handpiece. With these systems, there is a method to “watch” areas with more than just your judgement. The patient also can become directly involved in the discussion by seeing these results and not just told to “come back for a filling.” This leads to better rapport, better trust, and actually less nervous patients since they have a better understanding of what is about to happen instead of wondering. That’s not to say they will love it, by any means, but offices that follow this get a lot more patients saying “thank you” when they leave. And of course, there’s always the new patient who “hasn’t had a cavity in years, so why now?” He or she will not run out and say, “All this new dentist wants to do is make money on me!” This is something we all have seen and heard before.

You should all be aware that we are also entering an area of remineralization and chemical rebuilding of hydroxyapetite. Products like TCP (3M ESPE), MI Paste (GC America), Recaldent (VOCO), and others have the potential of slowing down or even reversing incipient damage. Some practitioners initiate this in the office and send the patient home with product for continuation. Compliance must be reinforced, especially if the areas are not completely visible. And if you are wary of the claims, the use of the technology products mentioned above can show the progress very clearly and validate this process to both the practitioner and the patient.

If restorations are recommended, keep in mind that the smaller (minimally invasive) lesions can be restored with bioactive products. Glass ionomers are well-known products to use in small lesions and even as sealants, and they excel in fluoride release as well as being recharged as additional fluoride is introduced in the oral cavity. A new set of restorative materials (Pulpdent’s Activa) and cements (Doxa’s Ceramir and NuSmile’s BioCem) claim to rebuild damaged enamel inside and at the margins of restorations. These are also helpful in larger restorations. Taking the idea beyond the scope of this discussion, we also have products such as Biodentine (Septodont), Theracal (BISCO), and Calcimol (VOCO) that are using this technology to rebuild the floor of deep restorations, doing what Dycal was supposed to do.

This is surely a lot of product information to absorb at this time. I feel like I took you up and down the aisles of a dental exhibit floor, and if so, this was my intent since this is what I do in my “spare” time. And as always, please feel free to stop me if you see me at a meeting or contact me through Dentistry Today.

The bulb in my trusty old Pelton Crane Light Fantastic went out. Checking around the office, I found a little white box that contained a wrapped bulb and what looked like a cheap pair of pliers. Instructions said to pry the socket prongs apart and carefully remove the expired bulb, being sure the switch was in the off position. (No matter how many times I turned that light on and off, without the bulb in, I was not totally sure if it was off.) Then, without touching the new bulb, wriggle it in with one hand while holding the prongs apart with the “pliers.” Those of you who have had this experience know about wrapping a 2 x 2 around the bulb and struggling to snap the new one in at the exact moment you release the pliers. Luckily, this is not a daily task (but indeed a memorable one). In addition, most lights have a glass parabolic reflector that gets quite hot and often burns through the reflective coating. Reflector replacement can be done by the dentist or staff, but this is always is a tense process. And how many times do you have to tell patients this: “Do not touch the hot light!”

In another era, those of us “early adopters” who used headlights had a large fiber-optic box with a hot bulb and an expensive, heavy black cord that attached to the headlight. How many times did you try and walk away from the chair, almost pulling a muscle in your neck?

Figure 1. DentalEZ’s everLight.
Figure 2. A-dec’s LED light.
Figure 3. Ivoclar Vivadent’s Bluephase Style curing light.

Thankfully, these scenarios have come to a conclusion. When you look at new chair lights and headlights, the bulbs are gone, replaced by light-emitting diodes (LEDs). These also show up in curing lights, laser guiding lights, and other equipment. And when you go to a retail store for bulbs for your home or office lighting, you are now told that they don’t even make the old 60W incandescent bulbs; you now have to spend $5 to $30 for a new LED or compact fluorescent light (which is now falling in disfavor). For dental use, the great thing about LEDs is that each one can be programmed to emit a specific frequency from the light spectrum. (Remember ROY G BIV?) For general lighting from the ceilings or lamps, we want “full-spectrum, color-corrected light.” There are a few fluorescent bulb companies that manufacture these for existing ballasts like Vita-Lite, although green offices are shying away from all fluorescents. We must be aware that composites and bonding agents are sensitive to specific frequencies, and herein lies a problem; the new overhead chair lights using LEDs are full spectrum, which helps in shade matching as well as giving excellent directed light. The composites and bonding agents we use will set at the blue wavelength, which is contained in these overhead LEDs. Thus, the materials will begin to cure immediately. To overcome this, all new chair lights have a “curing” setting where the full-spectrum LEDs are shut off, and a set of orange lights come on. You can see these clearly in the new lights and continue with your procedure. Also, since there is no need for the reflectors, design engineers have devised some very slick “space age-looking” lights. They are compact and lightweight, and many come with a guarantee of 7-plus years on the bulbs.

With respect to the curing frequencies, we should be aware of a little chemistry. Camphorquinone is the photo initiator for most of the materials sold today, and they photopolymerize with blue light. In former times, butyl hydroxytoluol or lucirine was used, needing ultraviolet light for curing as well as other photo initiated chemicals. And there are other chemicals around too. Initially, Ultradent Products gave us the Ultralume (now VALO, covering 395 to 480 nm), and Ivoclar Vivadent offered Bluephase (now Bluephase Style, covering 385 to 515 nm). These along with other models use multiple frequency LEDs to cover all products.

But frequency is not the only thing; intensity is important too, and with time, the LEDs as well as the fiber-optic “pipes” can degrade and lower the light output. (Note that some, like VALO, have the LEDs right in the tip.) This has to be constantly monitored, or you will have partially cured composites. Kerr Corp recently launched checkMARC (checkmarc.net), a service that allows offices to determine if lights are working properly. All magnification manufacturers have incorporated this LED technology into the once heavy, bulky, and sometimes tethered lights. Independent companies have headlights that will fit all loupes. One, ultralightoptics.com, has a light that weighs a mere 3 g. Again, be careful when bonding and placing composites. All of these new headlights have a drop-down orange filter to use during that process.

Current research shows that certain oral pathogens can be killed by the blue frequency between 400 and 470 nm. This could lead to in-office or even at-home treatment devices. There are already units being sold in Europe called Photo-Activated Disinfection devices that are capable of doing this.

There are other areas where LEDs have appeared, including in our automobiles, again thanks to low power, low heat, and long life. (For more technical information, I will post details on our website, dentistrytoday.com.) And finally, LEDs are more environmentally friendly and will give you a greener office. On this topic, visit ecodentistry.org; it might just be your first step.

The backbone of any dental prac­tice is the management system. In its infancy, it merely replaced billing systems and the appointment book. As the systems became more complex and computing evolved, most practices assembled a robust network with full office connectivity and a central depot for information and network control called the server. These servers are the heart of the system and have to be constantly maintained and monitored, much like a patient in the ICU. As new updates are received from practice management software companies, they have to be in­stalled on the server and perhaps at each workstation. Many practices receive disks or email instructions for the download and ignore them for several reasons. One is the fear that an update will shut the system down or just make changes in some processes that users might not understand immediately. Of course, software companies do their best to ensure that their updates are workable, but as we all know, there might be some odd feature that a practice has in its network substructure. Some practices wait until others upgrade and await reports that all is well. Usually this means months of running an older system and forgetting to do the update altogether. Unfortunately, this philosophy fails when there is a call to a support hotline, and you are asked when you applied the latest update.
Practice networks are also connected to the In­ternet, and connections must be carefully monitored to prevent attacks from outside sources. If (or when) employees decide to “wander” in cyberspace, malware could be introduced into the network. We have all seen even the most complex corporate networks being vulnerable; data can be corrupted or even hijacked without the practice knowing it. There have to be safeguards in place.
As far as backing up data is concerned, in this day of HIPAA, the server and all backups should be encrypted, especially those taken off premises. This is a task that many practices ignore. Backups are often created by copying data to flash drives, external hard drives, DVD media, and even laptops, and these items are of­ten taken home. Many are soon returned to the practice, meaning that there are none off site, which would be tragic in case of a fire or other catastrophe. Your priority, should a catastrophe strike, should be to immediately exit the office, not look through cabinet drawers to grab the latest backup.
Also, backup storage devices could be lost or stolen, and if the information they contain is not encrypted, it becomes freely available to the new owner, and your liability could be staggering. Thankfully, there are many online backup systems available to a practice, and most maintain a copy of your data. But if there is a server failure or a catastrophe, if you get the data back from an on­line backup system, it is useless without the software programs themselves. This means you will have to reinstall the programs, but how? From the old disks you had when you started? But as you know, there have been several updates since then, and you will be spending potentially hours upon hours with tech support to get you up and running.
An online backup storage system is rarely an “image” of your hard drive, comprising all of the drive’s programs and data. Astute practices usually have virtual hard drives on the Internet such as VMware (vmware.com), but the average dentist is not always savvy enough to manage this; you need a professional information technology (IT) person/company. (And it cannot be your friend or cousin claiming to be an expert, willing to assist you in his or her spare time.)
There are many remote monitoring/backup services—some doing everything remotely; others utilizing an additional local monitor to complement the remote monitoring. Examples I have seen at trade shows are Lorne Lavine’s The Practice Byte Guard (thedigital­dentist.com) and DDSRescue, offered by Patterson Dental. And there are many well-respected local and national IT companies specializing in dental practices that not only handle this task but can also help with integration of all the cutting-edge digital products that I discuss in this column.
And yet another solution is appearing in dentistry and practically all other industries—the mysterious “cloud,” which is merely an Internet-based server. Using this protocol, all data, backups, updates, security, and more are handled remotely. A practice merely needs workstations that have Internet access and typically a browser or some software locally installed that in­cludes tablets and even smartphones. And after installation, data transfer, and initializing the practice data, these systems are affordable and usually based on a monthly service fee. However, many practitioners have concerns about Internet reliability, losing control of information, and the security of data if, for example, the service provider goes out of business. I shared these concerns with Andy Jensen, who has been working with practice management systems for years and currently is a principle in Curve Dental, a cloud-based system. In response, Andy stated, “The same thing happens to the practice when the Internet goes down as when the server goes down. The difference is this: the practice can hotspot a smartphone and have access to its schedule and treatment plans until connectivity is restored.
“The bigger question to ask is how often does the Internet really go down? For some practices, their server may crash much more frequently. It really is not that big of a deal for the vast majority of practices out there. We also recommend that a practice work with a good IT service to make sure the practice chooses a reliable Internet service pro­vider.”
And as far as data security is concerned, Andy’s company and the other companies are quite secure and will stay in business as long as there are the required numbers of customers paying the monthly fee. Also, companies allow practices to download its data at any time; the data always belongs to the user. If there is concern, this can be done on a regular basis, although it would defeat the whole idea of the cloud-based system. Today, we are seeing an increasing number of cloud-based systems. Some are new versions of existing systems such as Dentrix Ascend and Carestream Cloud; others are ICE, planet DDS, and Dentisoft; while others such as Eaglesoft and XLDent are in the wings.
I have only touched the surface here, and if nothing else, I advise you to take a closer look at your current systems.

A common scenario after a new patient exam is that the findings do not concur with what the previous dentist had found or had been “watching.” The patient often leaves, stating that he or she could not believe “all that work” that was needed. The patient laments, “I have been seeing ‘Dr. Oldguy’ for years, and I’ve never had to have a filling replaced, and I haven’t had a cavity for ages!” If there is not a careful discussion and explanation of why these things need to be done, the situation can end with a disgruntled lost patient. In this info era of Yelp, Doctorbase, Healthgrades, Angie’s List, and others, this can be a disaster. In earlier years, you could shrug this off, and the worst-case scenario would be that the patient would converse only with family and a few co-workers. This situation can be turned around, however, with a beaming clinician review if you let the patient see what you are seeing. The use of intraoral and digital cameras allows this to occur, giving the patient an instant understanding of open margins, fractured teeth, and more. And with some of the new digital caries detection units, an online clinician review could be one of amazement, highlighting how high tech and thorough his or her practice is. (There also has to be a bit of respect for the previous clinician since it was a long-term relationship, and as we all know, some patients present un­foreseen challenges.) There are many practice management consultants who can help you with your presentation skills and verbiage as well as explaining value and ROI. The basic information of show and tell, though, is still to me the beginning of this process.

Figure 1.Video Dental Concept’s QuickCam Duo. (See p. 41.)
Figure 2. Shofu Dental’s EyeSpecial C-II.
(See p. 30.)

There are plenty of serviceable 50-year-old-plus amalgams, and we have all heard patients’ reasons for keeping things status quo. How many times have you heard this: “Doc, if it ain’t broke, don’t fix it.” We have to define “broke.” It is good to be proactive, but you must use all of your tools to do this, and this is where documentation becomes critical. The late Dr. Robert Barkley, whose untimely death preceded intraoral cameras, stated that you should show pa­tients their teeth and explain in simple terms what you see, then leave them alone for a few minutes. There will always be questions asking what can be done, and you can easily lead the patient toward your proposed treatment. The intraoral camera is one of the best tools to accomplish this. The simple image of a tooth with a fracture in the enamel or a lost cusp appearing on a screen in front of the patient almost always evokes a question.

Many offices have an intraoral camera, and as we all know, it is never located in a room where you or someone else has to go get it. Due to time constraints, we often grab a hand mirror, pencil, and paper and try to ex­plain what is going on. Even with today’s digital patient education systems, patients still have to see their own issues. Although it would be ideal to have a camera in each treatment room, newer designs simplify their relocation. Newer dental units can be designed with a holder next to your handpieces, where a camera can be placed, and when it is picked up, much like the handpiece, it activates. If you are not purchasing new units and will be using one or 2 cameras for multiple rooms, connectivity is something to consider. Most of the newer cameras connect to your computer with a USB connection. To move it room to room, some cameras move with the cable, which you will have to plug into the USB port. If that port is on the computer itself, it could be a physical challenge. However, many of the new treatment room designs put a remote USB hub in an easy-to-access location for both these cameras and other devices you may add. Other camera systems re­quire you to install a cable in each room and use a quick disconnect, which for example could be in a holder next to the air/water syringe. In either situation, as long as everyone knows where the camera is stored, it is easy to get at. (Note that you will need barriers with the cameras, so they also have to be easily accessible.) There are many intraoral cameras on the market, and costs range (rather wildly) from $500 to more than $6,000, but you get what you pay for; obvious variables are image quality and lighting. In this day of multimegapixel cameras that fit in a phone, it shouldn’t be too hard to get a high-definition image at a reasonable cost. In fact, there are apps and accessories for camera phones to be used in this manner, although this might not be the most clean or efficient method to use. New LEDs are brighter and more color-corrected. For my own use, where I need images for publication and presentation, I need a high-end camera. I also have some others that I have accumulated throughout the years. The early ones are in a box somewhere in the office, and I often tell my staff, “Well, maybe I will need the old one some day.” When I look at the earlier images in my database, they actually were adequate for patient discussion. The newer models’ images are surely clearer and have features such as macro/zoom, which allows you to put the camera right on a fracture and look into the crevice. This is quite dramatic and often the best explanation to a patient why sometimes the tooth hurts when they bite on something hard. There are also ergonomic features to look at; location of the capture buttons and ease of operating them have to be considered. Also, ask yourself this: “How complex is it to change settings for one tooth, one quadrant, one arch, or the macro setting?” There is a photography parameter called “depth of field.” To me, this is one of the most critical parameters. How much range from the tooth out do you have to get a sharp image? Some are very tight and re­quire a setting change, while others are more flexible. What about image stabilization? It is not always easy to maintain a steady camera position.

Some of us believe we can use a standard digital camera for our imaging needs while being used for smile design, full-arch photos, and full-face photos. This is true, although a digital camera is not as quick as an intraoral camera when you have to get it, turn it on, get retractors and mirrors, and upload the image. (Not to mention the challenge of disinfection if you are in the middle of a procedure.) Although I have evaluated many excellent cameras, I would be remiss in not mentioning 2 solutions that have ap­peared at recent meetings. One, QuickCam Duo (Video Dental Concepts [Figure 1]), is an intraoral camera that has 2 lenses—one for intraoral on the wand tip and another for full face on camera’s main handle. Also, Shofu Dental’s remarkable EyeSpecial C-II SLR camera (Figure 2) is totally sealed, can be easily disinfected, has image stabilization, yields high-quality images (including zoom), and has special setting for taking shades. It connects with your computers via wi-fi, which bypasses cables and again maintains the sterile chain. I will soon be reporting on details of these as well as many other cameras with the presentation of everyday images from my practice. In the meantime, reassess your workflow, dust off that old unused unit, or look at some of the newer options.

This is a teaser. I have spent the first quarter of the year running all over the globe accumulating information for my writings and lectures. Meetings in the United States such as the Yankee Dental and the Chicago Midwinter surely had a lot of new information about current and future products. The pinnacle of meetings, however–the International Dental Show (IDS)–was held last month in Cologne, Germany. The IDS is held every 2 years and serves as the international launch for many products as well as a showplace for existing ones. This is unlike any meeting you have ever attended. First of all, there are no real courses or CE, although there are many professional presentations. IDS is an industry showcase, business to business, as well as a giant press event. Imagine 4 buildings the size of Chicago Midwinter’s McCormick Place, some with 3 exhibit floors.

Meeting with Francois Duret of Marseilles, France, considered to be the father of CAD/CAM dentistry, at this year’s International Dental Show in Cologne, Germany.
More than 138,500 visitors from 151 countries visited the show. For information on the 2017 IDS, visit ids-cologne.de.
Live demonstrations were commonplace at this year’s show, some involving complex surgeries.

This year, according to an IDS press release, there were “a record-breaking 2,201 exhibitors from 56 countries and more than 138,500 visitors from 151 countries.” And at the meeting, there is a different philosophy of visitor/company rep interaction: instead of standing in a booth, you can sit down, relax, and talk to a rep while enjoying a cappuccino, soft drink, sandwich, and in some cases even a beer! Of course, these booths are of mammoth proportions, allowing room for multiple complete operatory setups as well as live demonstrations, including dental procedures (including complex surgery) right in the booths.

The technology side of the meeting focused on both the clinical as well as the laboratory side dentistry. There must have been 80 companies with CAD/CAM lab products ranging from model scanners to giant milling machines for restorations (ceramic, zirconia, and precious and nonprecious metals including titanium, for example). One company, Dental Wings, introduced a milling system that uses lasers instead of burs.

Many new 3-D printers were shown that created models, appliances, temporary restorations, and gold copings, and some even printing 3-D cone-beam scans with true bone and enamel color in actual size. One of the printers was accurate to 16 µm. Also, implants as well as treatment planning software were in abundance. I never knew there were so many international implant designs and manufacturers.

Of course, intraoral impression scanners were being introduced from familiar and unfamiliar companies. Some of the newer systems are very small, light, and inexpensive but at this time are clinically unproven, with limited trials. Several were in the prototype stage being readied for launch “by the end of the year,” but since the next show is in 2017, the companies felt it important to show what is coming. Cone-beam units of all sizes and configurations were introduced, offering the promise of more functions, smaller footprints, lower radiation, and more. Some of these units will not be immediately available in the United States since there are regulatory processes that must be followed. Terms like 510K, FDA approval, and others were brandished freely.

Restorative materials and related products including innovative suction tips, mirrors, lights, endodontic handpiece units, and more were well represented. Several new handpieces, both air-driven and electric, were also shown, with some impressive air turbine designs rivaling the torque of electrics. It should be noted that the Kavo Kerr Group introduced more than 30 new products representing all areas of dentistry.

As I said, this is a teaser. I have volumes of information to sort through, and I will be filling this column with eye-opening reports and reviews throughout the year.

Now I just need some sleep.

I had a chance to talk with Mark Hollis and Patrick Klein of Mac Practice. This software has actually been in development for 30 years and currently has over 30,000 users in 31 countries. The Mac platform is the best for image management as well as simple integration of peripherals such as digital radiography. This software uses these advantages of the platform to produce a top of the line dental practice management system. In addition, common devices such as iPads and iPhones work flawlessly with the software due to the common backbone, allowing, for example, filling out a dental chart on one device and being able to see and edit it easily on the other. The graphics along with Apple's retina display produce fantastic periodontal and other charting. Apple's security is will known and MacPractice enhances it to be fully HIPAA compliant. It deserves a look on their website and further inspection with demos or even webinars.
Dux Dental ( now a division of Danaher) gives us the basics that we use every day. Even in the world of digital impressions we still have to take an occasional alginate. Identic, named after the identically shaped/sized particles is easy to mix, smooth and dustless alginate. A unique single use packet, that also serves as the water measure, can be mixed by hand or with their Alginator. This is a simple device gives consistent smooth mixes insuring no bubbles and is easy to load on the spatula as well as simple to clean. In addition after mixing, using their Clean and Lube gives a fresh surface and conditions the mixing bowl.
During the mid 1990s, I became aware of a new company that developed a CT scanning unit for dentistry called the NewTom 9000. It was quite a large device; a patient had to lie on a small table, and his or her head was placed in large, donut-shaped device, open, not tunneled like an MRI. The images were amazing. Structures like TMJ, nerve canals, impactions, and more were visible not only in slices like medical scans but reconstructed in 3-D (Figure 1). This seemed like just the thing for an oral surgeon looking at third-molar proximity to the mandibular nerve as well as a great diagnostic tool for any sort of pathology and of course for fractures, reconstruction, and perhaps orthognathic surgery. The unit was giant and heavy and had a cost of I believe at least $200,000, but the manufacturer sold more than 300 units in a short time. It has since been updated to the NewTom 3G (Figure 2) and the new model, the NewTom 5G.
Figure 1. An early 3-D construction image from the NewTom 9000.
Figure 2. The NewTom 3G, the same basic format as the original model 9000.
Figure 3. The i-CAT.
Several years later, I received a call from Imaging Sciences in Pennsylvania stating that it had developed a unit that looked similar to a panoramic system, albeit a bit larger and heavier, but was able to do these same type of scans with the patient in a sitting position. They called it the i-CAT (Figure 3). Again, it seemed initially to be only of interest to oral surgeons, but as the software evolved and more awareness came into the world of general dentistry, many eyes opened to the fields of endodontics, orthodontics, and eventually all areas of dentistry. The rapid increase in implant acceptance also gave these units a reason for existence since the 3-D images of edentulous areas allowed practitioners to find the best available bone for the procedure.
The evolution has been remarkable. There are now many companies offering these units in many configurations as well as companies offering a whole industry of diagnostic software. A big change came when dentists asked for units that did not examine the entire upper/lower arch and surrounding structures and just focused on one or 2 areas of interest. This allowed the units to use smaller sensors and lower radiation levels and be operated at lower costs. This is extremely valuable in endodontics, when trying to visualize numbers of canals and the anatomy, and it is very helpful in finding fractures or evaluating periapical lesions. In orthodontics, positions of erupting teeth, location of impactions, and excellent views of the arches, mandible, and maxilla give a lot of information that was previously difficult to determine.

Several years ago, a scathing article appeared in the New York Times accusing this technology of over-radiating young children. Unfortunately, the article’s headline and the first page overshadowed the rational explanations in the second part of the article. Above and beyond cautioning of overuse of the scans, which is really common sense, companies took heed and rapidly reduced the radiation exposure to amounts now less than panoramic images or a full series of radiographs, digital, or of course, with film. Note that the “full volume” units are still quite popular, including an upgrade of the supine NewTom 5G.
When integrated with intraoral impression scans, this technology gets even more amazing. Treatment planning of prostheses, especially in conjunction with implants, becomes very predictable, and software now creates “surgical guides” that further enhance the predictability and take out some of the potential human error with “guided surgery.” Taking this to its limits, a patient could come in, have a tooth removed, and in the same visit have the implant placed with at least a temporary if not a final crown.
In this and upcoming issues, we will explore the details of how this technology has its place in everyday dentistry in treatment planning, CAD/CAM, and more. In addition, this year will also bring us new models with new features and innovations, so keep your eyes and ears open, and watch us here and online at dentistrytoday.com.



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