Augmented reality isn’t just for gamers anymore. A cross-disciplinary team of researchers at the University of Western Australia (UWA) is developing software that will enable dentists wearing augmented reality glasses to use hand gestures to access information that then will be displayed in their peripheral vision. 

“A big problem at the moment is the amount of interruptions dentists face when performing procedures, with an estimated 20% of their day carrying out nonclinical tasks and a significant amount of time away from patients during a procedure to review critical information,” said lead developer Marcus Pham, an electrical engineering and computer science student.

“The technology we are developing will change this by providing dentists with all the information they need without them needing to interrupt a procedure, so they can focus entirely on the patient,” Pham said. “This means the time taken to carry out procedures will be drastically reduced, and the quality of dental work will also improve.”

Aside from providing these patient benefits, the technology also is designed to decrease costs in dentistry and help train dental school students. For example, it could provide students with accurate and fast feedback as they learn intricate manual tasks such as tooth preparation, instead of students seeking feedback from a teacher’s interpretation of their work. 

The researchers have been selected as one of 10 teams in Australia to be included in the Commonwealth Scientific and Industrial Research Organization ON Accelerate3 program, a 12-week collaboration that connects experienced and aspiring researchers to develop business models, find funding, and improve marketing before commercialization.

The team also includes Paul Ichim, DMD, of UWA Dentistry, Thomas Braunl, PhD, of UWA Engineering, and Rob Shannon, project manager of the UWA Innovation Quarter. After developing and testing the technology with students at UWA Dentistry, the researchers hope it will be available for commercialization as early as next year.

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Dentistry has seen some tumultuous times lately, with new regulations, a shifting economy, and cutting-edge technologies all changing the single-practitioner drill-and-fill model. Perhaps that’s why US News & World Report and CNNMoney/PayScale have released a pair of “Best Jobs” reports, with similar pay and job growth expected, but drastically different overall rankings for the profession.

US News & World Report called dentistry the number one job overall and the ninth best job in terms of pay. According to its figures, dentists enjoy a $152,700 median salary and a 0.1% unemployment rate, along with an 18% employment growth rate between 2014 and 2024, with 23,300 new openings expected. The researchers also noted dentistry’s average stress level and agreeable work-life balance in calling it the top profession.

CNNMoney and PayScale’s annual list of the top 100 careers in the United States also cited its 18% employment growth rate and estimated its median pay at a similar $151,000 figure, but ranked dentistry in 44th place. In compiling their rankings, CNNMoney and PayScale recognized today’s stronger job market, opportunities for advancement, job satisfaction, and overall job availability and growth in addition to pay. Stress and whether or not a profession is “meaningful” were factors as well.

“Dentistry is a business that allows you to work only a few days a week and make a great living, which leaves more time for you to spend with your family. It’s also great because of how much you interact with people. Nowadays so many jobs are computer based, and with dentistry you have to actually be there and you get to work with people,” said Desiree Yazdan, DDS, MS, an aesthetic dentist at the Center for Reconstructive Dentistry in Newport Beach, Calif.  

“Of course, one of the most valuable aspects is that you get to make a difference in someone’s life on a daily basis,” Yazdan added. “Whether it’s a small filling, or a full-mouth reconstruction, as a dentist you are creating a healthier oral cavity for your patients, and they are benefitting from you in one way or another.”

“We have so many tools to make dentistry efficient, predictable, and pain-free,” said Rico D. Short, DMD, an author and clinician practicing in Smyrna, Ga. “As an endodontist, I love instantly getting patients out of pain who have been hurting for days or even weeks. They are so shocked that a root canal can be done virtually pain-free and so fast.”

Generally, dentistry can expect growth in the years ahead. The ADA reports that dental spending increased again in 2015, indicating that the profession is rebounding from the flat years of the Great Recession. National dental care expenditures were $117.5 billion in 2015, compared to $114 billion in 2014 and $113.3 billion in 2013. Dental expenditures accounted for 3.7% of overall national health expenditures, down from 2000’s peak of 4.5% but still comparable to recent years.

The ADA notes that the increase could be the result of increased dental care utilization among children and adults covered by the recent Medicaid expansion. Dental expenditures financed by public sources have risen from 2% in 1990 to 12% in 2015, with a significant decrease in out-of-pocket spending since its peak in 2008. This shift in public funding also may reflect reduced private dental benefits, which are having an effect on the profession as well.

“Today’s economy has really changed dentistry,” said Yazdan. “More people are becoming educated about the importance of oral health. However, people today are so worried that they may not have enough discretionary income to pay for needed dental bills because their insurance doesn’t really cover anything anymore, so they do not want to or have the funds for dentistry like they used to.”  

As a result, there are still many people who don’t see their dentists for routine exams and care. One recent survey from Delta Dental indicated that 41% of Americans would like to see their dentist more often. But many people who ignore minor infections, pain, and other issues often see those problems get much worse before finally making an appointment or, worse, visiting their local emergency room for care. Of course, dentists want to change this mindset.

“The scope of dentistry has changed to more of a needs-based situation that caters to the immediate pain or emergency,” said Yazdan. “We have tried to take this and turn it into a preventive approach to avoid the pain, emergency, loss of teeth, and infection that comes along with real neglect. We are on a mission to educate patients and give them the tools to get and keep their teeth and gums health so that in the long run they spend less money and save their teeth.”  

“The need for dental treatment is pervasive. One half of the population in the United States does not seek regular dental treatment,” said Craig S. Kohler, DDS, MBA, who has been practicing in Chicago for more than 30 years. “It is a very personal health experience that takes careful diagnostic abilities and technical expertise. There will always be a demand for the competent, caring professional that helps people through some of the difficult health moments of their lives.”

In the years ahead, though, the person providing that care may have some different training. Today’s typical practice is staffed by dentists, dental hygienists, and dental assistants. But some states are now considering mid-level providers often known as dental therapists who would be allowed to perform procedures such as restorations and extractions themselves under the supervision of a licensed dentist. These proposals have drawn both controversy and concern.

“I’m optimistic about dentistry yet somewhat pessimistic about the future of dental care delivery,” said Gigi Meinecke, DMD, a private practitioner in Potomac, Md. “The practice of dentistry is and will likely continue to be exciting due to innovation and technology advances. However, if legislators and others outside the dental industry continue to push for changes to the classic model of the dentist-led team, in my opinion, the quality we’ve come to know and expect from dentistry will change, and as a result the career path will be less desirable.”

Maine, Minnesota, and Vermont all allow mid-level dental providers, while Washington and Oregon have authorized access to mid-level dental providers for native tribes while considering their use statewide. Alaska native tribes also have authorized dental therapy. According to the Pew Charitable Trusts, Arizona, Hawaii, Kansas, Massachusetts, New Hampshire, New Mexico, North Dakota, and Texas are exploring dental therapy’s authorization.

The ADA opposes the authorization of non-dentists to perform surgical procedures. While the organization acknowledges challenges in providing dental care to everyone, it notes that the number of dentists practicing per 100,000 people has climbed more than 4% from 2003 to 2013 and expects that number to increase 1.5% from 2013 to 2018 and 2.6% by 2033. The ADA, then, believes there are enough dentists to meet the nation’s needs, and efforts should focus on connecting patients to available resources. But insurance companies may have their say, too.  

“Presently, I don’t see insurance affecting the dentist-led team. But if legislators are successful in creating a mid-level provider, it’s nearly guaranteed that insurance companies will prefer reimbursing at a much lower level to a provider with less education. This could create a system where a licensed dentist sits at a computer reviewing treatment plans all day, possibly not even in the dental office, never interacting with patients, while a mid-level provider with less education performs the procedures,” Meinecke said.

Teledentistry programs already are emerging across the country, where hygienists and dental therapists perform care at schools and other community locations and then use digital communications to connect with supervising dentists. After conducting a 6-year study of its own programs, the Arthur A. Dugoni School of Dentistry reports that it can be an effective delivery system. Yet Meinecke urges caution as more practices adopt the model’s methods.

“In my view, this is much less desirable for both the patient and the doctor on many levels,” Meinecke said. “It could create incentive for large-volume practices with multiple ‘technicians’ churning out lots of treatment. Quality usually takes a backseat to quantity in those situations. This is bad for patients, and career satisfaction for the dentist would ultimately go down.”

Such factors are just additional roadblocks on the journey to a satisfying career. These days, the average graduating dentist carries an average of $255,567 in student loan debt. As a result, nearly 50% of today’s graduates join corporate-owned practices instead of starting their own. And while the ADA says that incomes for dentists are holding steady after years of losses, the rise of corporate dentistry may play a role there, too.

“There is an economic impact from the cost of dental education, which makes it more difficult for dentists to establish their own practice,” said Bobby Haney, DDS, who no longer practices clinically and now works exclusively in practice management, consulting, and coaching. “This is a big factor in the rapid growth of corporate dental practices and has most definitely lowered income for dentists.” 

“Dentistry is a great profession that contributes to the well-being of society. The salary reflects the challenges and difficulties dentists experience as they do a personal service for each patient,” said Kohler. “However, there will be fewer solo practitioners as corporate dental groups expand and the cost of new technology becomes difficult to purchase as an individual practitioner.”

Yet these challenges don’t seem to have dissuaded the next generation of dentists from taking up the profession, as they see work that can provide a living for decades into the future.

“The future of dentistry is very bright. People are living longer, and so are their teeth. Who really wants the old pull-out dentures? Not many. In fact, there are many patients getting orthodontics into their fifties and sixties!” said Short. “As an ADA Success Speaker, I get to travel to many dental schools and talk to the students. They are really smart, enthusiastic, and tech savvy. Dentistry will just continue to get better and better.”

Despite all of obstacles that dentistry faces now and will face in the years ahead, many clinicians remain committed to the profession and see value in both what it gives to the patient and to the practitioner.

“Dentistry is and has classically been a great career path, since it has provided the 4 essential ingredients that create a rewarding career: flexibility, variety, community—the ability to help people—and opportunity,” said Meinecke.

“There are very few careers that combine compassion for the individual, artistic capability to improve the lives of their patients, and the ability to improve the oral and general health of people,” said Kohler. “The dentist has a unique experience of knowing and providing for the same people for years. I love being a dentist.”

“It is still a rewarding profession both personally and economically. Income levels are still high compared to other professions, and there is always the joy of providing life-changing service to our fellow human beings,” said Haney. “In short, dentistry is changing in many ways but remains a wonderful and challenging career choice.”

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Good oral health begins in childhood. But many children don’t have access to oral healthcare, nor do they have the tools or education they need to take care of their teeth themselves. In 2006, the National Children’s Oral Health Foundation: America’s ToothFairy formed to provide an aggressive, collaborative response to these challenges and eliminate children’s preventable suffering from pediatric dental disease. Now, Jill Malmgren is taking the reins as executive director of the nonprofit organization as it faces these issues and more in 2017.

“It’s a problem that we know how to solve. There’s a solution out there,” Malmgren said. “It’s just a matter of engaging the dental community, and they’ve been so wonderful and supportive, and building upon that as well as promoting oral health to educate the public about its importance. Oral health often has been overlooked, and it’s so critical to one’s overall health. So there’s a great opportunity to really impact lives.”

Malmgren joined America’s ToothFairy in 2011 and worked in communications for the group before assuming the role of chief operating officer. During her tenure, she has overseen operations, strengthened relationships with key stakeholders, implemented systems to improve efficiency, and spearheaded new programs that contributed to the organization’s ability to expand services for vulnerable children and engage youth in oral health promotion. As executive director, she is replacing founding president and CEO Fern Ingber, who has retired.

“I’ve had the pleasure of knowing Fern for 10 years and working with her closely for 5. I think she’s just been a real innovator, a very larger than life individual, very passionate about the cause, and very committed,” said Malmgren. “She’s been a tremendous influence in this world and should be commended for her great work and how she’s really grown this organization to have it reach the point it’s reached today, and I look forward to certainly continuing that work and taking it to new heights.”

One of the primary goals of America’s ToothFairy is to connect children who don’t have access to oral healthcare with practitioners who can provide it. These families typically are unable to see a dentist because they don’t have the insurance to pay for treatment. Or, parents may be unable to take time off from work, or they lack transportation to get to the dentist. In some cases, parents simply don’t know how to navigate the healthcare system.

“There’s a gap that’s forming where these kids are unable to get the care they need. They may or may not qualify for a particular aid. We’ve got children in areas where maybe there aren’t dental services available,” said Malmgren. “There’s such a maze of information, it’s quite chaotic. So one of the things that we’ve been trying to do to overcome that is working with other agencies and organizations that interact with those children to help make those connections.”

The America’s ToothFairy Affiliate Network of community-based dental clinics and outreach programs provides dental care and education services to hundreds of thousands of these at-risk children each year. Since its inception, America’s ToothFairy has delivered more than $17 million in direct funding, donated dental products, and educational resources to its partners in the network to reach millions of children with preventive, restorative, and educational services.

“We connect with Boys and Girls Clubs or shelters and other organizations that serve children to help make that connection,” Malmgren said. “And we’re working with them to provide them with oral care products, provide them and their families with information on basic preventive care. And then, of course, what we want to do more of is finding ways to connect those children with the services they need.”

In fact, America’s ToothFairy notes, thousands of children across the United States either share a toothbrush with their siblings or don’t have one at all. That’s why the group calls February its National Children’s Dental Health Month, spotlighted by Smile Drives across the country. These programs collect products such as toothbrushes, toothpaste, floss, rinse, and more to distribute to local nonprofit organizations serving vulnerable populations.

“It’s a great way to give back to your local community and a fun way to participate and raise awareness of oral health and get people involved and talking about it and help people understand there’s a real need there,” said Malmgren, who noted that dental practices can collect items for a nearby America’s ToothFairy affiliate or for really any other group that serves children. “It’s also an area where we can make a difference.”

Donations don’t just come from individual practitioners and practices, though. America’s ToothFairy also works with companies such as GC America, SS White, Cosmedent, and A-dec to provide equipment and items in bulk. And with recent research showing that sealants can decrease tooth decay in children by as much as 80%, these goods can go a long way in ensuring the oral health of the children who benefit from them.

Septodont is wonderful, donating ToothFairy sealants to our affiliate network so that they can provide sealants to the children they serve. We are very grateful they provide tremendous amounts of that product to support those initiatives,” said Malmgren. “Certainly we agree there’s a tremendous opportunity there to really provide that type of service. It’s very much needed. And I want to see what we can do to support and grow that endeavor. 

Education is key to the America’s ToothFairy mission too. The Kids Club supplies educational activities, oral healthcare tips, and personalized letters from the Tooth Fairy to children, all for free. The #MySmileMatters Youth Movement challenges middle and high school organizations to take the lead in promoting oral health. America’s ToothFairy even offers patches for Boy Scouts and Girl Scouts who serve as oral health ambassadors.

These programs and others that America’s ToothFairy provides, however, benefit from the financial generosity of the dental community and industry. One of the organization’s biggest fundraisers is its ToothFairy Ball & Online Auction, held in November. Individuals and companies purchase virtual “tables,” with the funding used to award grants to the group’s affiliates that support their individual missions.

Sponsorships also are available, with Dr. Gordon Christensen, Henry Schein, Invisalign, James Ingebrand, Thomas & JoAnn Prescott, and TSC EcoSolutions contributing $10,000 each in 2016. Plus, many companies donated items to be auctioned, with bids starting at bargain prices. This year’s gear included a Bien Air iChiropro implant system, a Pioneer Elite Laser from Patterson Dental Supply, a Ritter M3 UltraFast Automatic Sterilizer from Midmark, a Cavitron Plus Ultrasonic Scaler from Dentsply Sirona, and a NOMAD handheld x-ray unit from KaVo Kerr.

“We have been very, very fortunate. Many of our underwriters provided great support, both in table sponsorships and in the items for the auction. The money goes to benefit the different affiliates that we work with throughout the nation to support endeavors that are serving children in need,” Malmgren said. “Right now those grant proposals are under review, but there’s a myriad of them.”

In fact, Malmgren and America’s ToothFairy invite practitioners and other dental organizations to get involved in any way they can, participating as bidders or donors in the auction, taking part in a Smile Drive, celebrating National Children’s Dental Health month in February in their own practices, or becoming part of the Affiliate Network themselves. Plus, the Practice of Distinction program provides participating dentists with educational and marketing materials they can use to promote oral health.

“I think we’ve got a lot of exciting things coming up for us,” said Malmgren, who added that interested dentists can visit the group’s booth and Celebration of the Smiles event at the Chicago Midwinter Meeting in February. “One of the things we’re continuing to see is the growing need for dental services and doing more in the ways of connecting those children with care, making sure that they receive the care that they deserve.” 

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You may be at the top of your game when it comes to clinical techniques. But how well do you handle the business side of your practice? Our team of experts explored marketing, finances, and personnel throughout 2016, and here are the Top 10 Practice Management Articles of the year, based on traffic at dentistrytoday.com. 

Use 9 Marketing Channels to Help Grow Your Practice

Jordon Comstock offers top promotional tips that you can use online and in the real world to attract and retain new patients.

How to Price an In-House Dental Savings Plan

Dr. Christopher Phelps reveals a strategy for cutting out the insurance middle-man and working with patients directly, improving both loyalty and case acceptance.

Design Your Mobile Website to Convert New Patients

With most patients turning to their smart phones to look up information, Lauren Hong provides 8 tips for making sure your website reaches this growing audience.

Outsourcing Billing Can Improve Cash Flow

Why tie up your staff’s valuable time with routine paperwork? Dr. Dorothy Kassab reveals how you can improve efficiency and reduce your expenses with some third-party help.

Five Signs You Should Invest in Digital Marketing

Are you on social media? How fresh is your website? Do you blog? Jackie Ulasewich discusses the importance of your digital footprint—and how getting online isn’t as hard as it looks.

Laser Dentistry Requires Bright Practice Management

Before you add a laser to your toolkit, check out what Drs. Saurabh Gupta and Rubina Khatoon have to say about safely managing them, training your staff, marketing them, and more. 

Retirement Reality: Going Beyond “What’s Your Number?”

You need to do more than crunch a round, seven-figure number for a goal. Victor Holloway walks practitioners through typically unforeseen obstacles that may arise.

How to Protect Your Practice’s Online Reputation

Despite years in a community, a single bad Yelp review can sink your practice. Naren Arulrajah offers strategies for managing how potential patients see you online.

Ignore the Business Side of Your Practice at Your Peril

The best clinical talent in town won’t ensure a successful practice unless you brush up on your marketing, operations, finance, and patient retention skills too, says Jordon Comstock.

Make Your Practice More Patient-Centric for More Success

The patient always should be the star of the show, according to Dr. Bobby Haney, and everyone on your staff needs to share this attitude.

 

The dental profession is always changing, and this year was no different. Here are the Top 10 News Stories of 2016 based on traffic at dentistrytoday.com.

Survey Ranks World’s Best Dental Schools

This year’s Quacquarelli Symonds survey included 15 US schools among its top 50 programs in the world.

California Bill Opens Funds for Student Loan Repayment Program

Total debt for today’s grads averages $255,567. Now, California offers relief to students who agree to work where dentists are needed the most.

Nasal Spray Dental Anesthetic Gets FDA Approval

The Kovanaze spray from St. Renatus delivers pulpal anesthesia to prevent pain during restorative procedures, with no needle necessary.

Abnormal Salivary Glands Linked to Dental Problems in Cleft Lip and Palate Patients

The saliva of some patients with cleft lip and palate has a different composition, impeding its ability to fight tooth decay.

Smoking Alters the Mouth’s Microbiome

More than 150 bacterial species showed growth in the mouths of smokers, while 70 other species showed sharp decreases in growth, significantly influencing tooth decay.

Breaches Lead to 15 Infections and One Death at NJ Practice

Patients receiving intravenous sedation during oral surgery came down with Enterococcus faecalis endocarditis, prompting action from the New Jersey Department of Health.

Pancreatic Cancer Risk Linked to Specific Oral Bacteria

Changes in the microbial mix in the mouth represent a likely risk factor for pancreatic cancer, which kills more than 41,000 Americans each year.

Despite Staining, Coffee Strengthens Teeth

Coffee prevents bone loss in the jaw. Plus, green coffee’s antibacterial properties may help protect the gums.

Amalgam Fillings May Raise Mercury Levels in the Body

Subjects in a recent study with more than 8 fillings had about 150% more mercury in their blood than those with no fillings.

More Evidence Links Alzheimer’s to Periodontitis

Researchers associate periodontitis with an increase in cognitive decline in Alzheimer’s disease, possibly via mechanisms linked to the body’s inflammatory response.

 

 

Our roster of bloggers addressed a wide spectrum of clinical issues that you probably will face in your operatory in 2017—if you haven’t already. Here are our Top 10 Blogs of 2016, based on traffic at dentistrytoday.com.

Traumatic Dental Injuries: Emergency Assessment and Treatment

Do you know what to do when a patient presents with abrasions, lacerations, and fractures? Drs. Alex Moule and Nestor Cohenca review the guidelines you need to follow to guarantee a full recovery.

What Is a Dentist Anesthesiologist?

Dr. Jason R. Flores explains the vital role that these physicians play in dental surgeries that require higher levels of anesthetic administration or increased airway management skills.

Oral Cancer Care Struggles with Three Misconceptions

How common is oral cancer? How do people get it? And should dentists worry about false positives? Jo-Ann Jones dispels the mistaken beliefs surrounding the growing rates of this deadly disease.

The Advantages of the Morse Taper Dental Implant Connection

These tools eliminate the challenges in maintaining and fostering pink aesthetics, reports Dr. Barry F. McArdle.

Desktop 3-D Printing Democratizes Implant Dentistry

Prices are falling fast on these cutting-edge technologies. Dávid Lakatos outlines how 3-D printers will enable dentists to make their own surgical guides and other valuable tools.

Antibiotics May Do More Harm Than Good

With the danger of antibiotic resistance spreading worldwide, Dr. Manor Haas discusses why you should consider alternative treatments when you encounter typical infections.

Fluoride Critics Use Flint to Push Their Own Agenda

Misinformation about the benefits of fluoride permeate the Internet. Now, Dr. Johnny Johnson Jr says, self-appointed advocates are twisting Michigan’s contamination crisis to fuel their propaganda.

Use Video to Educate Patients and Keep Them Loyal

Case acceptance can be tricky, especially when procedures are complicated and intimidating. Dr. Craig S. Kohler explains how you can incorporate today’s digital technologies to explain what you’re doing and put their minds at ease.

It Only Takes a Moment to Detect Oral Cancer

Dr. Wayne Kerr tells the story of how he had one of his friends in the chair for a routine exam, but an informed look inside the oral cavity led to a life-saving diagnosis.

A Short Case Study: Relax, Don’t Extract!

What would you do with a separated file at the apex in a mesial root? Dr. Rico D. Short explains how you can stay calm and save the tooth by bypassing it and placing some calcium hydroxide.

 

 

The year 2016 saw many innovations in practicing dentistry, and we’re proud to share them with you. Here’s a look back at the Top 10 Clinical Articles of 2016, based on traffic at dentistrytoday.com.

Single-File Shaping Technique: Achieving a Gold Medal Result

Clifford J. Ruddle, DDS, outlines the critical distinctions between shaping canals using continuous rotation versus a reciprocation technique.

A New Restorative Material for Pediatric Dentistry

Lance Kisby, DMD, reviews some clinical applications of a recently introduced flowable composite resin system.

The Three Fs of Predictable Endodontics: “Finding, Following, and Finishing”

John West, DDS, MSD, describes how predictable endodontics is built on knowing and performing 3 mechanical skills known as finding, following, and finishing.

Simplifying Implant Overdentures: Contemporary Overdenture Abutment and Attachment Systems

Michael D. Scherer, DMD, MS, shares materials and techniques that will serve to simplify implant-supported overdentures.

Creating Well-Obturated Canals: The Use of Warm Vertical Condensation Techniques

Trent T. Lally, DDS, MSD; Eric Pacheco, DDS; and Garry L. Bey, DDS; discuss a new warm obturation technology, each author presenting a case example.

The Importance of Increasing the Success Rate: A Look at Procedures, Factors, and Clinical Practices 

Allan S. Deutsch, DMD, shares his own professional experience, highlighting ways to increase success rates in endodontics.

Choosing a Durable and Minimally Invasive Alternative: Posterior Partial-Coverage Lithium Disilicate Restorations

Edward Lowe, BSc, DMD, and Nelson Rego, CDT, present a case report highlighting the steps required to achieve predictable and aesthetic partial-coverage posterior restorations.

Digital Design: Predictability, Profitability, and Efficiency

Joyce L. Bassett, DDS, and Matthew Roberts, CDT, explore state-of-the-art, real-time digital design and link 3-D prosthetic planning with fundamental principles.

Composite Versus Ceramics, Part 1: Young Patients and Fractures

David J. Clark, DDS, in the first of a 3-part article series, describes the new role and applications for direct composite restorations in conservative aesthetic dentistry.

Creating the “Perfect” Class V Composite: The Matrix Is Key

Paul C. Belvedere, DDS, and Douglas L. Lambert, DDS, present reliable technique steps that will allow the clinician to predictably deliver successful Class V composite restorations.

 

Esther Wilkins, RDH, DMD, died on Monday, December 12, just 3 days after celebrating her 100th birthday. Upon her passing, the American Dental Hygienists’ Association (ADHA) called her “dental hygiene’s matriarch.”

Wilkins was the author of the 1959 textbook, Clinical Practice of the Dental Hygienist. Its 12th edition was published earlier this year. According to the ADHA, more than 905 of the dental hygiene education programs in the world include it on their syllabus.

Wilkins earned a certificate in dental hygiene from the Forsyth School for Dental Hygienists in Boston, Mass, in 1939. She worked in private practice and in a school clinic while pursuing a doctorate in dentistry, earning her degree from the Tufts School of Dental Medicine in 1949.

In 1950, Wilkins single-handedly established the University of Washington Dental Hygiene School program, developing the curriculum, teaching most courses, and serving as its director for more than 10 years.

“Dental hygiene lost a remarkable woman,” said University of Washington School of Dentistry Professor Emeritus Norma Wells. “Over the years we have given thanks to her in many ways as she brought dental hygiene education, an emerging profession then, to Seattle.”

Wilkins returned to Tufts to obtain a specialty in periodontology in 1964. Following graduation, she served in the periodontology department faculty at Tufts, teaching periodontal instrumentation well into the 2000s during a 45-year tenure there.

During her career, Wilkins developed more than 800 continuing education courses for oral healthcare professionals and presented them in the United States, Canada, and elsewhere around the world.

Known for her love of teaching, Wilkins often took time to speak with students and take photographs with them at professional meetings. In fact, the ADHA Annual Conference often would include the student quiz program, “Are You Smarter Than Dr. Esther Wilkins?”

“If you are a student in an associate degree program, I encourage you to continue and pursue your bachelor’s degree,” Wilkins said in a 2005 interview with the ADHA. “Then move on to your master’s degree. You must read, read, read, and keep up with the current research and literature.”

America’s ToothFairy honored her commitment to teaching with its Esther Wilkins Education Program. Launched with a generous gift that she made to the organization, the program provides dental hygiene professionals and students with educational tools and lessons for their outreach programs, supporting their role as oral health champions, leaders, and educators.

“We are deeply saddened by the loss of Dr. Esther Wilkins. She was a beloved teacher, mentor, and tireless champion for oral hygiene and children’s health,” said Jill Malmgren, executive director of America’s ToothFairy.

“Her generous support of America’s ToothFairy made it possible for volunteer dental hygienists and dental hygiene students to deliver oral health education and preventive services to thousands of underserved children,” Malmgren said.

Wilkins also remembered her roots as a dental student by establishing a pair of scholarship funds at Tufts School of Dental Medicine in 2008. And in 2010, she paid tribute to her time as a general science undergrad at Simmons College too by founding the $100,000 Esther M. Wilkins Endowed Scholarship there. The ADHA Institute for Oral Health awards scholarships in her name as well. 

With a belief that taking an active role in the hygienist community was vital and beneficial both professionally and personally, Wilkins also encouraged dental hygienists to join the ADHA and attend its meetings.

“No man is an island, and many dental hygienists work alone,” she said. “They may not have another dental hygienist in the practice that they can talk with. So volunteer. There are many opportunities to volunteer in your local dental hygiene association and in community health.”

Additionally, Wilkins was slated to receive the Tufts University School of Dental Medicine Dean’s Medal during a ceremony saluting her and other faculty on Friday, December 16. The award recognizes individuals who have demonstrated loyalty, service, and generosity. The school awarded the Dean’s Medal to her posthumously.

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If you deal with patients who exhibit significant anxiety in the operatory, maybe your next new employee should have 4 legs and a tail. Fishers Pediatric Dentistry of Fishers, Ind, recently added Pearly to its staff, a 7-month-old Australian Labradoodle therapy dog who puts patients, their families, and even the staff at ease during stressful procedures. 

“Usually when a kid comes in and they’re a little bit nervous, we do one of 2 things,” said practice co-owner Misti Pratt, DDS. “Sometimes we just say, ‘You can pet Pearly when we’re done,’ or sometimes we’ll even put Pearly on their lap and the kid is so focused on petting her and loving on her while they’re getting their teeth cleaned. It’s really been amazing. You’ll have a kid who is really scared, and then they’re just so calm and relaxed.”

Pearly’s onboarding at the practice began when practice founder Ana Vazquez, DMD, met a dog at a local park that also happened to help out at a nearby senior citizen facility. Impressed by the well-mannered pooch, Vazquez began investigating whether or not a similar therapy dog would be allowed for her practice, and, if so, what types of dog would be most appropriate.

“We found out that there are certain kinds of dogs that are hypoallergenic, though technically you cannot say that a dog is 100% hypoallergenic because you don’t know exactly what kinds of allergies the child is going to have,” said Vazquez. “And it’s the Doodles, almost any kind of dog that has been mixed with a poodle.”

Temperament was another issue. Therapy dogs need to be unflappable in the face of various uncomfortable stimuli. A dental office is home to loud noises from handpieces, compressors, and other equipment, plus harsh and sterile smells. Also, children don’t always know how to behave around animals, and therapy dogs have to resist provocation.

“You could imagine kids are pulling her ears, touching her eyes, putting their fingers in her mouth,” said Vazquez. “There are certain dogs who will let you do anything, so I had to find a dog who would allow me to do everything like that.”

Vazquez and Pratt visited a breeder called Colonial Village Labradoodles to pick out a puppy, though Vazquez noted that Pearly really picked them. They met the dog when she was just a month old, and after they had formed a bond and she had been weaned from her mother, Pearly went home with Vazquez at the age of 8 weeks. Training began immediately.

“Especially the first couple of weeks, she came to the office every day. She went through a process of desensitizing her to all the noise and smells in the dental practice, especially in pediatrics,” said Vazquez. “She was not working, but she was in certain spots in the office, just getting used to noises, to the kids, and to the smells.”

Pearly went to regular puppy classes as well, learning to take commands like “sit” and otherwise be well-trained. The practice also worked with a company called Medical Mutts that specializes in training service dogs. Medical Mutts visits the office every other week to train both Pearly and the staff. And, Pearly spent 2 weeks at “puppy boot camp” for more intensive work.

“She won’t be an official therapy dog until she’s a year old,” said Pratt. “Over the next 6 months she will continue to do training with the Medical Mutts trainer, and she will go away for another 3 weeks to puppy boot camp. But the trainer also trains us on how to handle her.”

There are 63 employees at Fishers Pediatric Dentistry, but only 8 of them are designated handlers, with one representative for each department. Medical Mutts teaches these handlers what verbiage to use, what eye contact they need to have, and how to keep it all consistent so Pearly is not confused. They work on this training often during lunch or other downtime.

The limited number of handlers also makes it easier for them to get to know her better, which is important because they need to be able to tell when she is getting tired, getting hungry, or otherwise needs a break.

“We try to get her off duty on those moments when we don’t think that it’s good for her,” Vazquez said. “That’s one of the reasons that we want a specific group that knows her. We know her mannerisms, and we understand her needs.”

Pearly doesn’t work with every patient at the practice. Some patients are afraid of dogs, so she only works with families that request her. A sign at the office also tells families when she is on duty and off duty. Patients can visit with her before and after invasive procedures. During noninvasive work like exams, cleanings, and restorations, Pearly will sit within reach of the patient or even on the patient’s lap, which actually makes the procedure more effective.

“They’re not as apprehensive,” said Vazquez. “We let Pearly lay down on the patient’s lap, and they don’t move. So, I know that I can definitely do a better restoration because I don’t have a kid that’s moving around. And they want to do good so they can go play with her, too.”

Pearly is especially effective in working with children who have special needs.

“Sometimes patients with different special healthcare needs such as autism like different behavior management techniques,” said Courtney Bradshaw, LDH, one of Pearly’s handlers. “We have found that bringing Pearly and utilizing her provides them an additional sense of comfort, and no other technique that we have found is as effective.”

The families in the waiting room can be even more nervous than the patient in the chair. Pearly then will spend time there too, keeping siblings and parents who are waiting entertained and engaged instead of thinking about the procedure going on in the operatory.

“A lot of times, I feel that it makes the parent feel just as relieved as the child when she comes into the room,” said Pratt. “And the adults seem just as excited about her.”

Plus, it’s no surprise that Pearly has had a similarly positive effect on the practice’s personnel.

“I have seen with my staff, in dentistry, there are days that could be pretty stressful,” said Vazquez. “I have seen changes in their behavior now that Pearly is part of our staff. You would be surprised how many times during a break, they would sit down with Pearly and talk to her. I think that she has been a benefit for all of us as well.”

“She’s been wonderful, every day to walk in and have a puppy greet you,” said Pratt. “It’s been really fun.”

Pearly’s positive effects on patients and staff alike have been noticed by the community at large and have helped the practice add to its patient base. As the practice’s ambassador, Bradshaw has showcased Pearly at events such as Woofstock, a concert festival that raised money for the Humane Society for Hamilton County. Pearly also has campaigned for the Behavior and Analysis Center for Autism and Answers for Autism.   

“We’re just trying to partner ourselves with different nonprofit organizations within the community and promote Pearly’s success,” said Bradshaw. “She definitely has made a name in our community, and we’ve received wonderful feedback from colleagues that have stopped by to visit her and meet her, wondering if a therapy dog would be a good decision for them.”

“It does take a lot of time, a lot of training. It’s a commitment,” said Vazquez. “However, we do a lot of hospital dentistry in pediatrics, and we see therapy dogs in hospitals. I think that therapy dogs are going to be a trend mounting in dental offices, and you will see more and more dental offices including therapy dogs as part of their behavior management techniques.”

The personnel at Fishers Pediatric Dentistry encourage dentists who are curious about adding a therapy dog to their practice to reach out to local organizations like Medical Mutts in their communities to find out more, as these groups specialize in training dogs to meet the specific needs of each facility they work with.

“This is the first dog that I’ve had in my life,” said Vazquez, who takes Pearly home every night when the office closes. “And I think that Pearly has been a blessing not only for our practice and our patients but in my life. I never thought that this fluffy, clipped animal could bring so much happiness. She is my best friend.”

“I’m just every day impressed with how much of a difference, how much comfort she brings,” said Pratt.

“I definitely think it’s going to be the future of dentistry,” said Vazquez. “Dogs will be part of it.”

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Many children are afraid of going to the dentist—particularly because of the needles they inevitably encounter. In fact, 13.9% of the 10- to 16-year-olds recently surveyed by the Oral Health Centre of Expertise in Western Norway reported high levels of intraoral injection fear. This fear was so strong, 10.6% of the 1,441 subjects surveyed said they would avoid dental treatment.

Of course, a reluctance to visit the dentist could have grave consequences on oral health. The researchers concluded, then, that while dental anxiety is a cause for concern, treatment of intraoral injection fear should be addressed even before treatment of dental fear. Karin G. Berge of the Oral Health Center of Expertise in Western Norway and the University of Bergen shared her insights about the survey with Dentistry Today.

Q: What is the difference between intraoral injection fear and overall dental fear?

A: Intraoral injection fear falls into the subgroup of injection fear in the blood-injury-injection fear category. It is characterized by fear of the needle related to dental treatment, whereas the other aspects of dental treatment are not associated with fear. These patients would typically avoid intraoral injections, but go through with other dental treatment. Dental fear covers fear of all aspects of the dental treatment.  

Q: Why did the study focus on children specifically?

A: Blood-injury-injection phobia is typically developed during childhood, with an onset prior to 10 years of age. This leads to a salient need for early intervention to enable children to receive intraoral injections and to prevent future problems of avoidance of dental treatment.

Q: You used the Intraoral Injection Fear scale and other questionnaires. Could you briefly describe them, and the kinds of questions they asked?

Four different psychometric instruments/scales were used:

  • The Intraoral Injection Fear scale is a 12-item scale validated for children and adolescents assessing different aspects (mainly to dimensions, “contact fear” and “distal fear”) and different triggers of fear of intraoral injections. Each response was scored from one to 5, (one = “not afraid at all,” 5 = “very afraid”).
  • The Children’s Fear Survey Schedule-Dental Subscale consists of 15 items measuring dental fear in children and adolescents. The 5 response options are graded from one (not afraid at all) to 5 (very afraid).
  • The Injection Phobia Scale for children is an 18-item scale assessing fear of injections, mainly extra-oral injections such as blood samples and vaccines. The 5 response options are graded from zero (not afraid at all) to 4 (very afraid).
  • The Mutilation Questionnaire for children is a 15-item questionnaire assessing fear of blood and injury. The questionnaire consists of 15 items, each ranging from zero to 4 (0 = not afraid at all, 4 = very afraid).

Q: The study noted that 13.9% of the children surveyed reported intraoral injection fear. How does this compare to rates among adults? If there is a difference, what is causing it?

A: The rate is similar, or a bit higher than the rates reported for adults. Some of the difference may be due to cognitive development and maturation in children. 

Q: Did children who already have had injections report less fear, more, or about the same? If there is a difference, what is causing it?

A: Children with no previous experiences of intraoral injections reported actually higher levels of intraoral injection fear compared to those who had previously received injections at the dentist. This may reflect that the first group probably also included “avoiders,” those who avoid intraoral injections due to fear. Additionally, the younger children probably have not had as much caries experience and dental treatment needs as adults.

Q: The study noted that 10.6% of children would avoid treatment. How would children avoid treatment? Wouldn’t parents make them see the dentist?

A: Based on self-reports, 10.6% of the children would avoid dental treatment if an intraoral injection was needed. The avoidance variable was targeting the treatment situation involving the intraoral injection rather than targeting attendance to the dental appointment. The youngest children are often accompanied by their parents or guardians attending the dental appointment and are therefore more in the position to avoid the actual treatment setting rather than the dental appointment. However, self-reports on avoidance behavior in children should be interpreted with caution. 

Q: How can this fear of injections impact oral health?

A: High fear or phobia of intraoral injections is associated with avoidance. Patients avoiding intraoral injections are more likely to either avoid further necessary dental treatment or experience painful dental procedures. Painful dental experiences are known to be predicate upon development of dental fear and anxiety, associated with reduced dental health.

Q: What strategies could dentists use to help their patients overcome these fears?

A: Cognitive behavioral therapy is an evidence-based and recommended treatment method for treating specific fears and phobia in children and adolescents. The main principles are gradual and controlled exposure to a hierarchy of anxiety provoking steps connected to intraoral injections. The patients’ catastrophic thoughts and anxiety symptoms are elicited during the exposure and furthermore cognitive restructuring is an essential part of the treatment.  

The study, “High Fear of Intraoral Injections: Prevalence and Relationship to Dental Fear and Dental Avoidance Among 10- to 16-Yr-Old Children,” was published by the European Journal of Oral Sciences.

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