A Mid-Decade Look: What’s Hot in Materials and Instruments

Howard Glazer, DDS

Our editor-in-chief, Dr. Damon Adams, interviews Howard Glazer, DDS, discussing new products and technologies that can make a difference for the clinician and team.

What is your overall impression of where dentistry is today with regard to materials, products, and techniques?
Dr. Glazer: There is no doubt in my mind that this is an absolutely wonderful time to be in dentistry. So many of the materials, products, and techniques we have today did not exist 5 years ago, and many will be replaced in the next 5 years. With today’s materials and products, we have the ability to provide optimal care for our patients and the ability to help them maintain optimal oral health for their lifetime. These materials allow us to practice the art and science of dentistry and not simply fill cavities.

What do you see as the biggest changes in those same categories in the last 5 years?
Dr. Glazer: While many of our procedures are, and continue to become, more technique sensitive, there are many that have become easier; and still others that have enabled us to provide better and longer-lasting treatment for our patients. With regard to materials and products, they continue to become faster and easier to use, but most importantly, more beneficial to the patient.

Toward that end, we are seeing the development of many more materials that are bioactive and will allow us to truly restore a tooth, not simply repair the tooth. For example, glass ionomers and modified resin glass ionomers, both of which are available from SDI’s Riva and GC America’s Fuji product lines, have always been great base/liner and restorative materials with their release of fluoride. Now, we are seeing the development of base/liner products that not only release, as in the case of Shofu Dental’s Giomer chemistry, but also recharge fluoride. Other products actually contain and enhance the exchange of calcium and phosphate ions within the tooth structure, such as with ACTIVA BioACTIVE (Pulpdent) base/liner and restorative. Cements like Ceramir (Doxa Dental) are also bioactive in their ability to form a nanocrystalline lock into tooth structure. This is so vital in the process of restoring the tooth to natural health, both from the outside and within.

Where do you envision dentistry in the next 5 years with regard to materials, products, and techniques?
Dr. Glazer: As mentioned previously, bioactive materials will continue to be important as well as our minimally invasive techniques in preparing tooth structure, such as hard- and soft- tissue lasers like Solea (Convergent Dental), and rotary instruments like Smart Burs II (SS White Burs) and Fissurotomy Burs (SS White Burs), as well as reducing the need for periodontal surgery with such innovative technology as with the LANAP (Millennium Dental Technologies) protocol. Of course, soft-tissue diode lasers, such as the Picasso and Picasso Lite (AMD LASERS), will continue to be important since it is a much better way to gently remove tissue in so many situations; none the least of which is in the daily operation of restorative dentistry. My mantra is you can only restore what you can see, and all too often, decay is subgingival. You need to access the decay, and the laser makes that very easy. The laser makes gingival retraction cord nearly obsolete and is a must for implant dentistry when it comes to removing the healing cap and the resultant tissue tags that are so often found obscuring the clear visualization of the implant platform.

Figure 1. Pretreatment on teeth Nos. 8 and 9 showing natural gingival tone and Class V lesions.	Figure 2. Gingiva has been “grayed out” using the Isolate function/mode in the EyeSpecial C-II camera (Shofu Dental) to allow for better shade selection.

Figure 3. With pink gingiva “grayed out” the Venus Shade Guide (Heraeus Kulzer) can now be used for proper shade selection.

Figure 6. Post-treatment: Venus Pearl finished and polished.

There will be a greater chairside use of fibers to reinforce temporary bridges, create space maintainers, and act as support for a temporary pontic and even in-office repair of broken removable prosthesis. Two favorites of mine are RTD Quartz Fibers and the StickTech fibers (GC America).

Conventional analog radiography will, pardon the pun, slowly fade away from mainstream usage and there will be an increase in digital radiography via sensors and phosphor plates. Our vigilance in protecting our patients from excessive radiation will be supported by devices such as Tru-Image (IDI) that uses direct collimation to minimize the scatter radiation commonly associated with tube-type devices. Of course, panoramic radiography and CB technology will continue to prove to be a valuable asset in diagnosis and treatment planning.

As our population lives longer and we see more gingival recession, which often means more sensitivity, we will see further need for products like Remin Pro (VOCO) and MI Paste Plus (GC America), which will nurture the tooth and help prevent sensitivity.

Figure 7. Conducting an oral cancer prevention examination using the VELscope Vx (LED Dental).

What impact will bioactive materials have in the second half of this decade?
Dr. Glazer: As I see it, bioactive materials will be in the forefront of product development as we move to the later part of this decade. Demand will be ever increasing for materials that will provide for healthier tooth structure, or replenishment of those essential components into our hard and soft tissues. Whether in dentifrices, adhesives, restoratives, or even cements, the focus will be on creating a healthier oral environment.

Is the profession ready for these changes?
Dr. Glazer: The profession will have to be ready for these changes because the public will demand “healthier” dental treatments. Patients are becoming more and more educated by the profession and the media, and because of this fact, we need to be ready to perform to a higher standard using the most up-to-date materials and techniques.

Figure 8. Pretreatment photo of patient using the EyeSpecial C-II camera.	Figure 9. Discussing the resultant photo and explaining treatment to patient.
Figure 10. Loading a syringe of buffered anesthetic from the Anutra Medical Dispenser (Anutra Medical).	Figure 11. Adjusting the disposable, bendable tip for the Picasso Laser (AMD Lasers).
Figure 12. ACTIVA BioACTVE base/liner and restorative syringes (Pulpdent).	Figure 13. BEAUTIFIL Bulk restorative (Shofu Dental).

Can the profession afford these changes?
Dr. Glazer: Throughout history, it has been shown that while new technology is expensive, the cost is reduced as more competitive products are developed. As I see it, our profession, like many others, has often been resistant to change. However, once shown the benefits of such change to the health of the patient and the oral environment, the profession has been quick to adopt and implement those treatment protocols.

Further, if the paradigm is shifting to bioactive materials, then, can the profession afford not to change? The move is to restoring a tooth both from the outside and within. As professionals in the healing arts, we must adapt to and follow those methods of treatment that will best serve our patients.

As a clinician and lecturer to the postdoctoral audience who are usually a group more willing to change, how do you view the responsibility of the dental schools in preparing our young colleagues for the future?
Dr. Glazer: Dental schools have a responsibility to teach the fundamentals of dental medicine, procedures, materials, and techniques. In just 4 years, that is a monumental task, one that most dental schools do quite well. However, I believe the schools also have a responsibility to educate the student on how to evaluate dental research and understand evidence-based dentistry. There is also a responsibility to make the student aware of cutting-edge products and how to evaluate and incorporated those into their practice.

Figure 14. Screen shot of Dr. Glazer’s preferred total engagement patient communication program (Smile Reminder [Solutionreach]), which allows doctors to reach their patients by email, text, or phone.	Figure 15. Photo-curing a resin restoration with the Fusion 4 curing light (DentLight).

What responsibilities do the third-party carriers have in keeping up with accepted and evidence-based dental procedures and proper reimbursement?
Dr. Glazer: Simply said, the third-party carriers have to take their collective heads out of the sand and recognize all the amazing procedures that dentist can now provide patients. They have to realize that we are now in the 21st century and their ideas of 20th century dental procedures are outdated, along with the fee schedules of yesteryear! It is high time they realize that the vast majority of dentists who accept and/or participate with third-party plans are not trying to simply get the maximum reimbursement, but are truly caring for their patients and performing state-of-the-art procedures using materials that often cost more than what they allow; and, these materials and procedures are scientifically well based. For example, it makes no sense to deny reimbursement for a single-tooth implant in lieu of a stationary bridge. The determination of patient treatment—ie, what is best for the patient, not the insurance company—should be left to the practitioner and not to an often-arbitrary policy rule.

There seems to be a good number of smaller dental manufacturing companies being acquired by larger ones. While it may be good for bottom lines, how do you see this trend impacting the everyday practitioner?
Dr. Glazer: It seems that like in the ocean, the big fish are eating the little fish. I see this as potentially stifling research and development as more money is spent on acquisitions before it is spent on the development of new and better materials. The true impact of this may be twofold. First, it may impact the practitioner by limiting his or her choice of materials. Second, and perhaps more importantly, it will impact the development of materials that could benefit our patients in the treatment of all dental maladies.

How can that average grassroots practitioner possibly keep up with all the new materials, products, and technology both from a learning and implementation standpoint?
Dr. Glazer: In today’s ever-changing and expanding world of materials, it is incumbent upon the dentist and his or her team to keep up with new technology, techniques, products, and materials. That does not necessarily mean they need to purchase said advancements, but they do have a responsibility to be aware of what is happening in dentistry. To do so means to keep up by reading the latest journals, attending continuing education courses, talking with their peers, looking to company representatives as resources and not salespeople, and perhaps getting some education via the Internet.

Having been in practice for 40 years, what do you see as the biggest advances since you started that have impacted how we practice dentistry?
Dr. Glazer: The answer to this question is almost an article unto itself. That said, let me try to break my answer down by category.

Communication and Education—First and foremost, there has to be patient education and communication. We have a responsibility to teach our patients about the benefits of dental treatment. To discharge this awesome task, we need to provide resources or links to those sites and resources that can provide answers, whether via our own websites, or those readily found on the Internet through dental schools, the ADA, and the AGD. Technique-oriented “how-to” articles, such as those found in this clinical magazine, also play an important role in making dentists aware of the extensive possibilities of treating a variety of patient problems. Remember, this is the art and science of dentistry, so we need to be creative and, at the same time, perform on a scientific basis.

We need to communicate better in the most up-to-date manner with our patients about dental health. This can be achieved through staff/patient communication, in-office brochures, social media, and digital communication vehicles. One such system that I use is Smile Reminder (Solutionreach). This is a high-tech system that reaches out to my patients via phone calls, e-mail, and text. Every month, my patients are educated about dental health via a newsletter. They are easily informed about changes in our practice relative to new services we can provide and the benefit of such service to their dental health.

Communication extends to the visual realm of the patient, and to communication with our specialists and laboratory technicians. Taking good quality photographs has been made so much easier for the dentist and team with Shofu Dental’s EyeSpecial C-II camera. Lightweight, affordable, and ever so easy to use, it is an example of an ideal camera for daily use in the office.

Anesthesia—Patient comfort is of paramount importance, and this rings true when it comes to anesthesia. With the recent advances in sodium bicarbonate buffering of lidocaine in a cost-effective and easy to use system, such as Onset (Onpharma) or the Anutra Local Anesthetic Delivery System (Anutra Medical), we can not only achieve rapid and predictable anesthetic comfort, but can further reduce the amount of lost productivity while waiting for our patient to realize full-tissue and pulpal anesthesia.
Oral Cancer Screening—I am passonate about oral cancer screening, early diagnosis, and prevention. I can happily report that there are many devices now available to help the doctor examine (such as VELscope Vx [LED Dental] and DOE [DentLight]) and screen (Brush Biopsy [OralCDx]) suspicious lesions. There are also some interesting new developments related to the use of saliva as a tool containing discriminatory biomarkers to aid in the early detection of oral cancer and other diseases. One such test for using saliva as a diagnostic fluid for oral cancer has been recently introduced (Salimark [PeriRx]).

Radiography—Digital radiography has made, and continues to make, a significant impact on the dental practice. Whether you chose sensors like the Clio digital x-ray sensors (SOTA Imaging), or phosphor plate technology with the ScanX and Swift systems (Air Techniques), you will be providing a better and safer experience for your patients. In the near future, you will see more information about rectangular collimation using a system like Tru-Image, allowing us to nearly guarantee a perfect image every time, while reducing the amount of retakes and excess “scatter” radiation. And, we will not be relying solely on radiographs for caries detection. The technological challenge has already been met but will continue to get better. With products such as Spectra (Air Techniques), the Canary System (Quantum Dental Technologies), and CariVu (DEXIS), the technology is already here and getting better each day.

Adhesive Resins (Bonding Agents)—Adhesive resins have changed dramatically since the early days of 4th generation, 2-bottle systems. Most popular now are the 7th generation self-etch systems such as BeautiBond (Shofu Dental), G-ænial Bond (GC America), Peak (Ultradent Products), and Adhese (Ivoclar Vivadent). We have potentially created new 8th generation with such universal bonding agents as Futurabond U (VOCO) and ALL-BOND UNIVERSAL (BISCO Dental Products), which can be used with the self-etch, total-etch, and/or selective-etch techniques.

Composite Resins—Along with the adhesives, the entire field of composite resin dentistry is changing quite rapidly. Flowable resins, that are virtually “no flow flowables” (BEAUTIFIL Flow Plus F00 [Shofu Dental]), or low flow (G-ænial Flow [GC America] and GrandioSO Flow [VOCO]) have made conservative dental procedures much easier.
With regard to “packable” composite resin materials, we have moved on from the early days of the sandwich technique to that of layering one- to 2-mm increments, to the rapid advances in bulk-fill materials. Along with these advances has come the need for an instrument that can shape and contour these resins while not sticking to their surface and creating “pull-back.” The OptraSculpt Pad (Ivoclar Vivadent) has made a huge difference in the placement of composite resin and will continue to do so with the further release of closed-cell disposable foam tips in a variety of shapes.

Creating composite restorations that mimic the natural beauty of healthy dentition has been made so much easier with highly aesthetic composite resins such as Aura (SDI) and Venus Pearl (Heraeus Kulzer).

Photo-Curing Lights—Curing these newer resins, and especially with bulk-fill resins used in 4-mm or greater depth, we must ensure that our photo-curing lights can adequately cure to sufficient depths. Right now, I believe that DentLight’s Fusion 4 has the most powerful light emission in direct collimation at depths more than 4 mm.

Electric Handpieces—And lastly, let’s not forget about our need for ergonomic cutting instruments like electric handpieces. We need to make them smaller, lighter, and well balanced like the MX-2 series from Bien-Air Dental that now utilizes Apple technology in having an iPod control for the operative and endodontic functions, and the iChiropro for implant procedures.

If you had to build the dream office, as a GP, what would it look like?
Dr. Glazer: Easy. It would look like a million bucks, and probably cost that much to build and furnish! All kidding aside, it would have to be designed as an extremely comfortable, functional, and highly efficient setting. High-tech equipment, such as CAD/CAM milling machines, digital impression units, CB technology, and digital radiography would be a must. Each operatory would have a hard- and soft-tissue laser as well as electric handpieces.

How is the current economy impacting the acceptance of new materials and products? And, how is the economy impacting the development of new materials and products?
Dr. Glazer: Despite what our politicians are telling us, our economy is still in a recession. It is also worldwide, as evidenced with the near collapse of financial markets in Greece, Italy, and Spain. And the Asian markets are also in a bad way. Of course, this impacts the research and development of new products and materials as well as driving the cost factor from manufacturer to consumer. To be fair, overseas manufacturers always have to be mindful of the cost of doing business in the United States, the largest market in the world. Currency fluctuation plays, and rightly so, an important role in how fast materials can be brought to market and how much can be spent on research and testing of those materials.

What can manufacturers do to help the profession more with regard to product and material development?
Dr. Glazer: Listen to the dentists and their office teams to learn what they need to better serve the patients. Ask patients what they want and expect, and also how they would change the dental experience in a variety of treatments.

Name the top 5 items you would like to see developed to make patient treatment faster, easier, and better.
Dr. Glazer: In no particular order, I would like to see:

1. A composite resin that is self-etch, self-adhesive, dual-cure to a minimum of 4.0 mm, bioactive, abrasion and plaque resistant, and will not break down at the enamel interface, and polish to a high gloss with long-term color stability.
2. Further advancement of laser systems for periodontal treatment and restorative dentistry that are simple to use and less costly.
3. A system, whether it be a medication taken orally or a topical medicament, that will prevent decay, regrow enamel, and maximize gingival health.
4. Continued advancement in the early detection of caries and potential oral cancers.
5. Simple-to-use, low-dose intraoral digital radiography systems that will provide the highest quality diagnostic images.

Dr. Adams: Howard, I want to thank you for taking time out of your busy practice and teaching schedule to candidly share your thoughts. You have become well known among your peers for your solid opinions and advice on what is and will be happening in the world of technology and dental materials. It is my hope that our readers will be motivated from your interview to learn a little more about a particular product or procedure that will serve to further improve the delivery and quality of dentistry in their practice.
Dr. Glazer: My sincere thanks to you, Damon, and to Dentistry Today for allowing me to offer my view of the present and desires for the future, relative to materials and products that will continue to enable us to provide faster, easier, and better treatment for our patients. Thanks also go out to the manufacturers that recognize and rally to the responsibility of helping us achieve our goals and aspirations for optimal patient treatment.

Dr. Glazer maintains a general practice in Fort Lee, NJ. He is a Fellow and past president of the AGD, is a Fellow of the American College of Dentists, International College of Dentists, American Society for Dental Aesthetics, the American Academy of Forensic Sciences, and a Diplomate of the American Board of Aesthetic Dentistry. He is former assistant clinical professor of dentistry at the Albert Einstein College of Medicine (Bronx, NY). Additionally, he is an attending dentist at the Englewood Hospital (Englewood, NJ) and is the deputy chief forensic dental consultant to the Office of Chief Medical Examiner, City of New York. He has been a visiting clinician at several universities around the country. He lectures internationally on the subjects of cosmetic dentistry, forensic dentistry, and patient management. He is a frequent author of dental articles and has been published throughout the world. Currently, he publishes a monthly column in AGD IMPACT entitled “What’s Hot and What’s Getting Hotter!” For the past several years, he has been named as one of the Leaders in Continuing Education by Dentistry Today and most recently was named as one of the top dentists in New Jersey by New Jersey Monthly magazine. He can be reached at (201) 224-2705 or at hglazer264@gmail.com.

Disclosure: Dr. Glazer, with 2 colleagues, invented and licensed OptraSculpt Pad to Ivoclar Vivadent.