Is High-Tech Equipment Really Worth It? Howard Speaks

Drs. Gordon Christensen & Paul Child on Extractions and Bone Grafts etlonMgzn wwdnatw.o September 2011 Dentaltown Magazine www.dentaltown.com

September 2011 » Volume 12, Issue 9 » Volume 12, Issue 9 » Equipment

Is High-tech Equipment Profile: ChaseHealthAdvance Really Worth It? by Dr. Douglas Carlsen, page 86

Howard Speaks: Suicide and Trust page 14

Out with the Old and In with the New Renovating your practice, page 98

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Extract and Graft or Extract and Dismiss? Drs. Gordon Christensen and Paul Child discuss various reasons why grafting is not provided and why it should be offered. 2828 A Potpourri of 7272 Endodontic Topics Drs. Kenneth Koch and Dennis Brave present tips to help dentists achieve better results with endo. Hugh Bleemer, president of ChaseHealthAdvance; and Barry Trexler, SVP of sales & marketing 6666

Articles GlidePath to Success 94 Dr. Diwakar Kinra discusses a twofold process when performing a root canal. Howard Speaks: Suicide and Trust In this article Dr. Howard Farran explores reasons 14 Out with the Old and In with the New dentists are stressed out including trusting staff and Shelby Stevens writes about why renovating your not delegating. 98 office with the latest and greatest will benefit you and your clients. Professional Courtesy: Surviving Prostate Cancer Dr. Thomas Giacobbi interviews Dr. Tom Trinkner 18 Point/Counterpoint: Lighting about his dental career and the sobering effect of a Headlamps or track lighting – we all have our own cancer diagnosis. 102 preferences, and there are noted pros and cons to every option. In this feature we’ve paired up a pro- Second Opinion: A Two Tier Standard headlamp message board and with an article on track- Dr. Rhea Haugseth argues against having a two-tiered 22 lighting benefits. standard of care for our nation’s most vulnerable children. Are Family Members Working in the Practice? Addiction in Dentistry Dr. Rhonda Savage presents the common issues that Dr. William T. Kane discusses addiction and provides 106 76 exist within practices that employ family and how to ways for dentists to seek help. overcome them. Treating the Dreaded Black Triangle and Other The Wild Side of Dentistry Dental Therapeutic Uses of Botox and Dermal Fillers 82 Drs. Dan Mairani and Steven Holifield were asked to Dr. Louis Malcmacher discusses a few of the ways 110 treat a 380-pound silverback gorilla that had been suf- dentists can utilize Botox and dermal fillers in soft- and fering from a dental infection. This is their story. hard-tissue dental therapeutic aesthetic cases.

High-tech Equipment – Worth It? 86 Dr. Douglas Carlsen encourages doctors to commit to their technologies by taking course updates, following Dentaltown (ISSN 1555-404X) is published monthly on a controlled/complimentary basis by Dentaltown.com, Dentaltown threads and using Facebook and Twitter LLC, 9633 S. 48th St., Ste. 200, Phoenix, AZ 85044. Tel. (480) 598-0001. Fax (480) 598-3450. USPS# 023-324 Periodical Postage Paid in Phoenix, Arizona and additional mailing offices. for quick comments. POSTMASTER: Send address changes to: Dentaltown.com, LLC, 9633 S. 48th St., Ste. 200, Phoenix, AZ 85044 continued on page 6

4 September 2011 » dentaltown.com Composite Manipulation Instrument

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Message Boards Townie Clinical

Equipment Endodontics: Thermafil Retreat 40 A mystery instrument, a helpful equipment tech, 52 This discussion of retreating Thermafil cases reminds finding a water distiller and fixing sticky syringe every one of the requirements for success in any buttons. Equipment is often our silent partner. Here is endo case. a small sampling of the many threads found on Dentaltown.com regarding equipment.

Anesthesiology: Product Profiles 48 Are Dentists Using Nitrous Anymore? Nitrous has been available for more than 100 years. Solution21 Will it ever go out of style? 81 Web site Design and Marketing Experts

Hygiene and Prevention In This Issue

From Trisha’s Desk: Dentaltown.com Highlights 115 Making the Connection 8

Hygientown.com Message Board: Industry News 116 Unimpressive Results 36

Perio Reports New Product Profiles 118 • Dental Treatment and Vascular Events 60 • Perio Patients Seen in Emergency Rooms • Host Modulation Helps Smokers Dentaltown Research: • Rapid Recolonization After Treatment 96 Restorative Dentistry • Pain Relief Patch for Perio Surgery Sites • Listerine Used for Ultrasonic Lavage 113 Ad Index Profile in Oral Health: 122 Marketing Magic 128 Dentally Incorrect Hygientown.com Message Board: 126 Abscessed Implant! ©2011 Dentaltown.com, LLC. All rights reserved. Printed in the USA. Publications Mail Agreement #40902037 Return undeliverable Canadian addresses to Station A, P.O. Box 54, Windsor ON N9A 6J e-mail: [email protected]

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8 September 2011 » dentaltown.com CEREC Software 4.0 represents a major enhancement and redesign of the CEREC software platform, bringing unprecedented power and performance to the CEREC process from start to ﬁ nish. Dental CAD/CAM is now more predictable and proﬁ table than ever before!

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facebook.com/CERECbySirona @CERECbySirona youtube.com/cerectube dentaltown.com highlights continued from page 8

09 ▼ Back to School

11 It’s September and that means back-to-school time If you have questions for students! While many of you won’t be heading about the site, call me at 480-445-9696 or e-mail me Message off to class this month, it doesn’t mean you’re done at [email protected]. from the learning. Because you need to stay at the forefront of your profession, Dentaltown.com offers online See you on the message boards, Online continuing education courses so you can learn the Kerrie Kruse latest in dentistry. Our courses cover everything Online Community Manager Community from endodontics to practice management, are free Manager to view and are only $18 per credit to claim your credits. With online learning, you can watch courses on your schedule and study at your pace all from the comfort of your home or office. Best of all, there’s no need to sharpen a No. 2 pencil!

HELPCENTER GETTAG

Feature of the Month Throughout Dentaltown We have online members from all over the world, but some people still haven’t Magazine, you can scan tag joined our growing communities. If you know of someone who should become codes to access information an official Townie, you can use the “Refer a Colleague” link to let them know. directly from your smartphone. Check out the Help Center’s Feature of the Month for more information! To scan these codes, visit http://gettag.mobi/ to download the free barcode reader to your VIDEOTUTORIAL mobile device. You can then scan every code you see in How to Manage your Communities Dentaltown Magazine to access The number of Townie communities that you have access to is growing. Make additional information, enter sure you don’t miss a thing by updating your list of communities. Go to the contests, link to message Media Center and click on the Tutorial section to watch a short video with step-by-step instructions. boards, comment on articles and more!

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Editorial Advisory Board *Continuing Education Advisory Board Member

Rebecca Bockow, DDS Kenneth Koch, DMD Krieger Aesthetic & Real World Endo Editorial Director Reconstructive Dentistry Wilmington, DE Thomas Giacobbi, DDS, FAGD • [email protected] Seattle, WA Hygienetown Editorial Director Dennis Brave, DDS Arnold Liebman, DDS Trisha O’Hehir, RDH, MS • [email protected] Real Word Endo Dr. Arnold I. Liebman Wilmington, DE Brooklyn, NY Editor Benjamin Lund • [email protected] Doug Carlsen, DDS Stan Mcpike, DDS Assistant Editor Golich Carlsen Stan Mcpike, DDS Marie Leland • [email protected] Denver, CO Jonesboro, AR Copy Editor/Staff Writer Chelsea Patten • [email protected] Howard M. Chasolen, DMD John Nosti, DMD, FAGD, FACE Creative Director Sarasota, FL Advanced Cosmetic and General Dentistry Amanda Culver • [email protected] Mays Landing, NJ Graphic Designer Mark Fleming, DDS* Krzysztof Polanowski, DDS Corey Davern • [email protected] Mark J. Fleming, DDS, Inc. Stomapol Vice President of Sales & Business Development Sarasota, FL Serocka, Wyszkowa, Poland Pete Janicki • [email protected] Regional Sales Managers Seth Gibree, DMD, FAGD Jay Reznick, DMD, MD Mary Lou Botto • [email protected] North Georgia Smiles Southern California Center for Oral and Steve Kessler • [email protected] Cumming, GA Facial Surgery Geoff Kull• [email protected] Tarzana, CA Executive Sales Assistant Stephen Glass, DDS, FAGD* Lloyd Ritchie Jr., DDS Leah Harris • [email protected] Advanced Dentistry of Spring Lloyd K. Ritchie Jr., DDS Spring, TX Pensacola, FL Marketing Director Jerry Kaster • [email protected] Brian Gurinsky, DDS, MS Donald Roman, DMD, AFAAID Circulation Director Brian Gurinsky, DDS, MS Roman Dental Arts Marcie Coutts • [email protected] Denver, CO Paramus, NJ

I.T. Director Eyad Haidar, DMD Tom Schoen, DDS Ken Scott • [email protected] Weston Dentistry Schoen Family Dentistry Weston, MA Internet Application Developers Wabasha, MN Angie Fletchall • [email protected] Nick Avaneas • [email protected] Joshua Halderman, DDS Timothy Tishler, DDS Northstone Dental Group Northbrook Dental Care, Ltd. Electronic Media Production Artist Columbus, OH Northbrook, IL Amy Leal • [email protected]

MultiMedia Specialist Glenn Hanf, DMD, FAGD, PC Glenn van As, BSc, DMD Devon Kraemer • [email protected] McDowell Mountain Ranch Dentistry Canyon Dental Message Board Manager/Director of Continuing Education Scottsdale, AZ North Vancouver, British Columbia, Canada Howard M. Goldstein, DMD • [email protected] William Kisker, DMD, FAGD, MaCCS* Online Community Manager Dental Care of Vernon Hills Kerrie Kruse • [email protected] Vernon Hills, IL

Publisher Howard Farran, DDS, MBA, MAGD • [email protected] © 1999–2011 Dentaltown.com, LLC. All rights reserved. Printed in the USA. President Copyrights of individual articles appearing in Dentaltown reside with the individual authors. No article appearing in Dentaltown may be reproduced in any manner or format without the express written permission of its author and Dentaltown.com, LLC. Dentaltown.com message board content is owned sole- Lorie Xelowski • [email protected] ly by Dentaltown.com, LLC. Dentaltown.com message boards may not be reproduced in any manner or format without the expressed written consent of Controller Dentaltown.com, LLC. Stacie Holub • [email protected] Dentaltown makes every effort to report clinical information and manufacturer’s product news accurately, but cannot assume responsibility for the validity of product claims or typographical errors. Neither do the publishers assume responsibility for product names, claims, or statements made by contributors, in message board posts, Receivables Specialist or by advertisers. Opinions or interpretations expressed by authors are their own and do not necessarily reflect those of Dentaltown.com, LLC. Kristy Corley • [email protected] The Dentaltown.com “Townie Poll” is a voluntary survey and is not scientifically projectable to any other population. Surveys are presented to give Dentaltown participants an opportunity to share their opinions on particular topics of interest. Seminar Coordinator LETTERS: Whether you want to contradict, compliment, confirm or complain about what you have read in our pages, we want to hear from you. Colleen Larkin • [email protected] Please visit us online at www.dentaltown.com

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Suicide and Trust

by Howard Farran, DDS, MAGD, MBA, DICOI; Publisher, Dentaltown Magazine

I recently came across a feature on Business life of a dentist can be! Insider.com called “The 13 Careers Where You’re Most On top of all of that pressure, many of us make Likely to Commit Suicide” by Mamta Badkar and Gus things harder than they have to be. My entire profes- Lubin).1 The list includes welders, mathematicians, sional life, I’ve lived by the five Ds: 1. Design Your musicians, carpenters, artists, authors and dancers. At Plan; 2. Drop Everything You Don’t Need to Do; 3. the top of the list: dentists. According to the feature, Delay Everything You Can’t Drop; 4. Delegate; and 5. dentists are 5.45 times more likely to commit suicide Do. Did you read number four? than average. The source material used for this report Delegate. came from the book Suicide and the Creative Arts and There are way too many dentists who don’t dele- the 2002 Social Science Quarterly article “Occupation gate; who have to control every single aspect of the and Suicide” – which were both based on data from practice. You’re already stressed out but even more so more than 20 years ago – and far from what I consider because you don’t delegate. You don’t delegate because a credible source, but the list got me thinking about the you don’t fully trust your employees. Why is that? correlations between dentists and suicide. As a dentist, you want your patients to trust you, Myth or not, in my more than 25-year career as a right? That’s why you went to school for eight years and dentist, I’ve lost too many friends and colleagues to sui- have credentials hanging on your wall. That’s why you cide. We have all heard stories of the “rampant suicide dress professionally. That’s why you’re a member of the rate in dentistry,” and we all know someone who has American Dental Association and why you take hours and been affected by suicide in one way or another. hours of continuing education. I’ve given hundreds of lec- Oftentimes, suicide is preceded by drug or alcohol tures in dozens of countries, and for 21 years, I’ve asked abuse. So it’s almost no surprise that dentists and musi- dentists in the room if they brought their staff with them. cians top the list; dentists and musicians are around The few docs who bring their employees with them usu- drugs a lot! Listen, I love likening you guys “rock stars” ally bring in around $2 million annually; the docs who but for other reasons! I also don’t want to turn this into don’t are burned out, give out negative vibes and might be a column on addiction – I’m leaving that up to the struggling to keep their practices open. You don’t want expert, Dr. William Kane, who runs the Missouri them to hear what’s wrong with your practice? Fine, but I Dental Association Well Being Program. I really want bet they know what the problem is already; you don’t trust you to read his article on page 76. them! The docs who bring their teams to lectures laugh Yes, addiction is a major contributor to suicide, but out loud when I talk about dysfunction in offices. I’ve what’s another factor? Stress! seen dental assistants in the crowd wad up a piece of paper Guys, there’s a lot on our shoulders. We all know and toss it at the doc’s head in jest when I mention some- it! We are expected to be on our game all of the time thing that docs do wrong. They all trust each other. and there’s very little room for error. Even though Nobody’s perfect. Everyone makes mistakes. These teams Dentaltown has eased some of the feeling of isolation, understand that. we still operate in our secluded little worlds constru- In the unhealthy office, the doc says to his staff, “I cting tiny things in tight spaces. We inflict pain on want to buy a CAD/CAM machine,” and the assistant people. Our patients aren’t usually happy to see us. doesn’t say a word (because arguing is either pointless Our entire practice, livelihood and staff’s paychecks or could get her reprimanded or fired) and calls Henry rely on how good of a practitioner we are. Oh, and Schein or Patterson. She might think it’s the worst idea don’t forget to tack on the stress of your personal life in the world, but she knows he doesn’t value her opin- – mortgage, car payments, house projects and getting ion, so she won’t give him her feedback. to little Johnny’s soccer game on time. Nobody out- In a healthy office with a staff the dentist trusts, side of dentistry truly understands how stressful the the dentist might think, “I’m going to buy a CAD/

continued on page 16

14 September 2011 » dentaltown.com

howard speaks Find us on Facebook continued from page 14 www.facebook.com/dentaltown

CAM crown milling unit. It’s going to cost me about how to take a quality impression? My dentist can’t $125,000.” He’s going to talk to his staff about it. If take an impression and he won’t listen to me.” This is so this is a really trusting setting, the staff is going to wrong! Your staff should be able to talk to you openly argue – passionately. There’s no disrespect to anyone, and honestly, and vice versa. If there isn’t open commu- but the staff might say, “No, doc, we really should nication, it means there is no trust. If you have someone take that $125,000 and spend $50,000 on marketing on your team who you know can’t do the job, fire them and get some help from an outside company. Then we and get someone who can. If you have someone who can should take the remaining $100,000 and remodel this do the job, you have to trust that person and delegate. old office.” The decision becomes a team decision. I lead from behind. For years, I have said, hire the They all trust each other and all want what’s best for best damn people in the world, get completely out of the practice. Whether the practice buys a CAD/CAM their way, stand behind them and just try to keep up is up to the team. with them. I don’t micromanage. If I ever feel like I have One of the biggest signs of trust is that your assistant to micromanage someone I would rather just fire that argues with you. My assistant, Jan, has been arguing person and find someone who I don’t have to micro- with me for the past 20-plus years! Let’s say I take an manage. Between Dentaltown and my dental practice, impression and give it to Jan to give to the lab. I’d if I have 40 blossoming people then the whole company either never see it again or she’d come back and tell me blossoms. But I’ll bet you it is not like that in 80 per- that it needed to be redone. She never timidly crawled cent of the dental offices in America. back to ask if I thought the impression was OK. She My favorite CEO in the world is still Jack Welch of would know if I made a lousy impression because she GE. At GE, there were almost 20 divisions that knows what the lab will and will not accept. Because I reported to Jack Welch and they ranged from light trust Jan and I trust my lab, I would retake the impres- bulbs to jet engines to nuclear power plants to NBC. sion. I never argued. If it wasn’t good enough for Jan, He knew nothing about how to make a light bulb or it wouldn’t be good enough for my lab. how to hire actors for a hit TV series. Rather than Dental assistants often approach me before a semi- trying to know everything about everything, he found nar asking me things like, “Dr. Farran, can you talk people who knew what to do and he trusted them. He concentrated on his team. Jack Welch had 500,000 Howard Live employees in about 20 divisions. He concentrated on the four legs on managerial economics: What is the Howard Farran, DDS, MBA, MAGD, is an international speaker score? What are we going to measure and focus on? who has written dozens of published articles. To schedule Howard What is the reward incentive? And what is the job to speak to your next national, state or local dental meeting, e-mail description? Jack Welch didn’t know how a jet engine [email protected]. works, he just had to know a job description and he Sept. 23 ■ Houston, Texas found all the engineers and the right people, designers, Houston AGD marketers and advertisers to run it. That’s trust! 800-286-1918 Remember what Ralph Waldo Emerson wrote, “Trust www.houstonagd.com men and they will be true to you; treat them greatly, and they will show themselves great.” Jack Welch lived Oct. 6 ■ Raleigh, North Carolina Nu Image-The Big “3” Dental CE by that, and you should, too! 2011 [email protected] Guys, you can fix this! You can turn this behavior Kim Wolozyn – 919-532-3192 around! Stop trying to do everything yourself. Start realizing that you can’t be perfect at everything and Oct. 11 ■ Spring Lake, New Jersey Asteto Dental Labs don’t get offended when your staff offers you con- [email protected] structive criticism. Start trusting your staff enough to 800-447-7750 delegate the day-to-day goings on at your practice. And please, stay healthy, not just for the life of your ■ Oct. 12 West Orange, New Jersey ■ Asteto Dental Labs practice, but for your own life.

[email protected] References

Seminars 800-447-7750 1. Visit: http://www.businessinsider.com/jobs-commit-suicide-2010-10#1- dentists-are-545-times-more-likely-to-commit-suicide-than-average-13 if you want to see the report. Word of warning: it’s a slideshow.

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Surviving Prostate Cancer

by Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

Dr. Tom Trinkner is a well-known dentist and lecturer with a special focus Data on on cosmetic dentistry. He currently practices full time in Columbia, South Prostate Cancer Carolina, and some of the highlights from his career to date include: teaching • According to www.cancer.org, at Pankey Institute, Pac Live, New York University and Las Vegas Institute, prostate cancer is the second most authoring multiple articles and numerous presentations to dentists. He is also a common cancer in American men. prostate cancer survivor. I recently had the privilege to speak with Tom about Number one is skin cancer. his dental career and the sobering effect of a cancer diagnosis. Tom had missed his routine physical because life got in the way, and a reminder from a physi- • The American Cancer Society estimates that 240,890 new cases cian patient to get his PSA level checked saved his life. This month is Prostate of prostate cancer will be diag- Cancer Awareness Month, and I hope this interview serves as a reminder to nosed, and 33,720 men will die any male dental professionals to get yourself checked. of this disease in 2011. How do you spend your time in terms of practicing • Prostate cancer is the second- dentistry, writing and speaking? leading cause of cancer death in Trinkner: I am still relatively involved in the Journal for the Academy of American men. Approximately 1 Cosmetic Dentistry mostly through e-mails and coming up with ideas for the in 36 will die of prostate cancer. publication. My general lecture time has significantly diminished partly due to prostate cancer. It was kind of a wake-up call for me to really focus more on my kids who are now eight and five, and my wife. I have had the privilege to meet the best people in dentistry. My core group of friends is really what pulled me through that period of time.

Do you have an associate or do you solo practice? Trinkner: I am solo. I have two hygiene full time, two front-desk and one amazing assistant.

What would you say is the most exciting trend in dentistry today? Dr. Trinkner and his children Trinkner: Clinically, I continue to be fascinated with some of the trends in micro-dentistry. Micro preps and catching things really early. Some of the tools we are using now are allowing us to do that. I try to keep my practice very simple.

I want to talk a little bit about your prostate cancer diagnosis. Trinkner: I don’t think I had any unusual symptoms compared to any normal 50-year-old guy at the time. I felt good. I have always worked out. One of my patients, an oncologist who I love, came in and told me he had just been diagnosed with prostate cancer. He was really shaken. He said, “I want you to make sure you have your physical. Go make sure you have your PSA checked.” I went in and everything else checked out great. I went home, and I was called back by my doctor the very next day. He said, “Your PSA is up. You’re 3.7 and the last time you had a 1.7.” I went in to have it redone and he called

continued on page 20

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me the next day and said, “You have gone up 2/10. I didn’t feel anything on Trinkner Timeline your digital exam but I want you to go ahead and see a urologist.” I went in to see the urologist and a few weeks later he said, “Digitally you January 2009- Elevated PSA on are fine but with your numbers, age, what your PSA is you have a 28 percent routine blood test chance of having prostate cancer. So one in four would have this. I want you to February 2009- Blood work repeated have a biopsy.” to confirm elevated number I went home after the biopsy and thought it would only take a few days to March 2009- Consultation with get results. It was two weeks. I was sweating bullets because it had taken so long urologist to discuss next steps to get my path report back. (biopsy recommended) When I went in I thought he was going to tell me I was fine. Instead he June 2009- Prostate biopsy said, “I hate to tell you this, but you are positive for cancer. You have prostate cancer.” I could hardly move. I was so taken back. July 2009- Two weeks after biopsy, results confirm diagnosis of cancer He was able to give the prognosis based on September 2009- Consultation with those biopsies? Dr. Shaw at St. Joseph’s Hospital in Trinkner: Yes. I was a type one, an early stage one. There is a lot of infor- Atlanta, Georgia mation within the pathology report that tells you what severity you have. It also defines the risk to how confined it is to the capsule of the prostate. October 2009- Robotic radical prostatectomy performed by Dr. Shaw Is the course of treatment clear or is this just one October 2009- One week of recovery of those things where you have multiple ways to time from surgery treat this? Trinkner: Multiple ways. The prostate is going to swell to a different size. If you are going to have a procedure – like the prostate removed – you have to have a couple months to healing. I could not do any form of treatment for a few months. It’s a waiting game. I spent the next two weeks researching prostate cancer. Fortunately, I had a patient in my practice who was a cardiologist, who also taught and did a lot with robotics in cardiology. He left to go do a fellowship in a hospital in Atlanta. I called him and told him my situation. He referred me to a friend at DaVinci program here at St. Joseph’s hospital in Atlanta and he does 10 robotic surgeries on prostates a week. He has done 2,500 of them. I scheduled an appointment in September and I went back a month later. I went in and had my surgery on a Thursday morning, and I was up moving around by Thursday afternoon. The next morning they took out my chest tube. It is an amazing surgery. There are four hands working at the same time. It is amazing technology. My pathologist called me on Tuesday and told me I have a three percent chance of having recurrent cancer from my prostate.

How many days did you lose out of your practice? Trinkner: I missed seven days of work. I had surgery on Thursday. I took the whole following week off and came back to work the following Monday. I went a little slower. My energy wasn’t quite what it was.

Start to finish you were dealing with this process for nearly a year. What lessons did you learn? Trinkner: I feel very blessed that I caught it early. It’s an easy test. Even through the biopsy it is an easy test. So there really is no excuse not to do it. And if you have to have surgery, if you pick the right person, the right place and you take care of yourself before the surgery, it doesn’t have to be difficult. ■

20 September 2011 » dentaltown.com

second opinion

A Two-Tier Standard Do the Youngest Citizens of the United States of America Deserve a Two-Tier Standard of Dental Care? by Rhea M. Haugseth, DMD

Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a “Second Opinion.” Perhaps some of these observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession. –– Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

The 2000 Surgeon General’s report on “Oral Health parental knowledge about good oral health practices in America” identified a “silent epidemic” of dental dis- and the importance of primary teeth, inadequate access ease in certain large groups of disadvantaged children.1 to nutritious foods and the belief in oral health “myths” This report identified dental decay as the most common such as “they are only baby teeth, they will fall out any- chronic disease of children in the United States, the way,” are well documented contributors to poor oral majority of this disease found in segments of the popu- health in this population of children. lation that live in poverty or low-income households A recent AAPD survey showed that more than 70 and lack access to an ongoing source of quality dental percent of members treated children who are at the care. Sadly, not much has changed since this report was most risk for high rates of dental decay. Because pedi- published. We know that dental disease in children has atric dentists account for approximately three percent a negative impact on a child’s capacity to learn, receive of all dentists in the United States, there are not enough adequate nutrition, attend school or even achieve a good pediatric dentists to treat these children. It’s imperative night’s sleep. Untreated dental disease in children also that our profession increase its emphasis on the preven- affects their home life, their parents’ ability to go to tion and early therapeutic treatments to truly impact work and their family’s health. When a child has dental the high decay rates present in our nation’s most vulner- disease, everyone in the household experiences a lower able children. quality of life. As dentists, we know that optimum oral Inequities often result from underutilization of health is highly correlated with optimum overall or sys- available dental services. There are numerous barriers to temic health, and we also know that the reverse of this adequate utilization of oral health services, the most is true – poor oral health in children has a negative notable include: impact on their overall health. 1. Lack of oral health literacy The American Academy of Pediatric Dentistry 2. Cultural beliefs and influences (AAPD), the recognized authority in children’s oral 3. Lack of knowledge of existing services health, advocates for optimum oral health and health- 4. Financial and job-related barriers care services for all children, including those with spe- 5. Geographical barriers cial health-care needs. The AAPD has long focused its 6. Transportation difficulties attention, resources and advocacy efforts on improving Assisting parents in overcoming these challenges will the oral health and access to high quality dental services result in an increase in utilization rates and a positive within the context of a Dental Home for those children impact on lowering the oral disease rates in children. In who have the highest risk of developing dental decay. addition to the treatment of existing dental disease, den- The idea has been proposed that access to care is the tal providers must emphasize education and prevention. root cause of these high-risk children’s problems. While Only by following this directive will we have any influ- access issues, and specifically access to dentists who ence on the “silent epidemic” of oral disease that is affect- treat Medicaid or State Children’s Health Insurance ing our nation’s children. Program (CHIP) recipients, are a part of the problem, A major component of AAPD’s advocacy efforts are it is not the only concern. Other issues, such as lack of focused on the development of oral health policies and

continued on page 24

22 September 2011 » dentaltown.com

second opinion continued from page 22

evidence-based clinical practice guidelines that pro- oral health literacy through education to parents, chil- mote access to and the delivery of safe, high quality dren and other caregivers. Allied personnel can also comprehensive oral health care for all children, includ- assist families in accessing a Dental Home through ing those with special health-care needs, within a coordination of care and case management. Using allied Dental Home. A Dental Home is defined as the ongo- personnel to improve the oral health literacy of this ing relationship between the dentist and the patient, nation could decrease individuals’ risk for oral diseases inclusive of all aspects of oral health-care delivery; in a and mitigate a later need for more extensive and expen- comprehensive, continuously accessible, coordinated sive therapeutic services.3 and family-centered way.2 Such care takes into consid- The AAPD is supportive of state practice laws that eration the patient’s age, developmental status and psy- would allow EFDAs who are currently employed by chosocial wellbeing, and is most appropriate to the dental practices in the community and schools for the needs of the child and family. Children who have a provision of limited preventive services and screening; Dental Home are more likely to receive appropriate parent and caregiver education; and coordination/case preventive and therapeutic oral health care.3 management to build the family’s relationship with the The AAPD, American Academy of Pediatrics (AAP), Dental Home. An increase in early prevention and oral American Dental Association (ADA) and Academy of health instruction, facilitated by outreach into the com- General Dentistry (AGD) all support the establishment munity to children and caregivers, will decrease decay of a Dental Home as early as six months of age and no rates in children most at-risk for oral disease. The later than 12 months of age. The early establishment of AAPD believes by utilizing allied personnel to improve the Dental Home provides time-critical opportunities to oral health access and literacy and the subsequent offer education on preventive health practices and, sub- decrease in risk for oral disease, this will decrease the sequently, reduce a child’s risk of preventable oral dis- need for more costly restorative treatments, thereby ease. Within the Dental Home, prevention can be reducing the overall cost for dental care. The few avail- customized to an individual child’s and family’s risk fac- able peer-reviewed studies of the use of EFDAs and a tors. In fact, growing evidence supports the effectiveness great deal of anecdotal information from our members of the early establishment of a Dental Home in reducing support this hypothesis.4,5,6 early childhood caries. Each child’s Dental Home should The idea of EFDAs practicing within the context of include the ability to refer to other dentists or medical- a true Dental Home, under the supervision of a dentist care providers when all medically necessary care cannot is contrary to other proposed non-dentist provider be provided within the Dental Home. The AAPD models purported by some to improve the access to care strongly believes that a Dental Home is essential for for disadvantaged children. Some of these models have ensuring optimal oral health for all children.3 even been implemented in a few select states, which has The Dental Home model is based on dentist- allowed for the limited study of these models. directed care; meaning the dentist performs the exam- Unlike the EFDA model, these proposed models ination, diagnoses disease and establishes a treatment need this – others are employed based on independent plan that includes the full range of services that meet practice models, whereby the allied personnel are a child’s individual needs, including preventive serv- allowed to perform diagnosis and treatment normally ices. All services are carried out under the dentist’s reserved for the dentist. These models offer no assur- direct supervision in this model (i.e., physical pres- ances that independent non-dentist providers will be ence during the provision of care). The dental team located in underserved areas. In fact, in countries that also might include allied dental personnel (i.e., dental have employed such models, evidence shows these hygienist, expanded function dental assistant/auxiliary providers often end up practicing in less remote areas, (EFDA), dental assistant) who work under the direct decreasing their impact on access to the underserved. supervision of the dentist to increase the dental office’s In all existing and proposed models, the non-dentist capacity to serve more children while preserving qual- provider receives significantly less education and train- ity of care. ing than a dentist. General dentists attend four years of Furthermore, the dental team can be expanded to dental school after completing their college education. include auxiliaries who go into the community to pro- Dentists who specialize in pediatric dentistry must vide outreach to families who might not be familiar spend an additional 24 months or more in a full-time with the current dental delivery care system and increase postdoctoral program, which provides advanced skills

continued on page 26

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in treating conditions and disease unique to children, as The AAPD strongly believes that a two-tiered stan- they grow into adulthood. dard of care should not exist for our nation’s most vulner- The few, limited studies addressing the technical able children. Services to this high-risk group should not quality of restorative procedures performed by non-den- be provided independently by non-dentists or “mid-level tist providers have found, in general, that within the providers” with less education and experience, especially scope of services and circumstances to which their prac- when evidence-based research to support the safety, effi- tices are limited, the technical quality is comparable to ciency, effectiveness and sustainability of such delivery that produced by dentists. There is, however, no evidence models is not available. to suggest that they deliver any expertise comparable to a Ask yourself – would you allow your children or dentist in the fields of diagnosis, pathology, trauma care, grandchildren to be treated by a non-dentist provider pharmacology, behavioral guidance, treatment plan with less education and training than a dentist? My development and care of special needs patients.3 guess is the answer to this hypothetical question would It is essential that policy makers recognize evaluations be a resounding “No!” that demonstrate comparable levels of technical quality In closing, I implore you to reject a two-tiered stan- which merely indicates that individuals know how to dard of dental care for our country’s youngest and most provide certain limited services, not that those providers vulnerable citizens. AAPD members believe every child have the knowledge and experience necessary to deter- deserves a healthy smile and all infants, children and mine whether and when various procedures should be adolescents, including those with special health-care performed, or to manage individuals’ comprehensive oral needs, deserve access to high quality comprehensive healthcare safely. The AAPD supports the use of EFDAs preventive and therapeutic oral health-care services pro- in providing this technical competence as a part of the vided through a dentist-directed Dental Home. ■ dental team representing a true “Dental Home.” The New Zealand model is often looked at as a suc- References: cessful model for non-dentist providers as it has been 1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services. in existence for many years. However, in New Zealand’s National Institute of Dental and Craniofacial Research, National Institutes of recent official government report of the oral health Health, 2000. 2. American Academy of Pediatric Dentistry. Definition of Dental Home. Pediatric status survey, the caries rate in New Zealand is higher Dent 2010; 32(special issue):12. than that of the United States, United Kingdom and 3. American Academy of Pediatric Dentistry. Policy on workforce issues and delivery Australia.7 Given this data, why do some individuals of oral health care services in a Dental Home. Available at: http://www.aapd.org/ media/Policies_Guidelines/P_Workforce.pdf and organizations continue to view this model as suc- 4. Bailit, H, Beazoglou, T, Drozdowski, M. Financial feasibility of a model school- cessful? The AAPD believes the greater use of EFDAs, based dental program in different states. Public Health Reports 2008 (123). 761- under the direct supervision of a dentist, will help 767. 5. Beazoglou, T, Brown, J, Ray, S, Chen, L, Lazar, V. An Economic Study of increase the volume of services provided within a Expanded Duties of Dental Auxiliaries in Colorado. Dental Home. This will have a much greater impact on 6. American Dental Association. 2009. Available at: http://www.ada.org/1620.aspx 7. Gillies A. NZ children’s dental health still among worst. The New Zealand Herald. access to care, prevention of dental disease and lowering March 6, 2011. Available at: “http://www.nzherald.co.nz/nz/news/article.cfm?c_id= the cost of treatment to at-risk children. 1&objectid=10710408”. Accessed March 14, 2011.

Author’s Bio

Rhea M. Haugseth, DMD, is president of the American Academy of Pediatric Dentistry. Haugseth has been an AAPD member for 29 years and has maintained a private practice in Marietta, Georgia. She attended dental school at University of Louisville and received her pediatric dental certificate from Case Western Reserve University. She has served as the AAPD’s president-elect (2010-2011), vice president (2009-2010), secretary-treasurer (2008-2009), parliamentarian (2005-2006) and the AAPD’s District III trustee (2002-2005). Haugseth is a fellow of AAPD and a diplomate of the American Board of Pediatric Dentistry, as well as a fellow of the American College of Dentists, International College of Dentists, Pierre Fauchard Academy and the Academy of Dentistry Internationale. She is also past president of the Southeastern Society of Pediatric Dentistry (2010-2011). Dr. Haugseth’s AAPD presidential agenda will focus on welcoming all dialogue that will advance its efforts in the fight for children’s oral health. Through its dedicated advocacy endeavors, the AAPD will continue to provide a voice for all children, so that a foundation for a lifetime of oral and overall health is established in every home.

26 September 2011 » dentaltown.com .EW 0ATIENTS !RE 9OUR &UTURE

6ISITUS/NLINEAT WWW.EW0ATIENTS)NCCOM socket preservation

by Paul L. Child Jr., DMD, CDT and Gordon J. Christensen, DDS, MS, PhD

One of the most frustrat- tion to the dentist for failure to graft a socket (not all reasons are ing situations encountered in listed, but these are the most common): dentistry today is the referred Dentist assumes the patient lacks adequate financial patient desiring an implant for resources for the procedure. Surprisingly, when full informed a recent extraction(s) where consent is provided, including the risks of not grafting, using no bone regenerative grafting visual aids demonstrating these risks, and the future possibility of procedure was offered or provided. The site usually has a signif- implant placement, many patients will opt for the graft, despite icant defect, both apico-coronally and bucco-lingually, requiring the added cost. Often, patients are able to “find” money when more extensive and costly grafting either at the time of implant they deem something important or necessary. Information about placement or in advance (Fig. 1). Situations like the one simple socket preservation needs to be explained to clarify the described are damaging to patients’ confidence in their dental procedure to the patient and justify the procedure. practitioners, as well as frustrating to the surgeon placing the Dentist lacks knowledge of bone grafting options. A dentist implants when the entire situation could have been avoided with who does not provide simple socket preservation does not need to complete patient education at the time of extraction. Prevention know every aspect of bone grafting materials and/or techniques in for these and similar situations is simple! Every extraction needs detail. However, it is required to know the long-term risks and to be preceded by an explanation of the risks and benefits of benefits of providing this service, so patients can make an edu- bone grafting in the extraction site. cated decision on which treatment option will best serve them. This article includes various reasons why grafting is not pro- Dentist desires income of extraction procedure and does vided and why it should be offered, makes suggestions for not want to lose revenue by referring the patient to another den- improved patient acceptance, explains simple informed consent tist or surgeon who provides socket preservation. This scenario and offers examples of how different patients were treated and is an ethical dilemma facing a few dentists, and might have risen prepared for future implant placement. This article does not due to the slowed economy. Each dentist needs to put the review an exact technique or include a detailed list of materials. patient’s best interests first by providing full informed consent as Our goal is to stimulate dentists to find CE courses and become discussed below. Making your personal financial income a prior- educated on this vital procedure, and to offer bone grafting as an ideal treatment to every patient before extraction.

Reasons Why Grafting Is Not Provided Often, when beginning treatment for an implant after the tooth has already been extracted, a patient is asked if bone grafting procedures were explained as an option, the patient denies any knowledge of being offered this procedure. Sometimes this is true, but a patient’s memory might be clouded by the emotional trauma of losing a tooth, the level of pain he or she was experiencing and relative financial priorities that Fig. 1: Patient desiring maxillary central implants after extractions without might have precluded grafting at the time of extraction. Despite socket preservation discussed or provided. Patient ultimately required extensive selective patient memory, the following reasons are cited in rela- hard- and soft-tissue grafting with pink porcelain as part of the final prostheses. continued on page 30

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Why Bone Graft When Extracting Teeth? Answering this question requires dentists to forget about Figs. 2 and 3: Patient was referred for implant consult one week after general themselves and focus on the patient. Excellent patient education dentist extracted chronically infected, non-restorable maxillary premolar. Early can easily provide this answer to the patient in 10 to 15 min- referral allowed immediate grafting of the site. 1 Figs. 4 and 5: Radiographs of grafted site and subsequent implant placement utes. The main reasons for socket grafting are: with crestal approach sinus lift. 1. Future bone loss and ridge resorption Figs. 6 and 7: Final restoration demonstrating good color match and adequate 2. Support of adjacent teeth and implants tissue healing. continued on page 32

30 September 2011 » dentaltown.com

socket preservation continued from page 30

3. Planning for future options, such as implants or a fixed Fig. 8 bridge 4. Some sites require bone grafting for implants 5. Fixed-prostheses might have a poor aesthetic result without the presence of adequate bone and overlying soft-tissue. 6. Easier to “preserve” now instead of “create” later 7. Avoidance of additional surgeries 8. Procedure is simple, safe and effective 9. Financial situations can change with time

Informed Consent Informed consent involves six areas and should be provided to every patient before any dental procedure. Provide a written doc- ument to the patient that explains the various options (as Fig. 9 Fig. 10 described below) and obtain a signature indicating that he or she understands and accepts the treatment. Use visual aids, including: actual patient photos, casts, educational models and videos to help patients understand the proposed treatment. Most of the patient education can be provided by the assistant, with the dentist answering detailed questions and obtaining the consent. Example consent forms can be obtained from many sources including the ADA, many surgical and implant associations, digital patient education software services (ImplantVision, etc.), continuing educa- Fig. 11 tion centers and more. Below are the six necessary areas that must be discussed for practitioners to obtain legal informed consent. Present all treatment options. In regard to extraction cases, all treatment options should include extraction only, extraction and immediate grafting anticipating later placement of an implant, extraction with subsequent grafting in one to two weeks due to infection or other factors preventing immediate grafting, extraction and referral to a surgeon for grafting, referral to a surgeon for entire procedure, extraction and grafting with potential for subsequent grafting later by a surgeon (i.e. sinus lift, ridge augmentation, etc.), extraction and simultaneous Figs. 8 and 9: Image and radiograph of failing central incisor next to a previ- implant placement with grafting to augment and many other ously restored implant placed too far apically. Patient education is necessary options that are specific to the patient’s condition. Whatever the before treatment for potential loss of gingival embrasure papilla fill and aes- option, be honest with the patient as to your ability to provide thetic challenge. Fig. 10: Extraction and socket preservation with allograft and soft-tissue the service at the same level as a specialist. augmentation. Discuss the advantages of each option. For this example, Fig. 11: Patient smile with provisional on central implant demonstrating aes- the advantages would include improved ability to receive an thetic challenge of filling papilla next to implant. Despite secondary soft-tissue implant at the extraction site, decrease of further costly grafting augmentation surgery and appropriate contour of provisional, pink porcelain procedures and improved quality of life with future implant was necessary. Patient was prepared due to appropriate informed consent. restoration. Also, discuss the advantages of providing the grafting yourself or referring to a specialist/surgeon. implant placement, the potential for continuing shrinkage of Discuss the disadvantages or limitations of each option. bone and gingival tissues or aesthetic challenges (Figs. 8-11). Many of the disadvantages were discussed above in the reasons Identify and explain the risks of each option. This section why bone grafting is not provided. A frank conversation with the of informed consent usually is explained with the disadvantages patient should occur, being realistic about potential outcomes. or limitations of each option, as described above. In differenti- For those who provide bone grafting, do not forget to include the ating a disadvantage from a risk, it is necessary to explain that a risks of rejection or loss of grafts, potential for infection, poten- risk is not necessarily a poor choice or will always lead to a dis- tial need to provide additional grafting at a later date or at the advantage. Each day, most individuals take a risk to drive to continued on page 34

32 September 2011 » dentaltown.com From Apnea to Zirconia Find the CE you need on Dentaltown.com

• Earn credits fast • More than 150 online courses in 27 categories • All credits securely organized in your account for your convenience

Approved PACE Program Provider Farran Media is an ADA CERP Recognized provider. ADA CERP is a FAGD/MAGD Credit service of the American Dental Association to assist dental profession- Approval does not imply acceptance als in identifying quality providers of continuing dental education. ADA by a state or provincial board of CERP does not approve or endorse individual courses or instructors, dentistry or AGD endorsement. nor does it imply acceptance of credit hours by boards of dentistry. 12/01/2004 to 12/31/2012 continuing education socket preservation continued from page 32 work, but it will rarely lead to an accident if caution and safety For dentists who desire to provide simple bone grafting, we are applied. Similarly, a risk is taken to place a foreign substance recommend obtaining the appropriate education, deciding in in the extracted site, but if good infection control measures are what clinical situations they desire to provide socket grafting implemented with careful surgical technique, infection and sub- and then implementing the procedure into practice. There are sequent clinical challenges can be avoided. many courses on socket grafting offered to general dentists, most Provide the cost of each option. Base your cost on the com- of which are taught by specialists. One of the best ways to pensation that is adequate for your time and expertise. improve your skills and confidence is to find a surgeon who will Overcharging a patient initially can result in decreased treatment be your mentor. Take time off to observe and learn from him or plan acceptance, decreased future implant placement, loss of her. Develop a relationship where you provide simple and pre- patient from practice and patient resentment. Some dentists pro- dictable services and refer more advanced cases to your surgeon. vide an incentive for those who state they have financial challenges, Most surgeons who develop these types of relationships experi- such as providing the extraction and grafting now, and if the ence increased referrals from general dentists. patient returns within a year for the implant placement (when they might be able to obtain the funds or third-party benefit plans Conclusion allow), the dentist discounts the implant placement. Plan for your With the advanced level of implant dentistry, combined patient’s future implant placement if they cannot afford to have all with the large number of patients who need implants, many of the procedure accomplished at one time (extraction, graft and teeth are being extracted without full informed consent implant placement). This preparation is in the patient’s best inter- regarding socket preservation. Dentists need to fully disclose all est and can be a great source of future revenue. the available options to patients when a tooth or multiple teeth Discuss the outcomes of no treatment. Although this step need to be extracted, even if it results in loss of revenue. Most is listed last, it might be best suited to discuss lack of treatment dentists can learn and provide simple socket preservation by first. Explaining the consequences of failing to graft now can developing a close professional relationship with a surgeon. motivate treatment acceptance. For a reasonable fee (i.e. extrac- Ultimately, these changes will benefit the patient, the general tion fee plus two to three times the cost of the bone graft mate- practitioner and the specialist. n rial), the procedure can be easier to accept than the alternative References: of extraction, grafting, implant placement and restoration equal 1. Taken from Clinicians Report, May 2010, Grafting Extraction Sites: Why, What, and How to several thousand dollars. Author Bios Dentist Education on Grafting Extraction Sites Dr. Paul Child is the CEO of CR Foundation, a nonprofit educational and Simple socket preservation is within the ability of most den- research institute (formerly CRA). He conducts extensive research in all tists who desire to provide this service. This excludes more areas of dentistry and directs the publication of the Gordon J. advanced procedures, such as ridge augmentation, block grafting, Christensen Clinicians Report, and their other publications. Dr. Child is sinus elevation, etc., although surgically oriented general den- a prosthodontist, a certified dental technician and maintains a private tists can learn these procedures as well. It is important for den- practice at the CR Dental Health Clinic in Provo, Utah. Dr. Child lectures tists to obtain adequate education and training on how to nationally and co-presents the "Dentistry Update" course with Drs. provide these procedures within their comfort level. Depending Gordon and Rella Christensen. He lectures on all areas of dentistry, with on whom you ask, this education and training can range from a an emphasis on new and emerging technologies. He maintains mem- three- to six-year residency, to a multi-session course or to a bership in many professional associations and academies. Further information is available at www.cliniciansreport.org. weekend course. Not all dentists are able to complete a residency, but they might have the potential to provide simple and Dr. Gordon J. Christensen is founder and director of Practical Clinical predictable socket preservation after taking a shorter course. Courses (PCC) in Utah. This group is an international continuing educa- The most important factor to remember is if you provide tion organization providing courses and videos for all dental profession- bone grafting procedures, you are expected to provide it at the als. He is also co-founder of the nonprofit Gordon J. Christensen same quality level as a specialist. Know your own limitations, who Clinicians Report (previously CRA), as well as an adjunct professor for to treat, who not to treat and when to refer. If you are a general Brigham Young University and University of Utah. He is a diplomate with dentist who provides bone grafting services, do not abandon your the American Board of Prosthodontics. Dr. Christensen has presented specialists, upon whom you may need to rely for future assistance. more than 45,000 hours of continuing education throughout the world If you are a specialist, work with your referring dentists and be a and has published many articles and books. Further information is available at www.pccdental.com. mentor. It has been our observation that working together improves revenue and overall patient and dentist satisfaction.

34 September 2011 » dentaltown.com

industry news

DentalDental NewsNews inin BriefBrief

The Industry News section helps keep you informed and up-to-date about what’s happening in the dental profession. If there is information you would like to share in this section, please e-mail your news releases to [email protected]. All material is subject to editing and space availability.

Queens Dentists Prepare for Cuba Humanitarian Dental Trip The Fialkoff Queens Dental Study Club is planning a humanitarian dental trip to Havana, Cuba in February/March of 2012. This trip is being organized by Dr. Bernard Fialkoff, founder of the study club, and Meghan Fialkoff, director of the Cuba Humanitarian Dental Trip. The attending dental practitioners will provide pro bono dental work and dental education to the Cuban lay and professional community. Dr. Fialkoff has chosen the University of Havana Dental School in which to do these pro bono services for the Cuban community. The group anticipates 30 dentists and dental staff to travel to Cuba for the trip in 2012. For more information on how to donate or volunteer, e-mail [email protected].

OCO Biomedical Receives Approval from Health Canada OCO Biomedical, Inc., received approval from Health Canada for the sale of Class II dental implants. OCO Biomedical now is permitted to market and distribute dental implants, as well as the placement instrumentation (Class III devices) throughout Canada. OCO Biomedical will be able to offer its dual-stabilization dental implants to the Canadian market. Previously in October 2010, OCO Biomedical obtained ISO 13485 and CE Mark certifications for approval to sell in Europe and many other countries. Visit www.ocobiomedical.com for more information.

Donald Tuttle Named New President and CEO of D4D Technologies D4D Technologies, LLC, has appointed Donald L. Tuttle as the company’s new president and chief executive officer, effective August 1. Previously, Mr. Tuttle served as president of specialty products for Sybron Dental Specialties, Inc./Ormco Corporation. During his 11 years at Sybron, Tuttle was responsible for the successful management of multiple companies and for driving double-digit revenue growth. Prior to this, Tuttle held senior leadership roles at a number of companies in the dental industry, including serving as president for Dentalview, Inc.; director of sales for SDS Metrex; vice president of sales and marketing for Ormco and president of Ormco and Sybron Implant Solutions. For additional information, visit www.d4dtech.com.

Steve Semmelmayer Brings Market Expertise to S-Ray, Inc. S-Ray, Inc., announces the addition of Steve Semmelmayer as a company advisor. Semmelmayer has more than 32 years in the dental industry. He is currently an industry director at American Dental Partners, Inc., and recently completed a 27-month tenure as CEO of Discus Dental, which he brokered for sale to Philips Electronics. Semmelmayer will bring his considerable experience, insight and industry relationships to help guide S-Ray, Inc., as it pursues license agreements, strategic investments and liquidity opportunities. He will also explore partnerships with international dental companies as a means to accelerate the development and introduction of S-Ray, Inc.’s “radiation-free” technology. Visit www.s-rayinc.com for more information.

continued on page 38

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ADA Honors Illinois Dentist with Hillenbrand Fellowship The American Dental Association (ADA) recently selected Dr. Elizabeth Shapiro of Waterman, Illinois as the 2011-12 ADA Hillenbrand Fellow. The ADA awards the fellowship every other year to a dentist who has demonstrated strong leadership potential and the desire to transition from practicing dentistry to a nonclinical dental career in a health-related organization. Like previous Hillenbrand fellows, Dr. Shapiro will learn about the inner-workings of the ADA’s agencies and departments; learn about other oral health organizations and federal and state government agencies; and have the opportunity to take aca- demic courses through the Kellogg School of Management at Northwestern University. Dr. Shapiro will serve as a Hillenbrand Fellow from September 2011 to August 2012. For more information, visit www.ada.org.

i-CAT Puts Clinicians In Control With Quick Scan Imaging Sciences International now offers Quick Scan, the lowest available dose 3D scan of the full dentition. Quick Scan is one of many proprietary tools that allow general dentists, orthodontists, oral surgeons and other specialists to maximize the clinical information they need while maintaining the ability to control radiation exposure to the patient. With Quick Scan, the entire patient dentition can be imaged in 3D for only 27uSv. This dose compares favorably to a typical digital panoramic scan of 24uSv, yet offers full three-dimensional radiography of both arches that provides accurate and distortion-free views not available with 2D panoramics. For more information on the low-dose Quick Scan, visit www.imagingsciences.com.

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38 September 2011 » dentaltown.com Probiotics. They aren’t just for digestion anymore.

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Now Available Through and other leading distributors. These threads come from the message boards of Dentaltown.com. equipment message board Log on today to participate in this discussion and thousands more.

Equipment

A mystery instrument, a helpful equipment tech, finding a water distiller and fixing sticky syringe buttons. Equipment is often our silent partner. Here is a small sampling of the many threads found on Dentaltown.com regarding equipment.

Mina Tadros, DDS EndoTreated Who Knows What This Instrument Is? Posted: 6/22/2011 I got my hands on these forceps, and I’m not quite Post: 1 of 10 sure what it’s for. Looks like extraction forceps but it’s so straight, I don’t see it easily fitting anywhere in the mouth... All it says on it is “Made in Germany.” No number or anything... Can someone give me ideas of what it is for and what its value is? ■

Gregory F. Strobel, DDS When I entered my dad’s practice, which he started back in 1932, Long Span Bridge he also had one of these instruments. I personally never saw the need Posted: 6/22/2011 for it. But he told me he used it for removing temporary crowns. Post: 4 of 10 Specifically back in the day when they used aluminum shell crowns. You would place the blade at the ginigval margin of the crown and brace the opposite end on the occlusal surface, and then use the blade to slice through the aluminum crown so that you could then flex the metal and remove it. I do not know if this was the function for which it was designed, but I know that is how my dad used it. Hope this helps. ■

what happen It’s a temp crown splitter and ortho band splitter. ■ Posted: 6/22/2011 ■ Post: 6 of 10

Find it online at www.dentaltown.com What This Instrument Is

kmstratton Wet Vacuum Problem Solved by Benco Tech Posted: 6/3/2010 A dentist’s worst nightmare (not being able to practice dentistry) was easily fixed. Post: 8 of 62 I bought this practice about a year ago, so I have no idea how old the compres- sor and the vacuum are. I sit down to work on my first patient and the suction does not work. I had to reschedule her and she was fine with it. The handpieces work just fine. So, it’s the vacuum. Before today, I couldn’t tell you what was what. I go to the basement where they’re kept, and the vacuum is hot and not running. The

continued on page 42

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fuse button is popped, so I replaced it and nothing. I unplug the machine and plug it back in and makes a noise before shutting off. I call Benco and wait. They get here within two hours. My next patient is at 12 p.m. (it’s a very small practice). The vacuum is an Apollo Dental Product wet vac. I noticed the water leaking too. The Benco tech arrives and hears the problem. He takes the cap off the top in the center and starts rotating the knob that’s in the canister. He says the minerals in the hard water can jam the impeller all the way down at the base of the vac. He gives it a good twist and it finally turns. Plugs the machine back in and it is up and running. Thank you Gary from Benco! What a relief. He says it has got a ways to go before needing to be replaced. I guess that’s why they have “dry” vacuums nowadays. Anyway, I hope this helps people with similar problems. If it’s not the fuse, it’s the hard water deposits in the turbine that’s causing it to get stuck. ■

Rick Lindquist Some days a good technician is a godsend! Good service is the rea- ricklin son to buy from a supply house and Benco does a great job. Posted: 6/21/2011 Interestingly enough, the Ramvac (the best dry vac) was invented by Post: 2 of 8 a farm boy dentist who was fed up with minerals plugging up his wet vac. Dr. Robert A. Meyer was that farm boy, thus the RAM in Ramvac. Apollo is owned by Midmark these days. They have a liquid that can be poured into the pump to dissolve those hard water deposits. Sounds like that should be done a couple times per year for preventive maintenance. You can also bet that your pump will perform better without all that mineral buildup. ■

Find it online at Wet Vacuum Problem www.dentaltown.com

fishdrzig Sticky Air/Water Syringe Button? Posted: 7/13/2011 I have an air/water syringe. The button on the water side sticks frequently and Post: 1 of 6 does not pop up automatically, so water leaks and it needs to be pulled up manu- ally. What causes this and what is the fix? Thanks. ■

GopherDDS The buttons can be easily replaced. You can order parts from Rick (techguru) at Posted: 7/13/2011 American Dental. On my syringes, I have to remove a pin from the side to replace Post: 3 of 6 the buttons. When the button is replaced sometimes you need to depress it slightly to get the pin back in place. Sometimes you only need to replace an o-ring or a spring to fix it. Either way, it should be an easy fix. Rick can also talk you through troubleshooting the problem. ■

Rick Zieska A previous poster mentioned Vaseline – lubricating the buttons techguru can help, but you want to use a silicone-based lube, not petroleum. Posted: 7/13/2011 Petroleum-based lubes will actually speed deterioration of the o-rings. Post: 4 of 6

continued on page 44

42 September 2011 » dentaltown.com Introducing the newest additions to the Temrex Family of Basic Essentials BASIC ESSENTIALS Diapers and a pacifier BASIC ESSENTIALS Copalite Varnish and Solvent The original and most reliable dental varnish. Applied under gold and amalgam restorations this varnish will help retard decay and the recurrence of cavities. This well tested and completely reliable varnish has anti-microbial and anti- viral properties. 1/2 oz. bottle each of Copalite® Varnish and Copalite® Thinner/Solvent holds enough to treat 600 teeth using two applications.

For more information on Copalite Varnish & Solvent as well as DOC'S BEST™ Red (or White) Luting Cement with Activated Copper, Coplaite Snapbond and the Formatill Kit contact: 1-800-645-1226 or 516-868-6221 Fax:516-868-5700 www.temrex.com equipment message board continued from page 42

Depending on the specific button, you might need to disassemble the button to get the lube to the “stem,” which is the actual moving part. For syringes with a pin that holds the button in, we always recommend holding the buttons all the way down to remove or replace the pin. That will get it lined up every time (if you think about it, you need to be able to push the buttons all the way down when you use it, so it would have to be lined up). ■

Don Ton, DDS I agree with silicone lubricant – Chemplex 710. I used to buy and change out DonDDS a whole bunch of syringe push buttons. Now it is a weekly routine to clean up and Posted: 7/13/2011 lubricate, no more throwing away money for new buttons. My time is around three Post: 5 of 6 minutes each. ■

Find it online at Sticky Air/Water www.dentaltown.com

fliegenfischen Posted: 5/12/2010 Water Distiller Suggestions? Post: 1 of 25 So I keep getting clogged handpiece water lines. Repair guy says water is hard here and I should really use distilled water. Does anyone have suggestions on a water distiller unit? Do you guys just use the countertop ones that can do four gallons a day? Brand suggestions? How much to spend? Thanks. ■

Shannon S. McGee, DDS What you will need will depend on how many chairs you have running full emcgee time. We used to use about two to three liters per chair a day, including hygiene. Posted: 5/12/2010 Change out the bottles at lunch. Long crown and bridge procedures used more. Post: 2 of 25 Don’t forget your autoclaves – they are probably clogging as well, only more slowly. Most distillers are good for about a year, and then need to be replaced. Depending on the volume you need you might be better off buying gallons at Wal-Mart. The larger distillers can get pricey. ■

timagrenz I have sold the Tuttnauer large unit. It has been very reliable. One office I have Posted: 5/12/2010 ■ Post: 3 of 25 it in is an eight op – three doctor, two hygiene practice. Just keeps ticking along. ■

Rick Zieska Not only that, but you’ll also need self-contained systems to feed the techguru water to the units (if you don’t already have). If not, you might consider Posted: 5/12/2010 just getting a water softener for the office. Post: 5 of 25 What do you have for instrument cleaning? An ultrasonic? If you use a dishwasher/cleaner you’ll also want to treat the water for it. This could also make you lean more toward a softener. If you do go distiller, we’ve had good success with our distillers (www.amerdental.com/sterilization-products/ water-distiller) and they have a one-year warranty, so you can certainly expect more life than “about a year” out of them. Nonetheless, Dr. McGee is correct; volume does enter into the equation.

continued on page 46

44 September 2011 » dentaltown.com

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One last thing, while hard water certainly can wreak havoc on your water lines, a more common cause of clogs (particularly to the handpieces) is biofilm. A water treatment system (combined with self-contained) will address this better than just using distilled (which could actually exacerbate the problem if used without treatment too). How’s the water to your air/water syringe? The line is the same size (1/8in, outside dimension) as the water feeding to your handpieces, so it should be almost as prone to clogging. Handpiece water does go through more valves however, so you could experience trouble with the handpieces first/more frequently depending on precisely where the clogs are. I don’t recollect if you’ve ever mentioned, what brand are your units? ■

doctortooth1 Can I jump in on one of my favorite topics? My staff calls me a water snob. Posted: 5/30/2010 I have a small two-chair general practice with an in-house water system that I Post: 17 of 25 installed about six years ago, stemming from a problem that turned out to be a little pin hole leak in a piloted valve in the floor box of my A-dec unit. Kept getting this rusty water in the cup fill; why patients complained is beyond me! It was worse than what you can imagine. I went through a distiller-phase for about three years (PureWater, Midi-classic) but it died. Tried to repair it; no go. It took a lot of energy and maintenance to keep it going. I told myself at the time that I was doing all that extra effort for the good of the patients. My retrospective opinion is that distilling my own was a waste of time, effort and money; and not necessary. I’m sold on the filtration/de-ionized system that I now use. The company is called ZeroWater and I have no monetary interest in them. It is just so easy and green. Won’t work on Statim water though. My old Tuttnauer autoclave works well with it. A water softener will run $800-1,000 or more. ZeroWater can be set up for about $125 and is at Home Depot. I order the filters direct ($12 each and there are two that are needed), and I change them about once a month at the rate I use. I am spending no energy to make the product unless you count the transportation fuel costs for FedEx to deliver the filters to me. And the best part: I don’t buy cases of the bottled water anymore for my wife to drink and then have to take those emp- ties to the recycling center. And it makes the best coffee I have ever had! I send the spent filters back to the company, so no landfill waste. I use the water for my units, my autoclave and the film processor; my family uses about six quarts a day. I don’t have an office dishwasher. Finally, I think that I am reducing my salt intake personally by drinking de-ionized, so it is healthier in my mind. One detail that might be interesting to some: for a while, I kept getting these little “floaties” that looked like what I imagine biofilm looked like in my unit bottles after about a week of use. I got rid of them by filtering (with a standard coffee filter) the chlorine dioxide disinfectant that I add to my water to maintain my lines; I don’t use tablets. I read about ZeroWater first on Dentaltown two years ago. ■ Allen R., DDS

Find it online at Water Distiller Suggestions www.dentaltown.com

46 September 2011 » dentaltown.com Are you tired of hearing “Love it, but can’t afford it right now”?

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*Research available upon request. Treat the Untreated. ©2011 Den-Mat® Holdings, LLC. World Rights Reserved. 801303300 08/11KJ This thread comes from the message boards of Dentaltown.com. anesthesiology message board Log on today to participate in this discussion and thousands more.

Are Dentists Using Nitrous Anymore?

Nitrous has been available for more than 100 years. Will it ever go out of style?

slcdentcent I’m starting up and it’s going to cost a pretty penny to get nitrous set up. Are Posted: 6/3/2010 dentists using nitrous much anymore? Are patients asking for nitrous? I only used Post: 1 of 62 it a couple of times in school, but didn’t find it super effective. Will it be a good return on investment? Thanks! ■

pedodel I use it on 15-20 patients a day. I could not practice without it! It helps a lot Posted: 6/3/2010 with kids but you still have to be pretty smooth. It does not take the place of good Post: 2 of 62 behavior management or good injection technique. I’m pretty sure this is the same with 99 percent of all pediatric dentists out there. I’m sure it helps with some nervous adults too. ■

jennypenny12 I am a GP and at our office (two doctors) we haven’t used nitrous Posted: 6/3/2010 in over a year and a half. Patients don’t really ask for it and when we Post: 3 of 62 did have it, we only used it on one patient per week on average. It just wasn’t worth having around. ■

gxm321 I’m a GP. I use it for all children, and any adult who requests it. I charge $50 Posted: 6/3/2010 for anyone who requests it. When I opt to use it I don’t assess an additional charge. Post: 4 of 62 I always use it at the start of IV sedation. You have a patient who is freaked out to begin with and then try to stick them with a needle. When I bought the office it was plumbed centrally. Don’t know that I would have taken on that expense on my own, but if I was to build a new office I would spend the money for central nitrous. It took me a while to learn to use it properly. Private message me if you have questions about proper use. ■

kmstratton I use nitrous all the time. I can’t imagine practicing without it. I’m one of the Posted: 6/3/2010 few who don’t charge for it and build the costs into my fees. I would say at least Post: 8 of 62 half of my adults use it and I use it on nearly every child. We get many fearful and traumatized adults and children and it is amazing how many patients I can turn around just by using nitrous and a great injection technique. I had it plumbed into all five of my ops when I did a build-out 10 years ago. I go through two tanks of oxygen per week and one tank of nitrous per month. Worth every penny. ■ continued on page 50

48 September 2011 » dentaltown.com From Equipment Footprints to Office Blueprints Find it all on Dentaltown.com

• Informative discussions regarding Clinical Procedures • Insights on supplies, equipment and even topics of leisure • Free classifieds, relevant online CE and much more! anesthesiology message board continued from page 48

ricklin If occasional use is anticipated, a portable is the way to go. For higher Posted: 6/6/2010 volume use, plumb it in. Post: 13 of 62 The gas is actually six to 10 times higher in price in the small bottles. But you can buy a lot of gas with $30K that you will save by not plumbing it in. So it depends. ■

woosailor Certainly a matter of exposure and experience. Posted: 6/6/2010 My dental school (happily ensconced in the dark ages) did not teach the technique Post: 15 of 62 because the head of oral surgery overdosed some kids from a reform school and they freaked out. Because of his mistaken overdosing, he pulled it from the curriculum and so I took my course at Detroit. Ignorance on the part of the head of the surgery department and many classes were not exposed to it because of his stubborn attitude. Worth every penny. Not many adults use it but for kids it is a fantastic practice builder. Have at least one generation of kids who have no fear of dentistry, largely because of it. Learned from a pediatric dentist that no injection is necessary in deciduous teeth and can count on one hand the times I have injected deciduous teeth, except for extractions. No acciden- tal lip bites and the kids are happier. I treat it with respect and do not joke about it. For those dentists who don’t use it. I find that they rationalize why they do not. I love the rationalizations and welcome them. Very pleased when I hear them because nitrous is a great practice builder for me. For those of us who do use it prudently, we wouldn’t be without it and it is a practice builder. For those who say it’s never necessary for anyone... ignorance is bliss. I love to hear people say that it is never necessary... neither is anesthesia. I would say only use it if you want Negotiating a Lease? to build a good practice. Otherwise rationalize away. ■

Don’t let the landlord Dr Daisy I was only using nit-

take advantage of you. Posted: 6/8/2010 rous maybe twice a year,

Post: 22 of 62 until I was converted by this thread: www.townie “ central.com/Message You have been a Board/thread.aspx?s=2&f=136&t=144285. total Blessing I use it more with kids now. The thread will carry “ you through my conversion process. I realized some from start to finish. things about the way I was practicing and I think I grew. I thought I was helping people more by not using it. My - Dr. Monique Jones friends here made me realize that maybe the opposite Chesapeake, VA was true. ■

To level the playing field, simply call toll-free or visit georgevaill.com/dt/ Find it online at www.dentaltown.com Dentists Using Nitrous 800-340-2701

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Thermafil Retreat

This discussion of retreating Thermafil cases reminds everyone of the requirements for success in any endo case.

Californication Patient had endo in 2004 and is now having pain there. Access went well and got Posted: 12/17/2008 three of the four carriers out of the three canals (two in the distal), but I can’t get the Post: 1 of 74 carrier out of the ML canal. Here’s a pre-op and a shot of where I am now (minus the carrier in the distal). Any ideas on getting that stupid thing out of there? ■

acemo1 Thermafil users can rationalize all they want about the technique. Posted: 12/17/2008 It’s foolish to put such a difficult impediment in a tooth. It is shortsighted. Post: 2 of 74 They simply should not be used routinely to fill root canals, we have way better techniques. ■

Jeffrey Walmann, DDS, RPh Here’s the deal: On this case you have to get each carrier out and get patent on jwalmann each canal or the case can be assured of failure. I hope you know how to do surgery Posted: 12/17/2008 on a mandibular second molar. I would re-check this tooth for isolated narrow deep Post: 4 of 74 probing depths and visually observe with a microscope for a crack. If you see one crossing the floor of the tooth then (in my book) it is a goner. ■ Jeff

Scott Kalniz It looks like an open margin on the distal. Take off the crown for better access. kalniz I’ll bet when you open it up you’ll see a large crack in the tooth. That’s what it looks Posted: 12/17/2008 like on the X-ray anyway. Post: 5 of 74 Thermafil is a wonderful obturation material. I’ve used it on more than 6,000 cases with only a handful of retreats, like less than 10. If you know how to do it then it’s very easy to retreat. Do those of you who complain about how hard it is to retreat Thermafil and plan for the worst only use temporary cement for your crowns just in case you need to remove them? Just sounds silly to me. I use what I like and what works in my hands. ■

continued on page 54

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Californication If you know how to retreat them so easily, could you please enlighten me and Posted: 12/18/2008 the rest of the people reading? Post: 6 of 74 Thank you. ■

Dinesh Singham I think the problem with Thermafil is the taper of the carrier is .04. Now if a factor78 canal is prepared to a taper of .04 and the same sized carrier is used, then the car- Posted: 12/18/2008 rier will become jammed into the canal and retreatment becomes difficult and frus- Post: 7 of 74 trating. If the canal is prepped to .06, then retreatment will be easier as there is now space to get a Hedstrom between the carrier and canal wall. I use a similar system (Soft-Core) and the carrier is .03 taper. I still find when I prep a canal to .04 the verifier can still be a bit tight. Usually in this case, I will drop the carrier size by one and find it reaches length quite passively. I don’t have this problem when I prep the canal to .06. I have retreated a few of my cases mainly due to missed anatomy and don’t have problem getting the carrier out. It usually takes about five to 10 minutes. Luckily I haven’t had to treat a jammed carrier case. Just my two cents. ■

rovster This is what happened to my tooth. Severely under-prepped and Posted: 12/18/2008 carrier jammed around the curve of a MB canal (#30). This is my per- Post: 9 of 74 sonal aversion to it. It took the specialist like three hours under the scope with ultrasonics to get it out. He was almost ready to throw in the towel. Good luck, man. ■

Scott Kalniz Speed and convenience are great kalniz reasons to select materials. What Posted: 12/18/2008 generation bonding material are you Post: 11 of 74 using? Why make things more difficult when easier and better products are available? I drive an automatic car because it is easier and more convenient for me. Same reason for microwave popcorn. My patients don’t want to sit in the chair for three Northbay to four hours when then can get quality work done in Networks much less time. You should always be striving for more is a nationwide efficient ways to provide care for your patients. Just remarketer of dental equipment because it has been done a certain way since the 60s or 70s does not mean that is the only “good” way to do • Quality equipment at a ■ fraction of the retail price something. Grow your mind a little bit. • Complete dental offices or individual pieces • Shipping and storage Jeffrey Walmann, Acemo really said it early on in services available DDS, RPh this thread about Thermafil. Yes, jwalmann most times I can get them out, Posted: 12/18/2008 sometimes not. But look at it from Post: 15 of 74 the patient’s point of view. He just had a root canal and crown, now he has a swollen jaw and hurts like continued on page 56

54 September 2011 » dentaltown.com

endodontics townie clinical continued from page 54

heck. You did the root canal and filled it with Thermafil. It might take me two visits, maybe three to get everything removed, disinfected, cleaned, shaped and obturated, mainly because of your choice to put something in the canal that can be difficult to remove. Then the patient has a brand new crown with a hole in it or needs a new one because the porcelain fractured while I was accessing it.

▼

Want to read more about Thermafil? Check out these informative message boards. This was the case from two years ago, which I described above – a pretty, young Thermafil is Great! woman in her early 20s with a swollen face. The guy only sent me Thermafil cases Search: Thermafil is Great of his that failed; as you can see, a couple of the carriers were impossible to totally Thermafil Retreat Technique? get out. This case took me three visits. That patient came back and the swelling was Search: Thermafil Retreat Technique gone and she was asymptomatic. I haven’t seen her since. But why put a patient through this and get her a compromised case when she paid for first class? By the way, speed kills. The time argument is insane. ■ Jeff

continued on page 58

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mandm_sudz Thermafil takes me longer. You want to talk fast. Clean and shape Posted: 12/18/2008 with ProTapers, and use the matching cones. You get a good tug back Post: 18 of 74 every time. Then down pack and backfill with Obtura. No waiting for the obturator to cool before you can trim it and move to the next canal. And when you’re done, you don’t have to drill like a dummy until the chamber is half clean. It’s also harder to get carriers in on a second molar without wiping out half of the GP on the edge of the access. ■

Henk van Diermen I’ve retreated a few Thermafils, but I think there is a lot of truth in Posted: 12/18/2008 what factor78 said about the taper. When there is more taper they seem Post: 19 of 74 easier to retreat. Today I did a Thermafil retreat and it took me about 10 minutes to remove three carriers, but it was a 0.06 taper. I’ve also had cases where it was impossible to remove the carrier. My technique is a 30 0.06 with 800rpm next to the carrier until resistance, chloroform in the canals. Then screw a Hedstrom 40 in the canal until it’s stuck and remove the Hedstrom with a hemostat using the tooth as a pivot point. ■ Henk

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CAESY Cloud WedgeGuard

CAESY Cloud is an online portal giving instant access to CAESY WedgeGuard from Triodent removes the risk of damaging the adjacent DVD’s multimedia presentations via the Cloud, compatible with tooth and the papilla. After cavity prep, the guard is detached while the PC and Mac desktop computers, smartphones, iPads and iPods. wedge stays in place, ready for the insertion of a matrix beside it. CAESY Cloud requires no installation; dental professionals can Leaving the wedge in place prevents reactive hyperemia, ensuring a sign up for the service online to gain access to the presentations for cleaner, blood-free working area. WedgeGuards are ideal for Class II immediate chairside use. After subscribing, users simply visit the and III cavities, veneers and crowns and tunnel preps, and come in Web site to access the full library of CAESY’s patient education pre- three sizes: small (white), medium (pink) and large (purple). For more sentations. For more information, visit www.caesycloud.com. information, visit www.wedgeguard.com.

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Simplicity Hygiene Package Safe-Vac

The Simplicity Hygiene Package from DentalEZ Group is designed to Safe-Vac is a disposable high volume evacuation tip with a soft, yet meet all hygiene needs in one package; it includes the Simplicity Chair, rigid cushioned tip designed to help prevent tissue trauma. The Light and Delivery Unit. The Simplicity Delivery Unit includes a new internal screen aids in many dental procedures to prevent time con- Simplicity head with two handpieces, saliva ejector, syringe and new suming blockages and loss of certain dental components. Safe-Vac DentalEZ integrated ultrasonic scaler. The chair is ergonomically is made in the USA with non-latex FDA-approved materials and is designed and offers the hygienist the best access to the oral cavity while precision engineered and quality driven. Visit www.safe-vac.net for maintaining proper positioning. The three-axis adjustment design of more information. the Simplicity light allows for the widest range of position- Safe-Vac ing over the oral cavity. For more information, visit www.dentalez.com.

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60 September 2011 » dentaltown.com PDAP DA Success Story Rapid Expansion “With the help of Productive Dentist Academy, my team adopted an ownership mentality that drives the practice. We have doubled production in less than a year>=<;:=987;865<;432=:1501<91:=940199====== right in the middle of a recession!” - DR. JOE KUNICK

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continued from page 60 LOOK EQUIA Fil and EQUIA Coat

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62 September 2011 » dentaltown.com new product proﬁles

ET Flex

The ET Flex from Brasseler USA is an interproximal finishing and contouring strip. The patented, safe, flexible design of ET Flex allows you to adapt the strip to meet all of your interproximal finishing and contouring needs. Grip ET Flex at or above the crossbar and the strip is taut for contact areas. Grip the ET Flex below the crossbar and the strip curves, allowing you to perfectly adapt to any contour. For more information or to order, visit www.brasselerusa.com.

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i-CAT Precise

The i-CAT Precise cone beam 3D system helps dentists in treatment planning for placing and restoring implants, performing guided surgery, extractions and other surgical procedures. It is exclusively integrated with Tx Studio software. Dentists can cap- ture a single arch to full dentition plus the TMJ complex with 3D scans of 8cm or 14cm diameters, and heights ranging from 8cm to 2cm and everything between. For additional information visit www.imagingsciences.com.

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From left: Forrest Estep, VP of inside sales; Susan Richardson, director of marketing; Barry Trexler, SVP of sales & marketing and Hugh ChaseHealthAdvance helps patients get the care they need. Bleemer, president of ChaseHealthAdvance. Overcomi

66 September 2011 » dentaltown.com corporate proﬁle chasehealthadvance

Elective, but often necessary, dental and health-care pro- equipment to buy or lease. Practices simply sign a provider cedures including advanced dental care, orthodontic work, agreement and select the payment plans that will best serve vision correction and cosmetic procedures often go uncov- their patients. Within days, the provider receives a wel- ered by insurance. In 2005, Chase began working to create a come kit with all the required information and materials to new financing option to provide affordable, flexible options get started. to help patients finance these treatments. Since day one, A highly trained and knowledgeable practice consultant is ChaseHealthAdvance has been focused on being an advocate assigned to every practice. These ChaseHealthAdvance con- for patients and practices. There is an ongoing focus on not sultants work closely with the doctors and their staff to ensure only looking for ways to improve and simplify the financing they are fully prepared and confident in presenting and pro- process, but also providing practices with innovative tools cessing financing options for their patients. Consultants main- and resources. tain an ongoing relationship with the practice. Should a practice have a question or new concern, practice consultants Background are always available by phone and e-mail. ChaseHealthAdvance helps patients overcome the finan- One aspect of the consultant’s responsibilities is to help cial barriers associated with elective procedures not covered by identify opportunities where new ChaseHealthAdvance serv- insurance. It does this by providing patients with no-interest ices can help the practice improve its business. The consultant and extended-payment financing plans. The organization’s can also introduce the practice to other ChaseHealthAdvance commitment to advocacy can be seen in its No Surprise products that could add value to the practice, such as business financing. ChaseHealthAdvance strives to make the entire credit cards, equipment financing and merchant processing financing process transparent by providing easy-to-under- services. ChaseHealthAdvance also provides numerous mar- stand product terms and disclosures for practices and their keting tools to help practices communicate the affordability of patients. The goal is to ensure nothing catches patients off- financing to their patients. Ready-to-upload Web banners are guard when they elect to finance their health care through available for the practice’s Web site. Patients can click on the ChaseHealthAdvance. With this clear and simple process, the banners to immediately apply for financing directly from the satisfaction patients experience during treatment from their practice’s site. ChaseHealthAdvance also has tools to help provider can extend to the repayment process as well. practices and patients determine the best financing options. As part of their commitment to practices and their There’s a downloadable payment calculator to help patients patients, in the upcoming months, ChaseHealthAdvance will find a payment plan that works for the family budget roll out a suite of new updates and features. With a commit- and understand the affordability of financing through ment to continued innovation and provider servicing, ChaseHealthAdvance. It also has a full set of co-branded letter ChaseHealthAdvance gathered input from doctors and office templates, which providers can use when sharing financing staff to help develop these new processes. These changes will information with their patients. include broad updates to practice and patient materials, and ChaseHealthAdvance has sponsored the printing of a wide Web sites that will make the financing process even easier. variety of resource guides, written by top professionals in the health-care industry, for providers who wish to continue their Committed to Providers education and make the most of their practice. These guides ChaseHealthAdvance is designed to be effortless for cover topics such as treatment innovations, practice manage- providers to implement. Enrolling is easy and quick. There ment and marketing information. All are available to are no enrollment fees, monthly minimums or required ChaseHealthAdvance providers for download online. ng

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dentaltown.com « September 2011 67 chasehealthadvance corporate proﬁle continued from page 67

Jared Wofford, Practice Development Consultant By outsourcing patient financing, practices allow ChaseHealthAdvance to take over these duties, freeing up front- office staff to focus on the practice’s core business – providing care to patients.

Through the ChaseHealthAdvance Web site, practices can manage their entire patient financing portfolio with no sur- prises. HealthAdvance-Online.com lets doctors and office staff from the repayment process is that patients submit new patient transactions quickly and easily, track current will be less likely to skip or delay follow-up treatments because open accounts and even produce custom reports. Coming soon, of an inability to pay. This can help avoid unnecessarily length- HealthAdvance-Online.com will also feature a new user inter- ening the treatment process. face and streamlined processes to make every aspect of practice Practices using ChaseHealthAdvance can also expand their administration easier. treatment offerings and implement the latest technologies. Patients considering advanced treatments can do so with Advantages of Using ChaseHealthAdvance less worry when they use ChaseHealthAdvance financing ChaseHealthAdvance is a great financing option for prac- and spread the treatment cost out over time with affordable tices that haven’t offered third-party financing in the past, as well monthly payments. as practices that have traditionally relied on in-house financing. Some practices that have a good cash-paying client base The ChaseHealthAdvance Difference might not see the need to extend credit to patients, but many Unlike other third-party financing companies, ChaseHealthAdvance providers report an increase in patient ChaseHealthAdvance is backed by a name that businesses acceptance after offering third-party financing. It has been and patients know and trust. As one of the world’s leading shown that patients will simply walk away from treatment or banks, Chase has the capital resources, the infrastructure and choose not to seek treatment because the perceived cost is too the customer service capabilities to serve dental practices and high for them. Third-party financing from ChaseHealthAdvance their patients. allows practices to offer affordable financing options and treat a ChaseHealthAdvance’s No Surprise financing is an open, broader range of patients. honest commitment to the patient. Financing terms are clearly ChaseHealthAdvance is also a great solution for practices that stated. Payment schedules are listed openly, and there is never a currently use in-house financing. While ChaseHealthAdvance large surprise payment, so patients know what to expect, from providers do pay a small service fee, third-party financing can the first payment to the last. No Surprise financing ensures help reduce a practice’s overhead. With in-house financing, patients know exactly what they’re agreeing to before they sign. dentists (and other health-care providers) spend a significant ChaseHealthAdvance has a broad range of No Surprise portion of their budget on financing administration and imple- financing options. For the dental market, patients can choose a mentation costs. By outsourcing patient financing, practices no-interest repayment plan of 6, 12, 18 or 24 months, or, for allow ChaseHealthAdvance to take over these duties, freeing up some procedures, an extended plan as long as 48 months. With front-office staff to focus on the practice’s core business – provid- generous credit lines and no down payments, patients can ing care to patients. finance up to 100 percent of the cost of treatment and afford ChaseHealthAdvance takes responsibility for administrating even the most comprehensive treatment plans. patient repayment of health-care transactions. The practice ChaseHealthAdvance also allows patients to reuse their receives its funding for treatments deposited directly into its credit lines for anyone in the family (even the family pet). The account, often in as little as 24 hours after the transaction. This funds can be used for any procedure performed by a can greatly improve a practice’s cash flow and allow for greater ChaseHealthAdvance provider nationwide, including vision, flexibility to reinvest in the practice. Another key benefit of orthodontic, hearing, cosmetic, chiropractic and veterinary using ChaseHealthAdvance and removing the dental practice care. It’s easy to find additional providers by using the Web site’s continued on page 70

68 September 2011 » dentaltown.com

chasehealthadvance corporate proﬁle continued from page 68

Provider Locator feature. Patients simply choose the type of available credit line within a few minutes. The streamlined provider they need and enter a zip code to find providers application process and quick credit decisions allow practices to nearby. Once they choose a doctor, patients can apply and more easily schedule treatments and perform procedures in a inform the practice of their ChaseHealthAdvance status, and timely manner. the practice can then look up the account, and schedule the MyChaseHealthAdvance.com desired procedure. In the upcoming months, ChaseHealthAdvance will begin This patient-focused Web site provides ChaseHealthAdvance issuing ID cards to all its account holders to make it even easier patients with fast and easy 24/7 access to their accounts. Patients to get additional care from ChaseHealthAdvance providers. are able to manage all aspects of their ChaseHealthAdvance The cards, which remain valid as long as the patient has an account from a secure login portal. They can check account bal- ances, view available credit, set up automatic account alerts and open credit line, will allow patients to easily share their even make payments from the comfort of their home or work- ChaseHealthAdvance account information with new practices. place. Patients can also contact a customer service representative Commitment to Patients through a toll-free number with any questions they might have. ChaseHealthAdvance continues to make it fast and easy for Learn More patients to apply for health-care financing and receive an instant credit decision. Whether patients are applying on their own or Now in its seventh year, ChaseHealthAdvance provides through their doctor’s office, the streamlined process speeds patient financing for health-care professionals across the United credit decisions. The clear and simple language in the financing States. One reason for the organization’s success is its dedication agreement ensures patients will get exactly what they expect and to continually improve the relationships and products offered to never be surprised by their payments. practices and patients. ChaseHealthAdvance has an online credit application To learn more about ChaseHealthAdvance financing process that makes it easy to apply for financing right from the options, visit AdvanceWithChase.com or call 888-388-7633 to dental office. Practices with iPad technology can also use the speak with a practice consultant. n custom Present and Apply tool for the iPad. This tool allows practitioners to walk patients through the case presentation A legal message from ChaseHealthAdvance: The information found above is educational mate- process in a simple, visual format. The tool helps communicate rial for you, a business entity, and not for your patients to view. Distribution or solicitation of affordability. It presents the options in a simple, easy-to-under- business from your patients using this material, directly or indirectly, is not permitted. stand manner and allows the patient to apply for financing right from the iPad. The application is quick and simple, requiring only basic information from the patient. If patients prefer, they may Present and Apply tool for the iPad. also apply from the comfort of their own home or office via phone or online application. The approval process is auto- mated so in most cases patients know their approval status and

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by Drs. Kenneth Koch and Dennis Brave

The dog days of summer are coming to end, which means “Evaluation with intra-oral periapical radiographs, clinical you should take the little bit of summer left to put your feet exam and pulp testing are the standard diagnostic modalities for the up and relax; the perfect time to have some fun with evaluation of pulpal and periapical pathology. However, two- endodontics! For this reason, we’ve put together a “potpourri” dimensional radiographs present limitations in assessing root of various endodonic topics – not heavy research information, anatomy, root canal morphology, bone and root resorption and but light and interesting tips to achieve better results with superimposition of overlying structures. CBCT has been shown to be endo. So, go to the fridge, get a cold beverage, put your feet significantly more sensitive in detecting periapical lesions, root up and let’s get started. resorption, root and bone fractures and additional canals. I also utilize CBCT to evaluate traumatic injuries of the teeth, for implant New, Less Expensive Rotary Files evaluation and pre-surgical planning for endodontic surgery (api- Yes, it appears there will be a number of new nickel titanium coectomy). The advantage of having three-dimensional images for rotary files introduced into the endodontic marketplace. Some challenging surgical and non-surgical endodontics and diagnosis will come from Asia, some from Europe and there might even allows a higher level of patient care.” be one or two from North America. Therefore, it should come as no surprise that the price range for these instruments will vary Anesthesia greatly. It also should be noted that the quality will also vary To consistently perform successful endodontics, the patient greatly. So, what should the clinician do? must be numb. Therefore, a good block technique is important. Our advice is to be careful and go with proven brands such If you are having challenges getting good results with your as Brasseler USA, Dentsply Tulsa or SybronEndo. More impor- mandibular blocks, try the following suggestions. tantly, the dentist must think in terms of endodontic systems, The first tip involves the pKa of your anesthetic solution. rather than just files. It makes more sense to have an obtura- For profound, long-acting blocks (for endodontics or quadrant tion technique and post system that will precisely match the dentistry) try first administering a carpule of 3% mepivacaine shape created by the rotary files. This is where endodontics is (without a vasoconstrictor) then follow that with a carpule of headed. Once you have endodontic synchronicity, the entire regular 1/100,00-epi lidocaine. You will get deeper, more pro- aim of melding endodontics into restorative dentistry becomes found blocks. This is not anecdotal, but rather a technique that much easier. We particularly like the EndoSequence sys- based on science. It works because of the difference in pKa val- tem (Brasseler USA) because it allows you (through its con- ues. Remember that you give the 3% mepivacaine first because stant taper preparation and bioceramic obturation) to achieve it is more comfortable to the patient. (This is a result of the pH such synchronicity. of the mepivacaine.) After the mepivacaine has been delivered, then follow that with a carpule of your regular lidocaine. This CBCT’s Role in Endodontics technique works great. This is an area that has been receiving a lot of attention in But what happens if you give a patient two blocks and the endodontics. Therefore, we have referred this question to Dr. patient seems very numb yet when you touch the tooth with Jerry Cymerman a Real World endodontist in Stony Brook, your round bur, the patient seemingly comes out of the chair? New York who routinely uses this technology. He says: What do you do? “Immediate referral to the endodontist” is not

72 September 2011 » dentaltown.com feature endodontics the answer we’re looking for! The nerve that causes this excruci- “Our advice is to be careful ating pain (when seemingly everything else is numb) is the mylohyoid. In order to sufficiently anesthetize the mylohyoid, and go with proven brands. you must locate it first. There are two locations where the mylo- More importantly, the dentist hyoid can be found. One is up at the condyle and the other is on the lingual side of the mandible, at a level equal to the apices must think in terms of of the lower second molar. The easiest way to anesthetize the mylohyoid is through endodontic systems, the Gow Gates injection technique. When using this tech- rather than just files.” nique, the patient is placed supine in the chair. With his or her mouth wide open, the syringe is directed on a line from across the corner of the mouth to the tragus of the ear. Entry is made (with a long needle) at approximately the level of the MGJ (muco-gingival junction) of the maxillary second molar and is advanced until it contacts bone. This is the condyle. The contents of the carpule are deposited in the region of the condyle, thereby soaking the mylohyoid nerve. This soaking contributes to the effectiveness of the technique. When properly performed, the Gow Gates is more effective than a traditional block. Also, it should be noted that many times when working on What about the mylohyoid at the lingual level of apices of anterior teeth (especially those with crowns) you do not need the lower second molar? This is an old oral surgery trick and you clamps. Instead, simply cut a piece of rubber dam and run it can simply infiltrate in this area and generally not more than through the contacts on the adjacent teeth. You can also use half a carpule is needed. Inject slowly because this area is very “widgets.” The rubber placed in the contact area will hold the vascular. A quick injection here can give the patient an unwar- rubber dam in place. This is a nice trick because you do not have ranted “rush.” It is because of these concerns that we much pre- to place a clamp on the porcelain. fer the supplemental mylohyoid injection to be in the vicinity of the condyle (Gow Gates technique). Safety Glasses We also recommend all dentists who want to learn the Gow We are still amazed (even in dental schools) at the lack of Gates technique do research on the Web or in textbooks, and safety glasses on patients. This should be a no-brainer! Did you obtain further information concerning the technique. ever get acrylic in your eye when adjusting a temporary or denture? It can be very irritating. Now, think about this – you Rubber Dam Clamps should be using bleach as your endodontic irrigant and, if you Our thoughts and recommendations concerning clamps: get some bleach in the patient’s eye by accident, it will be bad Anterior teeth: 9 N or 211 clamps will do. Bow clamps for both you and the patient. Please have your patients wear work well not only on anterior teeth but also on premolars, safety glasses or some kind of eye protection. Don’t wait until an particularly those teeth prepared for crowns. The 211 is the accident happens. most popular bow clamp. Premolars: 00, 209s are small clamps that work well on Coming Up Short all premolars. If you are using a Bioceramic sealer, such as BC Sealer, with Molars: 12A/13A are clamps with serrated beaks, sort of a Hydraulic Technique and find you are coming up short (after like tiger clamps. These are great for molars and will grab a confirmed trial fill), you are probably using to much sealer in on to anything. 12A/13A work UL, LR and UR, LL. You the canal. definitely need to have these clamps! The Hu-Friedy and Another problem could be what gutta percha cones are Aseptico clamps both work very well. being employed with the technique. The use of the wrong Optional clamps: W8A is a standard molar clamp that cones can result in the final insertion coming up 1mm short. can be modified; W3A is another molar clamp that works Consequently, we strongly recommend the use of the BC well on maxillary second molars and can make your life a coated cones when using the bioceramic technique. The bio- lot easier. ceramic cones are stiffer and will not collapse under the continued on page 74

dentaltown.com « September 2011 73 endodontics feature continued from page 73 hydraulic pressure. If one is using the BC coated cones, and instrument recently introduced by Brasseler USA, that has us still coming up 1mm short, then the answer is definitely too very excited – the Scout RaCe file. much sealer… The Scout RaCe comes in a number of sizes but the ones we We have found that dentists beginning this technique really like are the #10, #15 and #20, all in a .02 taper. While have a tendency to place too much sealer into the canal, even these instruments are extremely well-made and flexible, we also when they limit it to the coronal third. Therefore, we recom- like their ability to cut. Even though they have a non-cutting tip, mend that you do a few cases using the sealer in the same the Scout RaCe files are great at gaining length (and shaping) in manner as you did with the old conventional sealers (lightly those difficult canals. coating the cone and taking it down into the canal and coat- One clinician who has extensive use with these files is Dr. Ali ing the walls). By doing such, you will get a sense of how the Nasseh in Boston, Massachusettes. Here is what Ali has to say material flows in your hands. Then, as you get comfortable about them: with the flow rate you can start to inject a little bit of sealer “The Scout RaCe Files offer the same predictability in effi- into the coronal third only and then seat your cone through cient cutting of dentin that I’ve come to expect from their sister the sealer. files, the ‘EndoSequence’ File Series. These files have the addi- There are multiple videos of this technique on the Internet tional benefit of being very useful in thinner, more curved roots but one thing is generally not mentioned – a number of the found in most molars. With these small sizes, the clinician can specialists using this technique (after they inject the sealer) bypass the tedious work of hand instrumentation in smaller sizes take the last rotary file employed and use it by hand in a coun- and can benefit from the superelasticity of the NiTi metal with terclockwise motion. They proceed to take this file all the way the efficiency of rotary instrumentation vs. hand filing. to the established working length and then make a counter- “Following the use of a size 6 or 8 hand file, and some coro- clockwise motion with the file and remove it from the canal. nal enlargement (as recommended in all crown down tech- This process will remove any excess sealer that exists in the niques), the size 10-20 (or merely 10 and 15) Scout RaCe files flutes of the rotary file. It is a very clever technique and one can rapidly enlarge the canals and create a patent canal that that works well, but we believe that it can be avoided by sim- can then be instrumented predictably and safely with the ply using less sealer. EndoSequence Files or your rotary instruments of choice.” One other thing that needs to be mentioned is that we Instrumenting Narrow, Tight Canals believe the use of .02 taper rotary files (whatever system) should We have often talked about proper access and good lubri- be limited to those dentists with considerable experience with cation helping the clinician instrument difficult canals. rotary files. If one’s endodontic clinical experience is somewhat Additionally, we have talked about the crown down method limited, the clinician is best served using hand files (which are and using .04 taper rotary files. However, there has been a new also .02 taper) in these challenging narrow canals. n

Author Bios

Dr. Dennis Brave is a diplomate of the American Board of Endodontics, and a member of the College of Diplomates. Dr. Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in endodontics from the University of Pennsylvania. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for more than 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a co-founder of Real World Endo.

Dr. Kenneth Koch received both his DMD and certificate in endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. Prior to his endodontic career, Dr. Koch spent 10 years in the Air Force and held, among various positions, that of Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In addition to having maintained a private practice, limited to endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is also the author of numerous articles on endodontics. Dr. Koch is a co-founder of Real World Endo.

74 September 2011 » dentaltown.com

addiction feature

National and State Health & Wellness Programs

ADA Dental Health and Wellness Department Web site: www.ada.org/4497.aspx Contacts: Alison M. Siwek, Manager [email protected] 312-440-2622 Mary Gilliam, senior project assistant [email protected] 312-440-7473

State Dental Associations Colorado Dental Association Concerned Colorado Dentists Web site: www.cdaonline.org/index .php?option=com_content&view= article&id=102:well-beingprograms& catid=56:about-the-cda&Itemid=177 Contact: by William T. Kane, DDS, MBA Michael Ford 303-810-4475

Louisiana Dental Association Dental Well Being Advisory Committee Web site: www.ladental.org/cms/ content/view/181/41/ Contact: Jamie Manders, NODA [email protected] 504-366-8193

Maryland State Dental Associat- ion Dentist Well Being Committee Web site: www.dentistwellbeing.com/ Contact: Robert White, Clinical Coordinator 410-328-8549

Massachusetts Dental Associat- ion Dentist Well Being (C-DAD) Web site: cdad.org/ Contact: Thomas Derosier, Chair [email protected] 508-540-0303

very dentist from the first day of dental school has heard of the high rates of Minnesota Dental Association suicide, alcoholism and divorce in the dental profession. Dentistry has held this Dentist Wellness Program reputation for many decades. When one thinks of addiction, alcohol and drugs Web site: www.mndental.org/ are at the top of the list. There are also, behavioral addictions such as compul- dentist_home/member_services/well- ness_program/ sive gambling, sexual compulsivity, eating disorders, compulsive shopping and Contact: problematic Internet use. Dentists and their family members can be affected by Sand Creek Group Eone or more of these addictions. 800-632-7643 76 September 2011 » dentaltown.com feature addiction

Addiction is a complex primary, biogenetic, psychosocial, chronic progressive disease that if left untreated could lead to death. The good news is addiction responds well Warning Signs to adequate treatment. A recent definition of addiction is as follows, “Addiction coops the brain’s neuronal circuits necessary for insight, motivation and social behaviors. This The following are warning signs of functional overlap results in addicted individuals making poor choices despite aware- substance abuse, addiction and or ness of the negative consequences; it explains why previously rewarding life situations emotional disorders among dentists: 1 and the threat of judicial punishment cannot stop curtailing addictions.” • Increased difficulty at home, marital con- flicts, absences, problems with children Dentists are especially susceptible to • Wide mood swings; anger, depression nervousness addictions and emotional impairments • Unexplained absenteeism at work: isolation and withdrawal from community due to their stressful working and colleagues • Frequent need for medication environment and striving for perfection. • Decreased career satisfaction; avoidance of continuing education courses. • Legal and financial problems: driving under Dentists are especially susceptible to addictions and emotional impairments due the influence citations, lawsuits, debts to their stressful working environment and striving for perfection. Dentists are • Problems at the office with staff and trained to be both technicians and artists, performing exacting procedures in iso- patient complaints lated environments, determined to achieve the mythical “ideal restoration.” • Problems with licensing boards and Drug Dentists who are prone to addiction struggle with exaggerated fears, deficient inter- Enforcement Agencies personal skills, internalizing their patients’ anxieties, a competitive nature and easy

continued on page 78

dentaltown.com « September 2011 77 addiction feature continued from page 77

National and State Health access to drugs. These burdensome circumstances can result in the feelings of & Wellness Programs inadequacy or failure, and create a fertile ground for addiction and or psy- (continued) chological disorders. This begins on the first day of dental school and carries over following graduation. Some individuals deal with these stressors better Mississippi Dental Association than others. Stated another way, some of us deal with life on life’s terms bet- Council of Supportive Services ter than others. Web site: www.msdental.org/about- The percentage of the dental profession affected by addiction is basically mda/councils the same as the general population; estimates range from 11 to 20 percent. Contacts: Bruce Scarborough, Chair However, there are subtle differences specific for dentists with addictive dis- 601-446-8389 eases. For instance, the drug of choice may be different in most cases, but the Montana Dental Association disease of addiction is the same. Addiction tends to progress over time. At Dentist Health and Wellness first, addicted dentists can be a master at hiding their drug use from their Web site: www.msdental.org/about- family, office staff, and of course patients. Family and office staff might begin mda/councils to make excuses for deteriorating behavior and performance. When excuses Contacts: Ingrid McLellan, Council Member begin, this enables the addictive disease to begin to spiral downward. The iso- [email protected] 406-443-5526 lation of a solo dental practice further contributes to this process. The dentist with an addiction feels very isolated and alone. He or she feels that they Nevada Dental Association are the only one in the dental profession that are in the throws of addiction. Northern Nevada Dentist Health and Wellness Committee Addiction tends to progress over time. Web site: nndental.org/default.php?p=Co Contacts: Michael Day, Chairman [email protected] At first, addicted dentists can be a master 775-358-5265 at hiding their drug use from their New York State Dental Association Chemical Dependency Committee family, office staff, and of course patients. Contacts: Health Affairs [email protected] As addiction progresses, personal and professional lives deteriorate. Most 800-255-2100 individuals with the addiction tend to blame others, events, circumstances – North Dakota Dental Association you name it – for their problems. The dentist with an addiction will be in North Dakota Dept. of Health denial that he or she indeed has an addiction. For the most part, they are Oral Health Program incapable of asking for or receiving help. It has been reported that suicide was Web site: ndhealth.gov/oralhealth/ actually the result of the end stage disease of addiction. Contacts: Kimberlie Yineman, Director Often the denial is broken as a result of some sort of intervention. This [email protected] 701-328-4930 can come in the form of an investigation from a state dental board, a DUI, some type of personal or professional crisis, or even a well-planned profes- Rhode Island Dental Association sional intervention. The goal of an intervention is for the dentist involved to Dentists Health have a multidisciplinary evaluation by professionals in addiction treatment Web site: www.ridental.com/councils.cfm and hopefully follow through with the recommended treatment. This is Contacts: Robert Champagne when the healing begins as the dentist begins his or her journey in recovery. 401-351-1110 Raymond George, Jr. Discovering there are other dentists in recovery is very comforting and pro- 401-434-1127 vides tremendous support for those just beginning their journeys. Most state dental associations have programs to assist dentists, dental Colegio de Cirujanos Dentistas de team members as well as family members dealing with addiction or well- Puerto Rico being issues. These programs have been in existence for many years and have Commission of Oral Health helped thousands of dentists restore their personal and professional lives. Web site: www.ccdpr.org/portada/ There exists in dentistry, as well as other professions, something called, comisiones/26 Contacts: Arminda Rivera Mora, President “The Conspiracy of Silence.” This involves knowing or strongly suspecting a [email protected] fellow dentist or even a patient of an addiction issue and taking no steps to 787-242-1187 help this person. By saying nothing or doing nothing the individual with the

continued on page 80

78 September 2011 » dentaltown.com From Portland, Maine to Portland, Oregon We list what you need

Harness the power of ADS through the Classified Ads on Dentaltown.com. Click on the Classified Ads section and search for Dental Practice for Sale. And don’t worry, all of the other classified ad categories you currently use are still there for your convenience. www.dentaltown.com/classifieds addiction feature continued from page 78

National and State Health Generally, we, (the dental profession) keep silent & Wellness Programs (continued) by rationalizing, “It is none of my business,” Florida Dental Association Florida Dental Health Foundation or, “I am not my brother’s or sister’s keeper.” Web site: www.floridasdentalcharity. org/home.jsp addiction continues to suffer in desperation. Generally, we, (the dental pro- Contacts: Thomas Norman, fession) keep silent by rationalizing, “It is none of my business,” or, “I am not Director of Charitable Affairs my brother’s or sister’s keeper.” [email protected] Most dentists and dental team members know a professional colleague or (800) 877-9922 x7166 patient who is indeed suffering from an addictive disease. The suffering col- Indiana Dental Association league might be in one’s own geographic area or even a classmate in a differ- IDA Foundation for Dental Health ent part of the state or country. Indications that a professional colleague may Web site: www.indental.org/Foundation be having an addictive disease issue is not difficult to notice. Dentists need Contacts: Ed Rosenbaum, to be diligent as well with their patient populations for those in active disease Director of Professional Services as well as recovery. [email protected] It is fairly easy to familiarize yourself with knowledge of addictions. An 800-562-5646 excellent source of information is a dentist who is in recovery. Most are very helpful in sharing their stories of addiction and the journey in recovery. Our Iowa Dental Association patients who are in recovery are also great resources. Look on the Web site of Bureau of Oral and Health your State Dental Association to see if they have information concerning well Delivery Systems being or addiction issues. I have also provided you with a list of resources you Oral Health Center can contact. Web site: idph.state.ia.us/hpcdp/oral_ health.asp If you are concerned about a professional colleague, pick up the phone Contacts: Bob Russell, Bureau Chief and call the Program Director of the Well-being Program in your particular 515-242-6383 state. The information you provide is strictly confidential. Your phone call may save your colleague’s personal and professional life. Kansas Dental Association Briefly discussing addiction in the dental profession is comparable to a Oral Health Kansas writing exercise in Philosophy 101. The assignment: “Discuss the meaning Web site: www.oralhealthkansas.org/ of life as it relates to the forces of good and evil, compare and contrast, give Contacts: Tanya Dorf-Brunner, two examples of each, and do this in 150 words or less.” This is the first of Executive Director several articles specifically on the various aspects of addiction in dentistry I [email protected] aim to write for Dentaltown Magazine over the next year. ■ 785-235-6039 Reference Maine Dental Association 1. Volkow, N. D., Baler, R.D., Goldstein, R.Z., Neuron 69, Feb 24, 2011 p 599 The Maine School Oral Health Program Web site: www.maine.gov/dhhs/ bohdcfh/odh/sohp.shtml Author’s Bio Contacts: Nicole Breton 207-287-3263 William T, Kane, DDS, MBA, graduated from the University of Missouri – Kansas City Anita Ring School of Dentistry in 1980. He maintains a general practice in rural Dexter, Missouri.In 207-287-3121 addition to practicing dentistry, Dr. Kane’s interest and passion have been in the area of recovery and wellness. Since 1987, Dr. Kane has been the Chairman of the Dentist New Hampshire Dental Society Well – Being Committee for the Missouri Dental Association. Additionally, Dr. Kane Something to Smile About.. served as a member of the Dental Wellness Advisory Committee (DWAC) with the American Dental Plan for Better Oral Health Association. Dr. Kane is very familiar with issues facing patients with addictive diseases and has Web site: www.smileplannh.org/ published and presented on these topics. He also completed an MBA in 1992 from Southeast Contacts: Jim Williamson Missouri State University. In the fall of 2010, Dr. Kane received his Fellowship in the American [email protected] College of Dentists. 603-225-5961

80 September 2011 » dentaltown.com product proﬁle

Solution21 Web site Design and Marketing Experts

Changes in the marketplace are occurring faster and faster. More and more, the working professional finds that not only must he be working constantly, but he must be constantly searching for new ways to expand his business. There’s an over- abundance of avenues for a professional to explore, but most people don’t have the time to look and find the best one that will suit them. Indeed, it seems that most of what is out there is designed with a one-size-fits-all mentality. Most service-oriented Web sites and online networks suit consumers looking for a broad range of goods and services, but what about those fields of specialty such as dentistry? This is where Solution21 comes in. Solution21 is a Web site design and marketing company geared toward professionals in the dental field. It offers a variety of features specifically tailored for dentists, dental labs, orthodontists, endodontists and other dental specialists. Many sites have do-it-yourself, Web site builder capabilities, but many of them produce cookie-cutter Web pages and lack the aesthetic and practical applications which the dental professional demands. Solution21 offers custom-made multimedia sites to its clients with exclusivity of design in their area. There are no templates. Solution 21 allows its clients to create a custom site from scratch. The client is in control, and can design a site that suits his needs and tastes. But a nice design isn’t enough. Advances in the online marketplace dictate that every Web site has to be an experience. Keeping that in mind, the staff at Solution 21 can create custom flash animation effects, making each Web site a unique experience for the online viewer. With more than a million visits to their clients’ Web sites, they are well on their way to doubling that number. More and more, video presentation is playing a bigger role in generating business online. Video presentation is no longer a luxury, it is a necessity. Merely informing a potential client of a service is not enough; that service must be shown to them. Solution21 offers a variety of video options from patient education videos, to walk-on spokesperson introductions, to in-office video showcases. Using professional actors and filmmakers, Solution21 can produce slick and accessible videos for any dental practice. Of course, none of this means anything if viewers don’t know a Web site exists. Solution21 will guarantee first-page placement on search engines for a flat fee. This is done in three steps. First, Solution21 will utilize search engine optimization in the form of Web site content, links and meta-data management to attract consumers to the client’s Web site. Second, the client’s Web site will be added to local listings on Google, Bing and Yahoo, thus ensuring that individuals working or residing within the client’s geographical area are notified of the dental practice and its contact information. Third, Solution21 will create accounts on Facebook, Twitter and Blogger, creating a presence and brand identity on the social networking platforms. This is combined with paid advertising to guarantee exposure. As the landscape in the marketplace continues to evolve, the practice of dentistry is becoming more and more competitive. With more avenues for growing a business, it’s imperative that those in the dental field utilize these new tools in such a way that will serve them best. Experience is key, and every dental professional owes it to his/herself to maximize business as effectively as possible. With Solution21 at your side, your future success is assured. n

dentaltown.com « September 2011 81 cosmetics feature

and other dental therapeutic uses of Botox and dermal fillers by Louis Malcmacher, DDS, MAGD The use of botulinum toxin and dermal fillers is one of the thetic dentistry cases as an alternative to gingivectomy, fastest growing areas of dentistry. While a few years ago, their use crown lengthening and veneers in dentistry was limited, at this point more 35 states allow the • Treatment of angular chelitis use of these materials for both aesthetic and therapeutic uses. At • Eliminating “black triangles” between teeth after periodontal the American Academy of Facial Esthetics, in the last couple of and implant treatment that did not preserve the papilla years we have trained more than 5,000 dental professionals from • Re-establishing lip volume for proper phonetics (in addition 46 states, all the Canadian provinces and from 28 countries or as opposed to teeth lengthening with fixed or removable around the world in these procedures through lectures and prosthodontics) hands-on courses. • Adding lip and peri-oral volume around the mouth for reten- There is no question that Botox and dermal fillers are well- tion of removable prosthodontics known for the aesthetic results they deliver in terms of smooth- In terms of these therapeutic uses stated, nearly every state in ing wrinkles and replacing lost volume in the face, especially the the United States and Canadian provinces allow the uses of Botox oral and peri-oral areas. Botox and Dysport are essentially mus- and dermal fillers because they are used for the practice of dentistry cle relaxers and dermal fillers, such as Juvederm and Restylane, as defined by the dental practice act. Many of these therapeutic uses are volumizers or plumpers. Once you have been trained on these of Botox and dermal fillers are exciting for dental practitioners procedures and thoroughly understand the anatomy, physiology, because they will help tackle some of the most difficult clinical sit- pharmacology, adverse reactions, etc., then you will find many uations that we often are confronted with. therapeutic uses in dentistry for both functional and dental aes- As an example, TMJ and facial pain have haunted dental prac- thetic purposes. titioners for years and are among the most frustrating cases we deal Now that dentists have been integrating these procedures into with. We, as dentists, have concentrated our treatment on the their offices, we continually find many exciting therapeutic uses to occlusion and teeth first and the muscles later. It is now time to clinical dental situations that have frustrated us in the past and we completely rethink this treatment progression. Now, using Botox had no decent way to address some of these clinical problems. therapeutically for facial pain and TMD, we can eliminate the pain Here are a few examples of therapeutic uses for Botox and der- coming from the muscle pathology first, and then we may go ahead mal fillers: and treat the occlusion or the actual joint much more easily and Botox dental therapeutic uses include: accurately than before. • TMD cases The dreaded “black triangle” usually tops the list of dentists’ • Bruxism and clenching cases frustration after the placement of crowns, bridges and especially • Facial pain cases including treating trigger points implants or after periodontal surgery. After treatment, the patient • Treatment of angular chelitis finally has a healthy periodontium or a nice new tooth surrounded • Gummy smile cases by two big black holes on either side of it, which the patient whis- • Orthodontic relapse and depressed orthodontic appearance tles, spits through or catches food in. While the patient should be • Reducing muscle hyperactivity for retention of removable thrilled that he doesn’t have to wear a flipper any more, he is disap- prosthodontics pointed at the aesthetic results because of the lost tissue. What are Dermal filler dental therapeutic uses in the nasolabial folds, our options? We can bond to adjacent teeth. We can redo the lips, mentalis fold and labialmental folds is used in the following: crown, remove the implant and try again with a new implant or • Gummy smile cases other frustrating treatment options that are very aggressive which • Establishing aesthetic dental lip lines and smile lines in aes- might or might not work. The placement of dermal fillers in these

82 September 2011 » dentaltown.com feature cosmetics

areas to literally plumb up papilla is a minimally invasive way to Fig. 1 create proper gingival contours. Let’s take a look at this case. Figure 1 shows the pre-op photo of a patient who has two all-ceramic crowns (e.max, Ivoclar and done by Aurum Ceramics Laboratory) on teeth #8 and 9 and some beautiful no/minimal prep Cristal veneers (Aurum Ceramics Laboratory). The crown on tooth #9 is loose and the radiograph in figure 2 shows the tooth has fractured at the gumline. Figure 3 shows the successful integration of a Nobel bone level implant and the new implant restoration in place. The dreaded “black triangles” in figure 4 (next page) is one of the most challenging aesthetic Fig. 2 Fig. 3 problems we deal with. We have a beautiful new crown but as you know, the full aesthetics depends on both the tooth and the soft- tissue integration, which is lacking here. Compare that to her original pre-op picture again in figure 1 and you can see why it bothers her. In addition, food collects in these areas and when she speaks, she finds herself spitting. She loves and hates her new implant crown, all at the same time. In figure 5 (next page), we treated her with a diode laser (Picasso Lite, AMD Lasers) to loosen the gingival attachment. We used 1.8 watts of power and placed the fiber tip into the sulcus. We initiated power and angled the tip into the thickest part of the interproximal tissue for a half second. We angled the tip in the fan-

continued on page 84

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dentaltown.com « September 2011 83 cosmetics feature continued from page 83

Fig. 4 Fig. 6

Fig. 5 Fig. 7 Fig. 8

ning motion three more times and intiated the tip as before. This having full lip competency, proper lip and smile lines and an aes- creates some space with the interproximal tissue. We then placed thetic result that will rival any of the other dental options with- some dermal filler (Juvederm Ultra Plus XC, Allergan Corporation) out picking up a drill or scalpel. While this treatment will need to into the papilla to rebuild it. Figure 6 shows the rebuilt gingival be repeated over time, the use of Botox and dermal fillers for the papilla which fills up the black triangles and takes care of her aes- use of soft- and hard-tissue dental therapeutic aesthetic cases is as thetic and functional concerns. The treatment appointment was much dental treatment as any of the other options previously quick and she can expect this outcome to last for eight months or mentioned. longer, at which point it will need to be repeated. This is a very It is our legal and ethical duty to give patients all of the options minimally invasive approach to a very difficult situation. It was available for their dental treatment. In this day and age, to do that, accomplished in a six-minute appointment. we need to get trained in the use of Botox and dermal fillers, as This author along with others have also successfully used Botox these are well-established, viable dental treatment options. The and dermal fillers intra-orally to correct other soft-tissue and mus- treatments described in this article clearly fall under the definition cle-caused deficiencies. of dentistry in nearly all of the state dental practice acts. Now that One more example is the patient with a gummy smile (Fig. 7). dentists understand the use of Botox and dermal fillers in dentistry If you look carefully you will see that this patient has an asymmet- for therapeutic and dental aesthetic cases and have become profi- rical gummy smile. What are our choices here? Orthodontics is a cient in their use through proper training, we can offer them in choice, but that is an orthodontic case that most orthodontists conjunction with or in addition to our current treatment options. don’t even want to tackle. We could send this patient to an oral sur- Botox and dermal fillers are here to stay and with more and geon to accomplish a maxillary Lefort I fracture and physically more intra-oral uses of these materials, they are fast becoming a move the mandible up and then hope the mandible occludes into integral part of every dental practice with ramifications in restora- it. Certainly, the way most dentists would treat this is with surgical tive, aesthetic, periodontal, orthodontic and prosthodontics impli- osseous crown lengthening, followed by crowns or veneers. cations. These procedures are the fastest growing area of dentistry Now we have a proven and safe minimally invasive option with the most significant, minimally invasive, therapeutic and with an appointment that takes 15 minutes and the use of Botox aesthetic outcomes available for many everyday clinical situations. and dermal fillers. Figure 8 shows the patient post-operatively Get trained today! ■

Author’s Bio

Louis Malcmacher, DDS, MAGD, is a practicing general dentist and an internationally known lecturer, author and dental consultant. An evaluator emeritus for Clinicians Reports, Dr. Malcmacher is president of the American Academy of Facial Esthetics (www.facialesthetics.org). You can contact him at 440-892-1810 or e-mail [email protected]. His Web site is www.commonsensedentistry.com, where you can find information about his lecture schedule and Botox and dermal fillers training, download his resource list and sign up for a free monthly e-newsletter.

84 September 2011 » dentaltown.com equipment feature

Two major fears middle-aged dentists face today are first, not being able to save enough to protect their lifestyle in retirement and second, practicing in an office with antiquated equipment. How can one reconcile spending a bundle on state-of-the-art equipment with the need to save that same bundle on retirement savings?

Must Haves There is high-tech equipment that you must have in today’s world in order to be relevant, regardless of price. • Digital Radiography Examples: Dexis Platinum, Schick CDR Elite; $20,000 to $30,000 for use in four to five operatories. It’s become the standard of care and more and more patients demand it. • Intra-oral Cameras Examples: Acucam Concept IV FWT, Digital DOC Iris; $13,000 to $20,000 for individual cameras in four operatories. This tool has been the best diagnostic and treatment planning dental tool for 20 years. Make sure you have easy access to a camera in every hygiene room by Douglas Carlsen, DDS and at least one doctor operatory. • Isolite Price for two is around $3,500. The high-tech answer to rubber dam. Makes your life easier and faster. Just using this might pay for the rest of the equipment on the “must-have” list. • SLR Digital Camera A Canon EOS T2I with macro, ring flash and other goodies costs between $2,000 and $2,500. If you do any cosmetic dentistry, and we all do, an SLR camera is a must. I don’t care if you rob your children’s college funds (don’t touch that IRA!) or stand on a street corner on weekends spinning signs. You need the above equipment now! To take out a $50,000 10-year loan at eight percent comes to $600 per month. Keep your cars an extra two years and you’re even after 10 years. And don’t scrimp; get quality products.

continued on page 88

86 September 2011 » dentaltown.com

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For Additondditonal Information visit WWW.WWW. GNYDMGNYDM.COMCOM equipment feature continued from page 86

The Big Kahuna’s Equipment And now, the most often cited items on a dentist’s fantasy wish list: • CAD/CAM impression and restoration production Examples: Sirona CEREC, Henry Schein E4D; $120,000+ •CBCT(cone beam computed tomography) Example: Gendex GXCB-500HD, Sirona Galileos; $150,000+ • LANAP Protocol (laser-assisted new attachment procedure) – Nd:YAG Laser “An additional Example: PerioLase MVP-7; $40,000+ $2,500 to $3,000 There are additional items, such as dental microscopes, caries detectors, loupes and many soft- and hard-tissue lasers that one might find on the cocktail party “hot per month payment topic” list. Can a dentist afford any of the above? Let’s analyze the situation from three view- becomes a night- points: the doctor’s debt structure, return on investment and the thrill.

mare if the dentist Debt Structure is out of the office Brian Hufford, of Hufford Financial, recommends the following percentages of a dentist’s net income for large purchases and debt structure.1 for an extended Loans: 25 percent for all personal and practice loans. period due to Large purchases: Five percent of personal income. This includes personal and practice purchases of anything more than $3,000. illness or accident.” Debt Structure: If all practice and personal monthly loan payments are more than 0.8 percent of your total practice and personal debt, you are sacrificing your ability to save by paying debt too quickly. For a dental family with a net income of $250,000, large cash purchases must be no more than $12,500! Therefore, a cash payment makes no sense. Of course, a dentist would normally take out a lease or loan for large purchases. As indicated above, one still needs all practice and personal loans to total only 25 percent of net income. For a typical dentist with a net income of $250,000, this means all loans, from home mortgage, cars and practice must be $5,200 per month or less. Also, savings for retirement needs be in the 15 percent range, or $3,000+ per month. With CAM/CAM and CBCT leasing at $2,500 to $3,500 per month, the burden of new equipment seems impractical. Unless…

Return on Investment If the equipment provides a quick positive return on investment, I’ve always been in favor of purchase. In this case, one can bypass the above debt paragraph and go for it! I would caution most dentists to take on an additional large payment, even if you’re certain you’ll cover that payment. Only after practice and student loans are paid off or an emergency fund of $100,000 is available should this be an option. An additional $2,500 to $3,000 per month payment becomes a nightmare if the dentist is out of the office for an extended period due to illness or accident. Let’s look at actual Dentaltown threads to shed light on CBCT, LANAP and CAD/CAM. CBCT: Posted by Dr. Jay Reznick 6/24/2011 My monthly payment is about $3,500 per month. I do about 30 to 40 CBCT exams per month (on a 3.5 day work week). I charge $195 for most scans. That is $5,850 to $7,800 per month income... …My case acceptance rate is higher, because I do not need to send the patient out for a scan, and then reschedule them to review it. Patients love the convenience, and I love the higher patient follow-through rate. My surgical time is cut in half, allowing me to

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88 September 2011 » dentaltown.com General Dentists CAN do Ortho

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schedule more surgeries each day. This is where the profit from having the CBCT happens. All in all, investing in CBCT technology is one of the best things that I have done in my practice. Bottom line from reading many threads: CBCT is a wise investment for those com- “Purchasing CAD/ mitted to a practice stressing placement and restoration of implants or for those who do CAM or any high- extensive orthodontics. LANAP: tech equipment Posted by Dr. Charles Payet 3/4/2011 without proper Let’s use my PerioLase payment as an example: • $1,500 per month payment training is a recipe • Average case fee $4,000 • Average three hours of time for LANAP (one should also figure the time “lost” in follow- for disaster. It up appointments. would be like • Let’s assume $400/hour overhead (mine’s actually lower than this, but for easy numbers) not including the laser = $1,200 owning a Ferrari • Roughly that’s $1,300 profit, or $433 profit/hour on the first case each month and never really • On all subsequent cases per month, since the laser cost is already covered, that’s $2,800 profit, or $933 profit/hour. driving the car out Bottom Line: The positive return on investment threads out-number the negative about 20:1. This one looks like an easy positive ROI. of your driveway.” CAD/CAM: There are many threads analyzing the number of units necessary to manufacture per month to break even, comparing the monthly CAD/CAM lease with blocks and other supplies to a typical lab fee. Consensus is that the break-even point appears to be some- where between 15 and 30 units, depending on the price of your typical lab fee. For additional thoughts on financial issues related to CAD/CAM and CBDT, Dr. Sameer Puri, director of CAD/CAM Dentistry at the Scottsdale Center and co-founder of www.cerecdoctors.com, offers comments.

Carlsen: For someone wishing to provide CAD/CAM restorations and have a positive return on investment quickly, how should that dentist stage purchases, education and promotion? Puri: Purchasing CAD/CAM or any high-tech equipment without proper training is a recipe for disaster. It would be like owning a Ferrari and never really driving the car out of your driveway. Having said that, the newer generations of CAD/CAM machines have made the process much easier than before. Now, most doctors can do basic stuff right out of the gate and the training is there to fine-tune and simplify the procedures. With regards to staging, through my own experience as an advanced trainer who has trained thousands of doctors through our CEREC Training Web site, my recommendation is to get basic training within one week of purchasing the machine. Then I would recommend supplemental (intermediate/advanced) training within 90 days. We have a whole series of courses that teach quadrants, anteriors, bridges and more. When a dentist can now do one’s own bridges, implant abutments and smile makeover cases in house, I would argue that the training is definitely worth the investment.

Carlsen: Please discuss the financial value of also incorporating CBCT with CAD/CAM. Puri: The integration of CEREC and Galileos allows you to virtually plan your case on the CEREC, take the restoration that you designed and put it on the patient’s 3D X-ray data. This shows you where your planned final restoration would be in relation to the patients bone, tissue

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90 September 2011 » dentaltown.com Exclusively Distributed by equipment feature continued from page 90

and other vital structures. The data is then used to manufacture a surgical guide that will allow the placement of the implant exactly under your planned restoration. The fact that this can be done in just a few minutes in front of the patient is a great educational tool and a great case presentation aid. Increased financial return to the doctor is gauged in several ways: 1. increased case acceptance 2. ability to diagnose and treat more comprehensively 3. wow factor and marketing 4. decreased cost for surgical guide and diagnostic wax-up

The Thrill A huge reason to consider the above equipment is the dentist’s wants. Dentists have literally transformed their practices overnight with CAD/CAM, CBCT and LANAP. Dentists have also gone broke after purchases like these. What’s the difference? In talking to many dentists of all ages, the answer is commitment to the technology. Ongoing excitement and engagement are essential. In 1992, I made a total commitment to a technology that showed little chance for a positive return on investment and wasn’t new or sexy. It was a commitment to precise gold castings. How in the world did I sell that? Easily, by letting patients know and feel that I provided the best. And I retired early in 2004 due to that commitment. Plan your purchases, docs. For intra-oral cameras, for example, provide a half-day of training for you and your staff, either with a manufacturing rep or equipment tech. Learn how to take photos, how to print and how to present your findings to the patient. Make sure all clinical staff can use it efficiently. Have a review meeting a week or two afterward. Other equipment, such as CAD/CAM often involves a total change of practice direc- Author’s Bio tion and vision. This has changed doctor’s lives! Continuing education and product Douglas Carlsen, DDS, owner updates are essential, yet the doctor and staff often display the “We’re the best” attitude. of Golich Carlsen, retired at Patients feel the excitement and tell others. age 53 from private practice In the end, the thrill often overshadows any debt structure and return on investment and clinical lecturing at UCLA calculations. Yes, this from the finance and math geek! School of Dentistry. He writes and lectures Buying Don’ts nationally on financial topics from the point of view of one that was able to retire early Don’t buy just because you think you should use a new technology. on his own terms. Carlsen consults with Don’t buy because you can fully deduct using Schedule 179. Remember, you will always dentists, CPAs and planners on business receive the full deduction spread over several years. Those who profit from this deduction systems, personal finance and retirement have very special financial cases and need CPA analysis. Those who purchase because of tax scenarios. Visit his Web site: www.golich problems without tax advice normally end up with even larger cash flow problems. carlsen.com; call 760-535-1621 or e-mail Don’t (blindly) buy used. There are definite bargains out there. I question, though, the at [email protected]. sagacity of paying a large amount of cash for an item that might be antiquated. You might be handicapped in not having a product that is easily upgradable. I’m also not sure that purchasing used shows the level of commitment that buying new does. And yes, this is from the guy that rarely buys a new car!

Final Thoughts In the end, the doctors who thrive are the ones who totally commit to their technologies with a fun attitude. Take course updates, follow Dentaltown threads, use Facebook and Twitter for quick comments. Engage your passion! Have all staff attend promotional and educational meetings. Be proud and show off your technology! ■

References: 1. Brian C. Hufford, CPA, CFP, “An Economic Survival Guide -- Move Toward Your Fears -- Not Away,” AGD Impact, January 2009.

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by Diwakar Kinra, DDS, MS

The molar root canal is probably one of the most challenging Properly opening the pulp chamber will allow you to follow the procedures in dentistry. Proper planning can help reduce the frus- “map” on the floor of the tooth to guide in canal location. tration many of us feel when a difficult case presents itself in our Entry Angle – This concept refers to the dentinal triangles schedule. There is a twofold process when performing a root canal. which are evident at the cervix of the tooth. Realizing these exist First is the mental preparation needed to execute and secondly is and removing them allow for easier access into the canals. the technical tools needed to prepare. Canals, Curvature and Calcifications – As you are working your way down the tooth notice the number of canals/roots Mental Preparation (always search for as many as anatomy allows). Degree of root Before beginning any procedure, I perform what I like to call curvature and width of canals should be focused on before picking my “Kinra Kwik Glance.” This is simply a 30-second examination up a drill. of the radiograph to mentally prepare myself for the challenges Straight Line Access – The goal of the “Kinra Kwik that lie ahead. I visualize the tooth from cusp tips to the apex. Glance” is to obtain foresight in achieving straight line access. This short amount of time could save you tremendous time, Removing impediments on the glidepath will allow for faster effort and frustration during the procedure. By making this a rit- determination of working length. Clinicians should know they ual and remembering the acronym A.P.E.C.S., it might make have achieved this when the file is taken to working length and some of your cases easier to navigate. then stands straight up. Therefore, the file’s reference point is A. Angulation the same cusp as the canal that is being cleaned and shaped. P. Pulp Chamber Previously it was always taught to get working length with E. Entry Angle hand files before proceeding with the remainder of the root C. Canal, Curvature and Calcifications canal, via rotary instrumentation. It was almost a “race” to the S. Straight Line Access apex. Now, modern thinking tells us to pre-enlarge the coronal Angulation – This can be determined with at least two prop- aspect of the canal to improve straight line access. This removes erly taken radiographs. Taking note of the long access of the tooth the triangles, corrects the entry angles and decreases the cur- and/or rotations will decrease the likelihood of mishaps early on vatures, which allow for straighter access to the apex. Taking in the procedure. This will allow you to determine the correct time in the beginning of the procedure to do this will make angle to access the tooth. cleaning and shaping easier and faster with many rotary Pulp Chamber – Examining the pulp chamber for calcifica- endodontic systems. Before, achieving working length was tions, chamber height and pulp stones will help recognize done with mostly hand files. Now, this concept is being mod- whether you are “unroofing” the chamber or perforating the floor. ernized with the PathFile.

94 September 2011 » dentaltown.com feature endodontics

Technical Preparation Keeping these points in mind throughout the procedure will The newest and most revolutionary change to glidepath man- allow you to focus on the end product: a clean, well-shaped and agement is the PathFile (DENTSPLY Tulsa Dental Specialties). successfully obturated root canal. This single class of instruments has changed my practice After locating canals, I placed a slightly bent #10 C-file into tremendously in the past six months. The ability to negotiate the canal and went down approximately 16mm, rinsing copiously canals has been simplified to just three files. It helps produce with sodium hypochlorite after every file placement. Following a wide open glidepath to assist in determining a quick working the rinse, I placed purple rotary PathFile to 16mm followed by a length. Once this is achieved, your rotary instrument(s) of white rotary PathFile to the same length. Next, a #10 C-file was choice can be used quickly to shape the canals with less fear negotiated to working length. After confirmation with an apex of breakage, unwinding or other mishaps normally associated locator, I enlarged the glidepath with PathFile series with mechanical treatment. (purple/white/yellow) and reconfirmed working length with a The method described below is how I use these files when a #15 handfile. The working length was set at 24mm and I pro- difficult molar presents with calcification and curvature. ceeded to clean and shape with the ProTaper Universal rotary sys- Step 1: After location of canals I place a slightly bent #10 tem (DENTSPLY Tulsa Dental Specialties). C-file into the canal and go down the canal approximately two- This initial glidepath preparation allowed for the remainder of thirds of the way. Rinse. the root canal therapy to be stress free. What previously took 10 Step 2: Place purple (ISO 13) rotary PathFile to the same to 15 minutes, now takes three to five minutes and without sac- length. Rinse. Negotiate white (ISO 16) rotary PathFile to same rificing efficacy. This new method not only allows for more pre- length. Rinse. By pre-enlarging the coronal two-thirds of the dictable glidepath management, but the savings in time will allow canals, steps 3 and 4 will be quite simple. for a more productive practitioner and satisfied patient (Fig. 3). ■ Step 3: Place #10 C-file to working length. Confirm with apex locator. Rinse Step 4: Enlarge glidepath with PathFile series (purple/white/ yellow). Rinse. It’s at this point that we can reconfirm working length with a #15 handfile. Achieving working length should take less than three minutes total. This initial preparation of the glidepath will now allow for a smoother transition to any rotary instrumentation series of choice. After using this sys- Fig. 1: PathFile NiTi rotary instruments (DENTSPLY Tulsa Dental Specialties). tem in 100 cases I have not seen any file breakage. There has PathFile 1 (Purple) tip 013, PathFile 2 (white) tip 016, PathFile 3 (yellow) tip 019 taper .02. Endodontic engine setting: 300rpm, torque 5-6 N/cm. been unwinding of the files, which were then easily discarded. There has been reduced unwinding and breakage of my rotary instruments (ProTaper Universal) since implementing this method in my office.

Case Example A patient presented to my office for root canal therapy on tooth #30. After proper diagnosis, the patient was anesthetized. Before rubber dam placement, the “Kinra Kwik Glance” was Fig. 2 Fig. 3 performed from cusp tip to apex. The major alerts that were noted (Fig. 2). Angulation – No major angulation or rotation issues. Author’s Bio Pulp Chamber – Slight chamber recession, and possible pulp Diwakar Kinra, DDS, MS, received his dental degree stones at distal aspect of the chamber. from the University of Michigan School of Dentistry and Entry Angle – Difficult entrance associated with the mes- his master’s degree in endodontics from the University of ial canals. Detroit – Mercy School of Dentistry. He lectures globally Canals, Curvature and Calcifications – Canals appeared on endodontics and practice management. He is in private calcified, long and moderate degree of curvature. practice limited to endodontics in Flint, Michigan. Contact him via Straight-line access – Mesial cervical triangles will need to be www.kinraendo.com. removed for proper access to the apex.

dentaltown.com « September 2011 95 dentaltown research

Dentaltown Research: Restorative Dentistry

Dentaltown is digging a little deeper. Based on the monthly poll on Dentaltown.com we’re determining explanations for each poll result. Included with the poll statistics are the most popular write-in answers as well as small fun facts and recaps of the Townie Choice Award winning categories that coincide with our research topic. Don’t forget to participate in the poll on Dentaltown.com each month. The more opinions you can provide us, the more information and statistics we can supply to you. The following poll was conducted from July 1, 2011 to August 4, 2011 on Dentaltown.com.

Do you think porcelain fused to metal crowns will be completely replaced by metal-free? 632 total votes 54% What percentage of the time do you use No a rubber dam for restorative treatment? 63% Rarely 20% Sometimes 17% Majority of the time 738 total votes

Which of the following is most challenging with Class II composites? 46% 10% Post-op sensitivity Yes 4% Shade match 69% Interproximal contact 17% Other 733 total votes

13% More than What do you tell patients when they ask about 63% 10 years Six to the life expectancy of a composite restoration? 10 years 733 total votes A similar question was asked in a poll conducted in March 2010 What is the life expectancy of a Class II posterior composite restoration? 24% 749 total votes One to 6% One to three years 38% Eight to 11 years five years 42% Four to seven years 14% More than 12 years

96 September 2011 » dentaltown.com dentaltown research

How much time would you schedule to complete three Class II composites on the lower right? 18% 30 minutes 58% 60 minutes 24% 90 minutes 729 total votes

Dam History The rubber dam was first developed How long have you been using your current by Dr. Stamford Christie Barnum of bonding agent? New York in 1862. 8% Less than six months 9% Six months to one year Golden Factoids 23% One to two years Name: Gold 60% More than two years Symbol: Au 729 total votes Atomic Number: 79 Melting Point: 1064.43°C (1337.5801 K, 1947.9741°F) Have you seen an increase in direct Boiling Point: 2807.0°C restorations over the last 12 months? (3080.15 K, 5084.6°F) 48% Yes 52% No 730 total votes

Have you placed any gold Restorative Dentistry: 2010 Townie Choice Award restorations in the last Winners Recap 12 months? Bonding Agents: Clearfil SE Protect – Kuraray America, Inc. 720 total votes Composites – Anterior: 3M ESPE – Filtek Supreme Plus Universal Composites – Flowable: 62% 3M ESPE – Filtek Supreme Plus Flowable Yes 38% Composites – Posterior: No 3M ESPE – Filtek P60 Bonding Agents: Coltène/Whaledent, Inc. – Hygenic Dental Dam * Check out the December 2010 issue to see the additional winners in the Restorative Dentistry category.

dentaltown.com « September 2011 97 ofﬁce design feature

Why renovating your office with the latest and greatest will benefit you and your clients.

by Shelby Stevens

You might think you’re saving money or being “economical” by keeping your office and its décor as it was when you first opened 20 years ago, but the truth of the matter is that you might actually be losing clients and preventing new ones from coming in. By investing in the appearance of your office you’ll reap some major benefits and be able to show your clients that you care and you know how to evolve with the times, in turn growing your practice and reputation. Talk about being economical.

Who Cares? Renovating your office isn’t only about being able to show up to work in a fancy environment and showing your clients you have good taste, it’s about creating a positive space for your staff and clients so that they feel confident about the space too. It’s also about keeping up to par with the latest technologies and advancements in your field and beyond. “If your office is pink and mauve, and hasn’t been updated since 1975, what do you think your patients will think about you? They’ll wonder if your services are as old as your practice is,” Joey Wenum, vice president of sales and marketing of Blue Frog Construction points out. “Even if this isn’t the truth, that perception will be there.” When your clients see you’ve invested time and money in your own practice and work- space, they will then surmise that you’re a dentist who stays in touch with the latest trends. This will, in turn, lead them to trust you even more. And like a domino effect, this will encourage your internal referral base to grow extensively. continued on page 100

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ofﬁce design feature continued from page 98

“Just like when choosing a restaurant, you don’t want to go to the old run-down place that seems dirty and old, you want to go to the new place down the road that has the latest stuff,” Mike Rubio, vice president of operations of Blue Frog Construction says.

The Important Stuff There’s more to renovating your office than just creating a more visually appealing place – it’s also about renovating your equipment, technologies and more. The typical design of a dental office has evolved greatly in the last 20 years and has become much more efficient, so check into what you’re missing. One particularly important rationale to update your office revolves around the materials and chemicals that are currently present. Some materials used 15 to 20 years ago are likely highly toxic. For example, your cabinetry and the glue used to “Renovating is all about secure it can carry formaldehyde; your flooring and ceiling might have asbestos; and mercury has often been found in older lighting and ballasts. By keeping these being able to build out and never updating, you’re subjecting yourself, your staff and each person who walks through your doors to unwanted health problems such as asthma attacks, your office for state-of- mesothelioma and more. the-art equipment, and HVAC systems are also much more efficient than the setups from years ago. If you notice your staff getting sick fairly often, taking sick days or not feeling well that is what your patients while at work, get the air system and its quality checked. want to see. They appre- Newer HVAC and lighting systems also save a great deal of money, not to mention the hefty tax credits that are available. If your systems haven’t been renovated ciate that you stay up- in the last 10 years, you might be paying almost five times what you could be. Another important factor in updating your space is making sure that it’s ADA to-date with the latest. (Americans with Disabilities Act) compliant. If someone who is handicapped gets We want to provide for hurt in your office due to a rule not followed on your part, that’s means for a law- suit. This isn’t the best way to be economical! Examples of elements amidst your our community the office and property that need to be checked based solely on wheelchair accessibil- ity are the widths of doorways, counter heights and access into and throughout the utmost quality dentistry. building if there are steps and multi-levels. Other components to consider are levers It’s been my dream to on door knobs and fire exits and proper and accessible exits in the case of a fire or any other emergency. have massage chairs You should also consider ergonomics. For instance, how many steps does it take to get to a specific area? Let’s say 10 for the sake of example. Now, multiply that and TVs with head- number by how many times you make that trip each day, multiplied by five days a phones for patients to week and so on. Is this the most efficient way for this task to be done? Or can the sanitation devices be located closer to each dental chair? The printer closer to the listen to and not the drill.” computer? Think about your charts and patient information as well. Do you still use all paper files and have them located in file cabinets spread from room to room — Dr. Daryl Kimche throughout your office? Consider going paperless and switching to electronic Kimche Cosmetic & Sports Dentistry records – it’s much more eco-friendly, takes up virtually no space and is literally Atlanta, Georgia right at your office staff’s fingertips. Renovation performed by Blue Frog Construction of Suwanee, Georgia. Time is Money When it comes to the scheduling of your renovation, be sure to go over this in depth with your contractor before the first nail is hammered. If you chose the best contractor for the job from the competitive bidding stage you’ve already gone through, you should have one who will work with you closely to ensure your practice is closed for a minimal amount of time, if at all. Typically, it’s ideal for you to be able to shut your practice down for roughly a week. If you think there are certain clients who just can’t go without their exam

100 September 2011 » dentaltown.com feature ofﬁce design

being performed in that specific time frame, get in touch with your peers. If you have a good relationship with fellow dental professionals, they will usually allow you to take a few clients in their facility to keep you going and occupied. “Allot yourself time to renovate,” Rubio says. “Don’t expect it to happen overnight.” Of course, contractors can work with you to not only work during the day, but to actually work overnight as well. You can get the work to take place on a 24-hour scheduling plan by shutting down for a short period of time, allowing the work to be fulfilled day and night to ensure it’s completed by the date originally stated. Another option is to attempt doing the renovation in stages, although this is the least efficient way. This process will not only take longer but cost more, too. The benefit to this type of schedule is that you’ll be able to keep your practice open each day with normal hours, sparing no time with your patients.

Aesthetically Speaking It’s a good idea to renovate and update your dental office every five years. If you feel as though this is too extensive and you don’t think an entire renovation is needed, at least consider updating the aesthetics. Keep in mind, too, that the life expectancy on the flooring in a commercial setting is roughly seven years. As you gather ideas and samples for the interior décor of your soon-to-be freshly rejuvenated office, it’s highly recommended to hire a professional for this feat. Many non-interior design professionals try to take this on themselves but have a difficult time getting it right and connecting with their clients and patients in this way. You want to create a warm and welcoming environment, giving your patients a sense of comfortability and positivity. Remove yourself from the equation and trust a designer to give you what your clients want – it’s his or her job to know what that is and give it to you.

Great and Not-so-great Expectations There are some things you should learn to expect when it comes to construction inside your office so you can prepare for what’s to come. Hire a local dental company to move your equipment out and back in. You don’t want to rely on your contractor and employees to handle this because it’s a large liability. Consult with a low-voltage company to update your computers, networking systems, phones, data, TVs, and audio and video entertainment. Also, as Rubio points out, don’t be afraid to think outside of the box. Whether you realize it or not, your staff has ideas and expectations for their work environment also and, if asked, many of them will more than likely have a number of negative comments about their currently outdated office.

What Are You Waiting For? By taking the time to create an environment that is pleasing to you, your staff and your clients, you’re creating a win-win situation. “The emphasis is to create a warm and welcoming environment that will reduce the stress of your patients and the add-benefit is a happier staff with increased productivity,” Wenum points out. Think of it this way: if you don’t do it, the next guy will. n

Author’s Bio

Shelby Stevens holds a Bachelor’s degree in Journalism and History from Georgia State University. She has been published in multiple magazines, such as the local Atlanta publications Jezebel, Tuxedo Road and Atlanta Home Improvement. She currently resides in Atlanta where she is a writer and works in retail advertising.

dentaltown.com « September 2011 101 point counterpoint

Headlamps or track lighting – that’s what we’re talking about today. We all have our own preferences, and there are noted pros and cons to every option. We’ve taken a pro-headlamp message board and paired it up with an article on track-lighting benefits. Read both and jump back on the message boards of Dentaltown.com to tell everyone which camp you’re in. Operatory Lighting: Controversies and Opportunities

by David J. Ahearn, DDS

In dentistry, new technologies bring with them challenges that shape the future of what dentistry is and how dentistry is delivered. There are tipping points that occasionally make change occur rapidly and, more commonly, gradual changes where new technologies are assimilated into the old. Over the coming years, lighting will be one of those areas of change.

History The history of lighting in dentistry reflects that of lighting technology in general. From its inception, electric lighting technology has been good at general lighting and less so at point source illumination. Further, lighting has historically been extremely inefficient with much of the energy used to produce light being wasted as heat. Lighting is responsible for 35 percent of the energy cost in a typical inefficient office.1 It can be even greater in hotter climates, when the extra cost of air conditioning is factored in.

If you have Rules dedicated hygiene A further challenge in lighting design relates to the much quoted “accommodation ratio,” which states that the ratio between direct lighting (the light that is directly placed rooms, never do upon a task) and ambient lighting (the general room light) should be no more than 3:1.2 assisted procedures This would mean that for a room illuminated to a recommended level of 300 footcandles (fc) of general lighting, the intraoral light level would be no more than 900 fc. In today’s there and all doctors world, this is significantly and unrealistically low. The least powerful dental light is rated at 1500 fc (at 700 mm focal distance) and many dental headlights have illuminations wear headlights, approaching 3000 fc, so no effort at satisfying this lighting requirement will ever be success- you certainly can go ful. A treatment room with a background light level of 500 fc would be uncomfortably bright, considered over-lighted and would likely exceed electrical power density standards headlight only here. of most state energy codes.

1. 2005 Buildings Energy Data Book 2. Dental Clinics of North America, 1978

102 September 2011 » dentaltown.com point counterpoint

This is the reason why headlight and microscope users often have trouble seeing out- Fig. 1 side the oral cavity during treatment. The contrast ratio is simply too great to permit rapid iris adjustment.

Choices With so many negative feelings about lighting and its costs, it is not surprising that the advent of improving technology in loupes and head lighting would lead to the concept that dental intra-oral lights could be replaced by headlights completely. Indeed, we see a number of practitioners around the globe are experimenting with headlights-only practice. The potential benefits of a headlight-only practice are clear: reduced cost and simplified operatory setup. This type of practice should be considered for startup and perhaps for high volume, high room count offices. Certainly if the cost savings in lights permits the addition of two more rooms, then the economics might dictate this, at least in the start-up phase. Unfortunately, rarely is the lighting so costly as to eliminate the funding of more than one addi- Fig. 2 tional room, at which point the benefits become less clear. Furthermore, converting to headlight-only practice does present other problems. First and foremost is what to do about the assistants. The solution here very much depends upon the degree to which assistants in your practice actually provide care. If the care provided is limited to logistics and custodial care (moving patients and sucking saliva), lights might not be required. However, if their practice includes fabricating temporaries and prophy polishing, you will need to outfit them with lights, and this most commonly means loupes as well. This diminishes cost savings significantly. The question of what to do in hygiene is much more simple. This is an area where wide field, relatively low-magnification loupes with headlights will have great benefit and very little downside. If you have dedicated hygiene rooms, never do assisted procedures there and all doctors wear headlights, you certainly can go headlight only here. Unfortunately, what tends to happen is that once all the staff members are fitted with quality loupes, the cost savings compared to lights is negligible. So what is it about dental Fig. 3 patient lights that causes doctors to hate them so much in the first place?

Why Most Patient Lights Are Inadequate The most common and generally least expensive patient light-mounting method – the chair mount – is also the least desirable and most trouble prone, with the combination of both drift and vibration being the most common complaints. Chair-mount lights also obstruct the operatory, which may be problematic with the use of some specialty equipment such as sedation monitors and portable nitrous units. Ceiling- and wall-mount lights are generally less aggravating to use with ceiling mounts having a rather specific need for exact placement, lest the unit regularly become rotated such that the operator or assistant must physically get up and use two hands to reposition the lights. Wall mount units generally do not have this problem, however, due to their arm length, they are much more susceptible to drift. For more than 30 years, the gold standard in dental lighting has been ceiling-mounted, dental-track lighting. Unfortunately, not all of these are universally great, but, there are a number of very good products on the market which I would like to specifically mention. The first is the A-dec 6300 (Fig. 1). A-decs’s lights are universally known for their flexible adjustability; their multi axis articulation eliminates much, if not all of the main complaints regarding operatory lights. The second light of note is the Pelton & Crane Helios 3000 (Fig. 2). This LED lighting system is the most energy efficient and advanced product in terms of actual per watt light delivery by a good measure. Pelton has a decades- long history of leadership in this segment. Next I should mention the TLC light by the Technology Lighting Center (Fig. 3). This light has perhaps more active fans and detractors than any other light. The TLC light contains efficient spot lights to the oral field and therefore acts much more like a headlight than continued on page 104

dentaltown.com « September 2011 103 point counterpoint continued from page 103

Fig. 4 does any other extraoral lighting product. This light also includes full patient monitor integration in both supine and upright positions. The last light that I would mention is the Ergonomic Products TBL light, which is new to the dental marketplace (Fig. 4). This light combines the features of the traditional track light by having a wider visual field with patient video monitoring for supine patients and then adds additional task lighting to critical work surfaces (to reduce the accommodation problems of headlight wearers). In addition, the TBL created an entirely new option for treatment illumination – single fixture mounting. The TBL light is an entire room solution with no other light source needed for the entire installation. For the mature general practice, intraoral dental lighting is here to stay. This will be enhanced by headlights and perhaps only replaced entirely in a microscope exclusive practice, which, for economic reasons, will continue to remain a rarity for some time. There are a number of products that stand out from the field that will meet the needs of virtually every practitioner without inconvenience or compromise, as a number of practitioners continue to experiment with lightless practice. n

Author’s Bio

Dr. David Ahearn is a full time practicing dentist in Westport, Massachusetts. Though located in a small rural town, his office ranks among the nation’s most productive practices. Trained in prosthetics at the University of Michigan, Dr. Ahearn, like many of us, struggled to reconcile the desire for the utmost quality with the requirements for practice success. His discovery and application of the principles of the Toyota Production System in the early 90s began a quality and productivity revolution that is at the heart of his design work. As the founder of Design/Ergonomics, Dr. Ahearn works with doctors across the country in designing comfortable, productive, and cost- effective practices. He has held faculty positions at both the University of Michigan and NYU’s College of Dentistry. He is also a founding member of the ADA’s Ergonomics Subcommittee and a contributor to numerous dental publications. He can be contacted at 508-636-6566 or 800-275-2547.

No Overhead Lights

wisnerjb Posted: 6/11/2011 I’m beginning construction on a Janacek/Design Ergonomics inspired building Post: 1 of 75 this month, and I’m contemplating no overhead dental lights. I love my LED headlight, and they’ve gotten so small and affordable that I’d prefer to just buy them for the staff and delete overhead dental lights. Anyone tried this or think of a reason it won’t work? I imagine it would be “less intimidating” to the patients and I might even avoid the stank eye glare from the old lady who accidentally has the overhead light in her eyes when we turn it on. Any thoughts? n

Molardaddy This is what Scott Leune has preached at Breakaway seminars. I do use loupes Posted: 6/11/2011 with a light, but there are times when it’s a hassle to put them on just to take a quick Post: 2 of 75 peek. Pulling the overhead light quickly helps. I wonder how the assistants are going to see if they have to pack cord or make a temporary when I am not there. The ambient lighting might not be enough. Some people have had luck with it and others like me are a little cautious. If you are absolutely cash strapped and want to save money on the overhead lights then it might be an idea you could flirt with as it is being done. n

104 September 2011 » dentaltown.com point counterpoint

I never use my overhead light, but I always have on my loupes and light source. donnanick If your assistants had a light source too I see no need for overhead light. If I were Posted: 6/11/2011 building new office I wouldn’t have them. n Nick Post: 3 of 75

Just be sure to have spare headlights on hand. I removed half the skr RDH overhead lights for six months because we all use headlights. Well then Posted: 6/11/2011 my light developed contact issues and stopped working. I had to hustle Post: 4 of 75 to re-install the overheads. But 99 percent of the time they are swung out of the way, unused. n

Headlights are great as supplemental lighting. The primary issue ricklin with headlights is the fact they are point source lights. Thus they are Posted: 6/11/2011 easily blocked and hard shadows are a fact of life. Post: 6 of 75 As far as light in the patients eyes. Best be very careful where you point your head. Headlights are secondary to a good operating light. You do not see the surgeons in the OR working without the operating light. Their headlights are secondary, the overhead light is primary. A quality overhead light is a necessity, despite what is promoted by those that sell seminars. Lighting in dentistry is a number one priority; one can hardly have too much light. Intensity, color and shadow reduction are the three primary requirements. Headlights can hit one or two of those three. Headlights are great; they are not a replacement for a quality overhead light. n

No overhead lights in our office either. We have LumaDents, Designs for Vision john galt dds DayLite Minis and also a couple from that young dental student from USC, Ultra Posted: 6/12/2011 Light Optics. All work fine. Each team member has goggles or loupes with them Post: 13 of 75 attached, and we rarely miss the overhead light. We did have one hygienist who groused about it, but she is gone now (not because of the light thing). Our rooms are small, maybe 9x9, but in my opinion seem larger thanks to no overhead light. The ladies in the office even have had the idea of turning off all the lights when they are treating patients, except for our headlamps. What do you think, would “Dentistry in the Dark” go over with your patients? One thing I would recommend if using headlamps is to provide sun goggles to the patients. Every once in a while I will move my head and if they did not have sun goggles on, they would probably take exception. The sun goggles also makes it easier for them to sleep. n

I have not used overhead lights since I got Designs for Vision Mini. Raj D I would however suggest that you have the overhead lights installed Posted: 6/13/2011 at least in one to two ops. The reason I say this is because if in the future Post: 18 of 75 you get an associate or hygienist that does not use illumination then it would not be an issue. n

Find it online at No Overhead Lights www.dentaltown.com

dentaltown.com « September 2011 105 ices ons behind w y pract facilitatepractice successful familymanagement feature What are the common issues in pra n practices that employ family? ily at Loyalty Sometimes Leads to n . gement Often, family members are flict use con l ated to the success of the other family he fal w The old saying, “family is thicker than n; a ne true, and yet too much caring can caus had ber when I met Bernadette. It was in th uble . As a hygienist, she worked for her son; He ce owner FAMILYand young dentist. Dr. Greggs ha f o lished his vision and goals, but he had troub g

erness eloping a consistent, fair style of leadership. H s nd the staff management and the business of oncern MEMBERSide ntistry to be much harder than actually doing uts ugh he dentistry. His mom, Bernadette, in her eager o tent to help him succeed, was openly voicing her con Workingette in and opinions during business hours and also ou a R. She felt the front office staff wasn’t diligent enou f arge o by Rhond in collecting at the time of service and inconsist vage, DDS and Sa in their insurance processing methods. Bernadet b the Practiceeggs r was clashing with the lead front office person. the She also clashed It’swith the notdental assistant personal; in char supplies. She feltit’s they weren’t just doing business a good job anager. needed to have more attention to detail. Dr. Gre bs, heir jo had difficulty enforcing his policies because of th Wishful thinking!acticIt’se complicated. Family members who work in the dental practice conflicting views betweencan Bernadette be a tremendous and the asset. But even the most dedicated, hard-working family member can experi- ome other team members. Hisence mom or create was tension, a microman stress and conflict in the practice. Can we really have the family history, emotions and knowledge of that person on a deepere level but also have a great working relationship? She told everyone how they should be doing the “I lov I’ve seen family successfully workaid, within the practice,d but there are reasons behind why it works. in detail. The stress drove the morale of the prac i What are the qualities that facilitatei successful family working relationships? Here are the common down. Acknowledgeissues It’s Easy that existto Take within Work practices Hom that employ family. Dr. Collins has been in practice for 26 years. Recognize that Loyalty Sometimes Leads to Micromanagement His wife is part of hisOften, front familydesk team members and arehe saimore dedicated to the success of the other family member. The old working with mysaying, wife!” “family Dr. Collins is thicker is a than very blood” nice, quiet,is true, reservedand yet too much caring can cause conflict. person. He dislikes Iconflict remember and when struggles I met Bernadette. to grow his It wasteam in the fall of 2001. As a hygienist, she worked for her and his practice.son; He’s a new worked practice very owner hard and through young thedentist. Dr. Greggs had established his vision and goals, but he had trouble developing a consistent, fair style of leadership. He found the staff management and years, taking a lot of continuing education. His primary the business of dentistry to be much harder than actually doing the dentistry. His mom, Bernadette, goal is to educatein her hiseagerness patients to helpand himprovide succeed, quality was openlydentistry. voicing her concerns and opinions during business His wife, Emily,hours isand concerned also outside that the the office. team members aren’t held accountableShe felt the forfront their office work. staff wasn’tThe assistants diligent enough in collecting at the time of service and incon- sistent in their insurance processing methods. Bernadette was clashing with the lead front office per- and hygienists aren’t actively communicating and son. She also clashed with the dental assistant in charge of supplies. She felt they weren’t doing a good educatingjob the and patients, needed todespite have moretraining attention and continuing to detail. Dr. Greggs had difficulty enforcing his policies education. Because the doctor is sensitive to conflict, he avoids team meetings, coaching and performance 106 September 2011reviews. » Thisdentaltown.com stresses his team and his wife. She’s quite verbal aboutmfort her asfeelings he’s sensitive duringher husband offto criticism.hours, andby which the defers Emily team causes the is feature practice management

because of the conflicting views between Bernadette and the other team members. His mom was a micromanager. She told everyone how they should be doing their jobs, in detail. The stress drove the morale of the practice down.

Acknowledge It’s Easy to Take Work Home Dr. Collins has been in practice for 26 years. His wife is part of his front desk team and he says, “I love working with my wife!” Dr. Collins is a very nice, quiet, reserved person. He dislikes conflict and struggles to grow his team and his practice. He’s worked very hard through the years, taking a lot of continuing education. His primary goal is to educate his patients and provide quality dentistry. His wife, Emily, is concerned that the team members aren’t held accountable for their work. The assistants and hygienists aren’t actively communicating and educating the patients, despite training and continuing education. Because the doctor is sensitive to conflict, he avoids team meetings, coaching and performance reviews. This stresses his team and his wife. She’s quite verbal about her feelings during off hours, which causes him discomfort as he’s sensitive to criticism. Emily is always very respectful to her husband and defers the decision making to him, but is upset by the team performance level. The built-up frustration comes through unintentionally in her tone of voice and her look, Traits of a Great Family Team Member and the tension in the practice is palpable. Both Bernadette and Emily have skills, talents and strengths; they are incredibly loyal to the doctors and • Be early • Follow through want them to be successful. But their strengths, if over- • Be dependable • Be friendly and have fun done, will create problems that should not be ignored. • Pay attention to your work • Be encouraging Deferential passive-aggressive behavior and the opposite, responsibilities; be accountable • Be a mentor micromanaging, will create conflict and tension in the dental practice. • Take a lot of continuing education; be excited about dentistry and learning about dentistry. Don’t Hire Someone You Can’t Fire! • Always speak positively about the doctor and the practice, both in There are many complex issues in practices that occur and out of the office. when family is involved; there is no single solution to the • Offer advice when asked or ask first before discussing a concern. problem. There are many layers that need to be peeled back to resolve the issues and change behaviors… if change is • If family employees and your employees just can’t seem to get possible. Both doctors will need to change to some extent along, you must resolve the issue. If you don’t, you’ll be “anti-mar- or their practices will continue to struggle. keting” your practice. Patients will sense the tension. Do you find yourself hesitant to talk about a problem within the office because of how it might impact you on the personal/home front? Are you walking on eggshells at work, worried about how he or she might respond if you treat them as you would your other employees? To be successful as a team member, Bernadette and Emily need to know their role in the practice. It can be a tough job, being a family member and an employee. Other employees, no matter how hard you work at being a great employee, will look at you differently. Because of this, your family member employee will always need to hold him or herself to the same (or even higher level) of accountability than employees who are not family members.

Be Aware Family Tend to Get Paid Too Much or Too Little Some dentists try to help their family out by paying more than the average wage for that employ- ment category, which can impact the total staff overhead. When calculating staff overhead and whether you have room for raises/bonuses, subtract out any additional pay that is above and beyond the norm. It’s not fair to neglect the rest of the team’s income; you’ll see resentment and unhappi- ness build if this is the case. Remember, when morale goes down, productivity goes down! The opposite of too much pay is too little. If your family member is paid at a lesser rate, is there a concern about resentment? Honest, open discussions are important to be certain this isn’t the case.

continued on page 108

dentaltown.com « September 2011 107 practice management feature continued from page 107

In addition to pay, gender difference or age differences that impact your relationship with your team might feel intensified with your family employees. Recognize that some conflict develops due to these differences and work at learning about better communication and leadership. Read about leadership and communication and put what you read to use. If family employees and your employees just can’t seem to get along, you must resolve the issue. If you don’t, you’ll be “anti-marketing” your practice. Patients will sense the tension.

Look at the Situation Through the Eyes of a Child Most of us don’t like to talk about these sensitive areas; it’s easier to sweep them under the rug. Yet talking about these issues is exactly what you’ll need to do in order for your office to have the harmonious atmosphere that patients seek. Sometimes looking at these uncomfortable discussions with the eyes of a child can help! Children are often quite blunt and have the uncanny ability to say what needs to be said in just a few words. As an example: My parents bickered at each other for years, creating uncomfortable moments for those around them. We always tiptoed around these tension-filled moments, hoping they’d go away. One summer when visiting my parents, we sat down for a lovely dinner. My mom snapped at my dad. “Bill, eat your salad!” “No!” he replied, angrily. And the conversation died as the two began to argue. Kaitlyn, our then six-year-old daughter, leaned back in her chair, arms crossed, and with a big grin on her face said, “Oh! Dinner and a show!” After a great belly-busting laugh, mom and dad apologized and acknowledged they hadn’t realized how their bickering made us feel. Our relationship deepened with the open discussions that followed through the years. As adults, we often worry about putting our foot in our mouth. Hurt feelings build up, layer upon layer, until silence or unexpected anger result. If your office is experiencing this kind of tension, encourage the conflicting parties to work out the problem on their own. The key to a successful employee/family relationship is that everyone in the office is treated the same. You need the same level (or higher) of accountability, timeliness and dedication to patient care from all of your employees, especially family members. If you find your employees don’t get along, send them to lunch with your credit card! If this doesn’t work, facilitate the discussion. There are two questions that you can ask yourself that will help take the emotional side of the problem out of the equation: Is “whatever is happening” in the best interest of the patient care? Is “whatever is happening” in the best interest of maintaining a healthy practice? Look at the problem with the directness of a six-year-old and resolve the issue. Working with family doesn’t have to be a problem as long as intentions are apparent, there is a general attitude encouraging open and honest communication and issues are addressed abruptly after surfacing. ■

Author’s Bio

Dr. Rhonda Savage began her career in dentistry as a dental assistant in 1976. After four years of chairside assisting, she took over front office duties for the next two years. She loved working with patients and decided to become a dentist. Savage graduated with a BS in biology, cum laude, from Seattle University in 1985; she then attended the University of Washington School of Dentistry, graduat- ing in 1989 with multiple honors. Savage went on active duty as a dental officer in the U.S. Navy during Desert Shield/Desert Storm and was awarded the Navy Achievement Medal, the National Defense Medal and an Expert Pistol Medal. While in private practice for 16 years, Savage authored many peer-reviewed articles and lectured internationally. She is active in organized dentistry and has represented the State of Washington as president of the Washington State Dental Association. Savage is the CEO for Miles Global, formerly Linda L. Miles and Associates, known internationally for dental management and consulting services. She is a noted speaker who lectures on practice management, women’s health issues, periodontal disease, communication and marketing and zoo dentistry. To speak with Dr. Savage about your practice concerns or to schedule her to speak at your dental society or study club, please e-mail [email protected], or call 877-343-0909.

108 September 2011 » dentaltown.com EDUCATION. ENTERTAINMENT. CAMARADERIE.

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110 September 2011 » dentaltown.com zoo dentistry

by Chelsea Patten, staff writer, Dentaltown Magazine

Imagine your first encounter with a silverback gorilla – an animal 10 times more powerful than the strongest American football players1 and tall enough to look you square in the eyes.2 Then… against all your better judg- ment, stick your hand in his mouth. That’s exactly what Drs. Dan Mairani and Steve Holifield did. Oscar Jonsey, or O.J. for short, is a 380-pound silverback gorilla. Silverback gorillas are endangered species3 native to the tropical forests of Western Africa. O.J., however, has spent most of his life at San Francisco Zoo in California. Mairani was approached in 2010 by long-time friend and head veterinar- ian at S.F. Zoo, Dr. Graham Crawford, to examine the gorilla who had been suffering from a dental infection. O.J.’s dental problem had likely gone untreated for years. Regardless of whether O.J. could feel the pain of the abscessed teeth or not, a disease can be debilitating in other ways like general malaise, bad taste in the mouth and various systemic complications due to the ongoing infection. Crawford told Mairani, “I don’t want one of my animals walking around with an infection in his face, so we’re going to treat this.” And so they did... The first step Mairani took was asking friend and endodontist Dr. Steven Holifield, of Sonoma, California for help. “We didn’t know anything about gorillas before, but we got in touch with Dr. John Sheels who does veterinary dentistry in Milwaukee. Mairani explains most of the tools used for humans, specifically the ones used for endodontics, are just too small to use on O.J. Their teeth, used as display and as a weapon, are roughly three-and-a-half times the size of a human’s. Dr. Sheels helped the doctors find larger tools, recommending DrShipp.com, an online retailer of veterinary dental tools, and explained what the doctors needed to have in their kits. “Dr. Scheels said we needed to bring the house because you never know what you’re going to need,” recalls Mairani. He also joined the American Association of Veterinary Dentists in his efforts to learn about the great ape. “Their anatomy is similar, but not identical,” says Mairani referring to the research he did prior to the surgery. “It’s more about the armamentarium than the differences in anatomy.” Beyond the larger scale, gorillas suffer from virtually the same dental problems as humans, although less so

O.J., a 380-pound silverback gorilla from the San Francisco Zoo needed some dental work, and Drs. Dan Mairani and Steve Holifield came to his rescue. continued on page 112

dentaltown.com « September 2011 111 zoo dentistry continued from page 111 because their diet in the wild tends to be healthier than the typical human diet. Gorillas share 97 percent of the same DNA as human beings. They have the same amount and same positioning as human teeth. Originally, Mairani and Holifield performed surgery on O.J. in December 2010. O.J. had two abscessed canines on his right side. The infections were on 27 and 6; 6 being the worst of the two. Mairani assisted Holifield with root canals and Mairani performed three interproximal fillings, one of which was an MO resin on 3. Mairani also did a cleaning. “I used Voco Futurebond as an adhesive agent fill and endo access fills.” The procedure took about four-and-a-half hours. Unfortunately one of the abscesses on his maxillary canine – 6 – was so bad the root canal failed, so the doctors had to schedule a second surgery for July 11, 2011. O.J. being wheeled on a gurney to the surgery center. O.J. is very familiar with his handlers, so he will back up into ray heads, an older Siemens unit, that was mounted on wheels by the fence of his cage to allow them to inject him with anesthesia, the zoo engineers so it could use be used on any of the animals. rather than dart him. This is less traumatic for the rest of the Mairani and Holifield describe their initial reaction to seeing nearby animals. Once O.J. passed out, he was intubated, placed on O.J. wheeled into the surgery center. “Everything about this ani- a gurney and wheeled to where the surgery would be performed. mal is massive. He looks like he could just tear you to pieces, but The zoo has a full facility with a surgical suite and X-ray he’s actually soft and cuddly. You kind of want to just play with equipment. Dr. Holifield borrowed an Aribex NOMAD digital him,” says Mairani. Laying on the gurney, O.J. is between two- X-ray system from his rep, and Dr. Mairani donated one of his X- and-a-half to three-feet thick from back to chest. He also men- continued on page 114

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dentaltown.com « September 2011 113 zoo dentistry continued from page 112 tions, “I was anticipating that he would smell pretty bad, but aside from his breath, which smelled horrible, he really didn’t.” “Even though I knew what to expect, I could not get over how huge his teeth were,” says Holifield. “I was concerned that he might move if not completely anesthetized… but it became apparent the S.F. Zoo vets knew what they were doing.” Mairani adds, “You feel rather insignificant when you are around something that big and strong. It really makes you appreciate life in general and it gives you a sense of where you are in the world.” The doctors knew O.J. had an abscessed tooth on his right side and would need apical surgery. From the X-rays, they were able to determine where the apex of the root was and made an incision on the outside of his face. “We tracked the fistula to help locate where to break through,” says Mairani. Mairani played MacGyver and made a band out of thick aluminum tape since the toffelmire and segmented band were too small. They cleaned the abscess, cut off the end of the root and sutured him up. The zoo then put O.J. on an antibiotic regime. “He’s fine now,” says Mairani, still glowing from the amazing opportunity he had to work on the great ape. The doctors said for the most part, they had the right tools, but they could have used a longer bur. Holifield adds, “We came prepared with special endodontic files and gutta percha, but the volume of space in the canal was enormous. It took a lot more filing material to finally seal the canal.” Another challenge was in taking a digital X-ray, “the biggest sensor I have is a #2. Trying to get a good digital image was next to impossible.” Everyone at the zoo – from zookeepers to security guards – hung around to witness the surgery. Mairani says, “How often do you get to be that close to something like that? He is so powerful and so humanoid. It was incredible.” Regarding the employees at S.F. Zoo, Mairani says, “They are the most caring, wonderful people I have ever encountered. Some people think zoos are a terrible place and would rather there not be zoos at all, but the staff at this zoo does everything it can to make these animals’ lives comfortable.” Mairani humbly notes, “Any dentist could have done what I did. Any dentist. Any endodontist… We just happened to know the person who required our services. It’s an honor. I’m just still thrilled to have been around something that powerful.” This isn’t the first animal Mairani has worked on. He performed needed dental extractions on a female tiger about 20 years ago and in September of this year, performed surgery on a gibbon – a species of lesser ape. He mentions his intention to continue to volunteer and work closely with the zoo. Whatever the zoo throws his way, he says, he will learn as he goes. “There is always plenty of material out there to keep learning.” n References: Top: Dr. Dan Mairani (left) and Dr. Steven Holifield discuss the goril- 1. http://www.awf.org/content/wildlife/detail/mountaingorilla la’s jaw structure. Middle photos: The doctors perform surgery on O.J. 2. http://nationalzoo.si.edu/Animals/Primates/Facts/FactSheets/Gorillas/default.cfm\ the silverback gorilla. Bottom photo: O.J. returned to his life at the zoo 3. http://www.earthsendangered.com/profile.asp?gr=M&sp=2212 with better oral health.

114 September 2011 » dentaltown.com from trisha’s desk hygiene & prevention

Making the Connection

by Trisha E. O’Hehir, RDH, MS, Hygienetown Editorial Director

June 24-25, 2011, marked the first Annual Scientific five tennis courts! Oral bacteria, endotoxins and Session for the newly formed American Academy for Oral cytokines all enter the blood stream and travel to other Systemic Health. There are academies for periodontics, parts of the body. Before getting to the heart, fetus, pan- general dentistry, dental hygiene, cosmetic dentistry, sleep creas or other organs, these toxic waste products travel medicine and others, so it’s only fitting and timely to now through the blood vessels, often penetrating endothelial have an academy for the oral systemic connection. This cells, the lining of the blood vessels. This is where changes organization was founded by Townie Dr. Chris Kammer occur, causing inflammation of the cells, allowing choles- and a core group dedicated to “Making the Connection,” terol to seep in and eventually breaking and leaking, leading as this first meeting aptly illustrated. to a coronary event. The two-day conference effectively made the connec- Casey Hein, RDH, MBA, is currently working at the tion between medicine and oral health with a line-up of University of Manitoba producing a vast array of sophisti- speakers demonstrating significant links between oral cated yet easy-to-follow multimedia modules to educate health and cardiovascular disease, high blood pressure, non-dental/medical professionals on the latest understand- stroke and diabetes. While this year’s audience was prima- ing and research linking oral disease and diabetes. rily dental professionals, with a few physicians, future Understanding the inflammatory process of one disease meetings are predicted to show an increase in the number helps one understand the inflammatory process of the of medical colleagues attending. other and how they are linked. Cardiovascular topics were covered by a physician- After a day and a half of scientific research building a nurse practitioner team who developed the Bale-Dooneen strong case for the oral systemic link, dentist and inventor Method of personalized risk assessment and disease man- of PerioProtect, Dr. Duane Keller, provided practical agement. Dr. Bradley Bale and Amy Dooneen created the information and scientific research to support a novel Heart Attack and Stroke Prevention Center in Spokane, approach to lowering the bioburden of bacterial biofilm Washington, to find the root cause of inflamed blood ves- prior to invasive periodontal therapy. Hydrogen peroxide sels that could ignite future heart attacks and strokes. Their and antibiotics used in the PerioProtect trays direct and goal is to prevent heart attacks and they seem to be quite hold the antimicrobial/antibiotic substance in the subgin- successful. Since beginning the center in 2003, they have gival area, significantly reducing biofilm prior to instru- treated 3,500 patients using the Bale-Dooneen Method mentation that would otherwise dump millions of and only one of those patients suffered a heart attack and colony-forming units and toxic substances into the blood has since made a complete recovery. Many of the patients stream. This is an interesting local delivery alternative to are physicians with cardiovascular disease. systemic antibiotics. Audience participants were familiar with dental and You’ll want to attend next year’s AAOSH Annual periodontal research supporting a link between oral dis- Session as the research in this area is ever increasing! See ease and many systemic conditions. How refreshing to be you there! n introduced to the vast array of similar research being published in medical journals. Several studies presented con- In This Section firm a strong link between periodontal disease and high 116 Message Board: Unimpressive Results blood pressure. It’s all about inflammation, similar to 118 Perio Reports periodontitis, so it makes sense that one would be linked 122 Profile in Oral Health: Marketing Magic to the other. The subgingival extent of the periodontal 126 Message Board: Abscessed Implant! open wound is about the size of the palm of your hand. Look for additional content in the Hygienetown Magazine digital edition. Picture this: the entire endothelial system is the size of

dentaltown.com « September 2011 115 This thread comes from the message boards of Hygienetown.com. hygiene & prevention message board Log on today to participate in this discussion and thousands more.

Unimpressive Results

Although the plaque control looks okay, these women in their 50s still have bleeding gums. What would you suggest?

newbie10 Posted: 2/2/2011 I have a couple of patients who came back for their first three-month recall with Post: 1 of 17 gingival bleeding and moderate pocketing. Their oral hygiene seemed really great, no plaque and regular flossers. Still the gingiva was red and bleeding. I cannot feel any calculus either. Both are women in their 50s, so I’m thinking hormones make them extra sensitive to the bacterial flora in their mouths. So what else can they do for oral hygiene other than Waterpik WaterFlosser? ■

JERSEY DEVIL It could be hormones, medications, mouth breathing, smoking, Posted: 2/2/2011 sinuses or a systemic factor like diabetes. Ask them more questions about Post: 2 of 17 their health and habits. Most medications that people in their 50s take cause dry mouth. Dry mouth causes the plaque to stick to the teeth quicker, even if they have great hygiene. Using Biotene products and xylitol products can help with the dry mouth. But if it is systemic it needs to be identified by their MD and treated! ■

rdh1982 Are you familiar with Sunstar Americas’ Soft Picks? My patients who Posted: 2/3/2011 have been using this simple yet very effective interdental gum-friendly Post: 4 of 17 device have less bleeding. My only complaint about this particular product is that local stores can’t re-stock them fast enough for my patients; it is that good! ■

shazammer1 I would ask you to do two things. During your spiel to them, hand Posted: 2/3/2011 them the floss and ask them to show you their technique. You might be Post: 5 of 17 astounded. Don’t help them until you see how it is being done, probably very wrong. Secondly, before you pick up a scaler drop five drops of Butler GUM disclosing solution under their tongue and ask them to swish it around for 30 seconds front and back. Rinse and then show them what is missed every day. You might be astounded again. It could be a health issue or it could be loosey goosey home care that we tend to take for granted and shouldn’t. One time I dispensed a power brush to an older guy and told him to brush with it instead of his regular brush and I had him back in a week to see how he was doing. Disclosing showed plaque all over. I asked him to bring his brush in with him the next day and when he showed me his brushing technique he never turned the brush on. I took too much for granted. He was using it like a manual. ■

newbie10 That sounds so much like my young lady patient who asked me Posted: 2/4/2011 which teeth she should be flossing! I showed them on their first visit Post: 6 of 17 how to do sulcular brushing and spool flossing. Review of technique seems OK. I just received a boxful of disclosing tabs to give away so I

116 September 2011 » dentaltown.com message board hygiene & prevention

will use that too next time she comes in. I will try to see the health issue angle; kind of awkward too since this one works in the hospital taking care of sick people. But then again... ■

Great suggestions everyone. Many people do not go to regular doc- DentalNutrients tor visits. Therefore, we have to be the ones to nudge them toward reg- Posted: 2/4/2011 ular medical checkups – just as important as regular dental checkups. Post: 8 of 17 Does your office have a wrist blood pressure cuff (BP) (available at Walgreens) so you can easily and quickly take a BP on every patient? I could tell you stories from my chiropractic practice that would curl your hair, including one 42-year-old guy who had a BP of 220/110. I refused to treat him and told him he had to get to his MD as soon as possible and get his BP under control. Instead he called his doctor for a refill on his BP meds and he was dead in two weeks of a heart attack and stroke. ■

I sometimes explain easy bleeding during a prophy as “fair complex- hotflosser ion.” If a patient has freckles, light complexion, fair or reddish hair, you Posted: 2/11/2011 will many times find that despite their good home care, their gingiva will Post: 9 of 17 bleed easily. Many well-experienced RNs would tell you similar stories. I have never read a study or article about it, but having worked in the U.K. for many years, I found that more red-haired folks had “bleedy” gums than others. ■

To soothe this kind of gingival problem I would get the patient to zellie put a teaspoon of granular xylitol in a glass of water and sip this as a Posted: 2/11/2011 drink. One glass during the morning and then repeat this again after Post: 10 of 17 lunch. The benefits of xylitol will help establish a healthy biofilm and a healthy mouth, usually in a very short time. If this is a yeast infection, xylitol is very effective on that also. ■

As already suggested, evaluate their floss and tooth-brushing technique to ensure lorita it is truly effective. Evaluate their diet, especially vitamin Bs and protein for tissue Posted: 2/12/2011 repair. Evaluate the gingival tissue by spraying air upon them; do they lack stippling Post: 12 of 17 and appear to have a shiny appearance? Also is the pocketing more prominent in the bicuspid region than the classic molar area? Have you considered aggressive periodontitis? If so, have them dip their toothbrush in baking soda at night and use Spry mints, not the gum (any time during the day, but no rinsing until at least 30 minutes), it is more about the time the bacteria are exposed to the xylitol, not the amount. Have your clients dissolve the mint and swish it between their teeth. One a day is plenty. This will stabilize the tissue and prevent further bone loss. I personally feel this is because the immune system is out of balance. ■

Find it online at Unimpressive Results www.hygienetown.com

dentaltown.com « September 2011 117 hygiene & prevention perio reports

Perio Reports Vol. 23 No. 9 Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science.

Perio Patients Seen in Dental Treatment and Emergency Rooms Vascular Events Periodontal disease is best controlled with regular main- Treatment and control of periodontal disease might tenance visits and adequate daily oral hygiene. When regular reduce the risk of cardiovascular disease. Other research sug- dental visits are not followed, serious problems occur and gests a transient risk associated with invasive dental proce- patients seek treatment at hospital emergency rooms. Those dures and the likelihood of a heart attack or stroke in the without dental insurance also seek care in hospital emergency first few weeks following treatment. Low grade chronic rooms. Data is collected each year from emergency rooms inflammation is linked to cardiovascular disease. Acute across the U.S. and published in a Nationwide Emergency inflammation after surgery or a bacterial infection is associ- Department Sample (NEDS). ated with a short-term increased risk of changes in blood Researchers at Harvard University in Boston, Massa- vessels leading to stroke or heart attack. chusetts analyzed data from 2006 NEDS to determine how Researchers at the Eastman Dental Institute in London, many visits were because of periodontal problems and if these England analyzed the United States Medicaid claims database emergency visits led to hospitalization. to determine if invasive dental treatment led to heart attack During 2006, there were 120,033,750 emergency room or stroke immediately after treatment. A total of nearly 10 visits with 85,039 of these visits being categorized with a pri- million patient records over a five-year period were analyzed mary diagnosis of periodontal disease. More patients were to find 20,000 who had been hospitalized for either stroke or seen on weekend days than on weekdays. Some of these cases heart attack. Of these patients, 1,152 underwent invasive also had other medical problems including diabetes, heart dental procedures prior to hospitalization. disease, lung disease, liver disease, thyroid problems, alcohol Invasive dental procedures included all treatment codes abuse or HIV. A total of 1,167 of these emergency room vis- related to periodontal therapy and tooth extractions, with its required inpatient hospitalization. 89 percent of these procedures relating to extractions. The financial implications of these emergency room vis- No vascular event occurred on the same day as the den- its were close to $33.3 million with an average charge per visit tal visit, but the majority happened within four weeks of of $456. For those who were also hospitalized, the charges treatment. Although invasive dental treatment might be escalated to $15,248 per visit. linked to vascular events in the month after treatment, the Inpatient hospitalization occurred more often for those long-term benefit of treating dental disease far outweighs with multiple medical problems and for those with a primary this risk. These findings do provide evidence of the link diagnosis of acute or aggressive periodontitis rather than between acute inflammation and the risk of vascular events. chronic periodontitis. Clinical Implications: Within this targeted population Clinical Implications: Prevention of periodontal disease of Medicaid patients, invasive dental treatment might with effective daily oral hygiene and regular dental and present a transient risk for heart attack or stroke in the dental hygiene visits is important to treat and prevent first four weeks following treatment, but this risk is out- serious periodontal conditions that might otherwise lead weighed by long-term benefits from dental treatment. patients to seek treatment at a hospital emergency room. Minassian, C., D’Aluto, V., Hingorani, A., Smeeth, L.: Invasive Dental Treatment and Risk for Vascular Events. Ann Elangovan, S., Nalliah, R., Allareddy, V., Karimbux, N., Allareddy, V.: Outcomes in Patients Visiting Hospital Emergency Intern Med 153: 499-506, 2010. n Departments in the United States Because of Periodontal Conditions. J Perio 82: 809-819, 2011. n

118 September 2011 » dentaltown.com perio reports hygiene & prevention

Host Modulation Helps Smokers

Smoking is a serious risk factor for periodontal disease data demonstrated improved periodontal healing following and compromises clinical healing following therapy. scaling and root planing when host modulation therapy was Smoking suppresses the body’s immune response, triggers the provided for smokers. Differences were more pronounced in release of cytokines which destroy healthy connective tissue moderate and deep pockets compared to shallow pockets. and prevent these cells from organizing and healing. Despite When these low-dose drugs are given to smokers in conjunc- a great deal of research confirming the role of smok- tion with treatment or maintenance, bacterial counts ing in the progression of periodontal disease, are reduced for the most pathogenic species. treatment and maintenance are the same for Since smoking causes an increase in inflam- smokers and non-smokers. There are no well- mation, providing a host modulation drug established protocols to follow when treating that reduces the level of cytokines released periodontal patients who continue to smoke. will enhance healing. Researchers at the University of Alabama, School of Dentistry in Birmingham, Alabama Clinical Implications: Based on the research, reviewed the literature to determine if the use of it makes sense to offer a host modulation drug host modulation therapy in smokers would be benefi- to smokers being treated for periodontal disease cial with both scaling and root planing and during mainte- and smokers receiving periodontal maintenance. nance care. They reviewed 31 abstracts on the subject and narrowed it Geisinger, M., Holmes, G., Geurs, N., Vassilopoulos, P., Reddy, down to 13 full articles, of which nine were relevant to their M.: Host Modulation for Smokers Undergoing Periodontal question. The two host modulation drugs tested were low-dose Maintenance: A Review of Current Evidence. Clin Adv doxycycline and low-dose flurbiprofen. Overwhelmingly, the Periodontics 1: 54-60, 2011. n

Rapid Recolonization After Treatment

Bacterial biofilm is the trigger which starts the periodontal Samples were taken from seven teeth in randomly selected quad- disease cascade. Researchers have identified hundreds of bacter- rants on days one, two, four and seven. ial species within biofilm and grouped them according to path- Baseline bacterial counts were higher in periodontitis sub- ogenicity by color groups. Red and orange are the most jects compared to healthy subjects. Supra- and subgingival pathogenic; green and yellow less so; and purple and blue the counts reached or exceeded baseline levels at day two. least pathogenic. In both groups, there were two spikes in repopulation of Researchers at the Forsyth Institute in Boston, Massachusetts subgingival plaque, between days one and two and between days wanted to know if there were differences in plaque recoloniza- four and seven. This might be due to environmental changes in tion and species after instrumentation in both periodontally the subgingival area favoring different species. healthy and diseased patients. A group of 38 patients partici- pated in the study; 17 had chronic periodontitis with at least Clinical Implications: Skipping oral hygiene for just two eight teeth probing over 4mm and the rest, considered days allows bacteria to rebound to baseline levels or higher. healthy, had less than 20 percent of sites with gingivitis, red- This is good information to share with patients. ness or bleeding. Supra and subgingival plaque samples were taken from 28 Uzel, N., Teles, F., Telles, R., Song, Z., Torresyap, G, Socransky, S., teeth in each individual at baseline. Subjects then received either Haffajee, A.: Microbial Shifts During Dental Biofilm Re- a prophylaxis or full-mouth scaling and root planing. Plaque Development in the Absence of Oral Hygiene in Periodontal Health samples were taken immediately after treatment on all 28 teeth. and Disease. J Clin Perio 38: 612-620, 2011. n continued on page 120

dentaltown.com « September 2011 119 hygiene & prevention perio reports continued from page 119

Pain Relief Patch for Perio Surgery Sites

Ketorolac (Toradol) is a non-sterioidal anti-inflammatory drug used to control pain and inflammation. It is delivered by injections or in oral tablets often causing gastroin- Ketorolac testinal (GI) problems. To avoid GI problems, other delivery systems have been investi- gated, including transdermal delivery, ophthalmic solutions and an oral rinse. The newest delivery system is an intra-oral patch made of two bioadhesive polymers: hygroxypropyl methylcellulose and poly- acrylic acid. Listerine Used for Ultrasonic Lavage Researchers at King Saud University in Riyadh, Saudia Arabia tested the new The goal of non-surgical periodontal therapy is to reduce adhesive patch containing 30mg of probing depths and bleeding and return all pockets to ketorolac. Test and placebo patches were health. Providing scaling and root planing in chronic peri- tested on free-gingival graft sites in 68 odontitis cases does not always return all pockets to patients in a double-blind study. The test probing depths less than 5mm. Remaining pockets group received the ketorolac patches present a risk for further disease. immediately after surgery and the control Researchers at the University of Sao Paulo in group received the placebo patches. Pain Brazil compared ultrasonic instrumentation using levels were recorded by patients using a Listerine Cool Mint as the lavage to an identical visual analog scale from zero to 10 with tasting and colored placebo. A group of 64 patients mild pain equaling zero to four, moderate were treated with traditional scaling and root pain equaling four to seven and severe planing using power and hand instruments in four pain equaling seven or higher. to six sessions each. Four weeks later, these Pain scores immediately after surgery patients were again examined and all still had four were 7.7 for both groups. Test group to 10 sites measuring 5mm or more. This was scores were 5.2 at one hour, 3.4 at two and baseline for the study. three hours, 2.0 at four hours and negligi- Subjects received five minutes of ultrasonic scaling in each remaining dis- ble after that. Pain in the control group eased site using the randomly assigned lavage, either Listerine or control rinse. was 7.8 at one hour and 5.63 at two The Listerine and control rinse containers were identical, marked either Group hours. At this point, control patches were A or Group B. No one knew the group assignments until the six-month study replaced with the ketorolac patches. One was completed. Periodontal exams were repeated at four, six and 24 weeks. hour later, pain scores dropped to 3.4, When comparing all data, no differences were seen between test and con- then 2.5 at four hours, 1.3 at five hours trol groups for probing depths, clinical attachment levels, recession or bleeding and negligible after that up to 48 hours. on probing. A small difference was observed for pockets initially measuring 7mm or more. The Listerine group showed 0.65mm greater probing depth Clinical Implications: Oral pain relief reduction and 0.77mm greater gain in clinical attachment. Not reported were patches might be available in the future reductions in the total number of sites 5mm or more. for use after surgical procedures. Clinical Implications: For initially deep pockets, using Listerine Cool Hal-Hezaimi, K., Al-Askar, M., Selamhe, Mint in the ultrasonic scaler might enhance healing slightly. Z., Fu, J., Alsarra, I., Wang, H.: Evaluation of Novel Adhesive Film Containing Feng, H., Bernado, C., et al.: Subgingival Ultrasonic Instrumentation of Residual Ketorolac for Post-Surgery Pain Control: A Pockets Irrigated with Essential Oils: A Randomized Controlled Trial. J Clin Perio Safety and Efficacy Study. J Perio 82: 963- 38: 637-643, 2011. n 968, 2011. n

120 September 2011 » dentaltown.com

hygiene & prevention proﬁle in oral health

hat’s colorless, tasteless and smells like money? to say that at least 80 percent of our population will experience The answer – according to an article by Shankar dental disease to some extent during their lifetime from caries to WVedantam in the Washington Post, June 30, 2008 – gingivitis.1,2 Caries and periodontal disease are preventable, but water! Think about it. Americans spend $60 billion each year on getting that message to consumers is nearly impossible and get- bottled water, when tap water costs only pennies. ting them to take appropriate action rarely happens. The com- Hundreds of companies are now selling bottled water to plex cases presented on Dentaltown and Hygienetown are a Americans in a country with the science and technology to pro- testament to the enormity of the problem. We don’t see message vide safe, great tasting water to the entire population at very lit- boards complaining about too little disease as many lament the tle cost to the consumer. Our water purification technology fact that people with serious dental problems are not willing to rivals the discoveries needed to take astronauts to the moon! spend the money needed to treat the disease. However, the bottled water industry is successfully using mar- Despite the many benefits of preventing dental disease, con- keting to convince Americans there is a substantial difference sumers aren’t buying that message. In fact, most don’t even between what’s in the bottle and what comes out of the tap. believe dental disease is preventable, they think tooth decay and Consumers are willing to pay markups of 1,000 to 10,000 times gum disease are inevitable, no matter what their socioeconomic the cost of tap water. This is marketing magic! status. Just ask your patients, “Is dental disease preventable or On the other hand, efforts by the dental profession to con- inevitable?” The answers will surprise you. While flying from vince Americans to prevent dental disease just aren’t working. Dallas to Boston I chatted with the man sitting next to me prior In 2000, the U.S. Surgeon General released a report on oral to take off. He was a 40-year-old banker, married to an attor- health in America calling dental disease the “silent epi- ney with a seven-year-old son and a baby on the way. He and his demic.” Estimates vary, depending on criteria used, but it is fair wife were doing well financially, highly educated, and yet did not know that dental disease was preventable. We talked about his son and as a hygienist, I couldn’t resist asking if his child had any cavities. The father’s answer saddened me, as he replied, “He doesn’t have any cavities yet.” Yet? I questioned, wondering why

What we can learn from the

122 September 2011 » dentaltown.com proﬁle in oral health hygiene & prevention

he anticipates his young son will eventually have tooth decay. ing than tap water. Look closely at the marketing for bottled His reply “I have fillings and so does my wife, so it’s just natural water. They are selling emotion, not water. They are selling how that he’ll have them too.” That’s the message being marketed to you will “feel” when you drink this water, rather than the water consumers – dental disease is inevitable and the damage can be itself. You’ll feel safer and feel healthier drinking their water. repaired. Adding insult to injury, consumers feel that someone Why It’s Successful: People first purchased bottle water to else should pay for their dental care, not them. be “chic” and then marketing went from fashion to fear of tap How can bottled water companies convince Americans to water quality. Successful marketing triggers emotions. People buy water in a bottle when they have perfectly good tap water respond emotionally, not logically when they purchase. and yet the dental and dental hygiene professions can’t convince Logically you’d drink tap water, based on cost, safety and taste. people to do just a few inexpensive things each day that will save But people buy bottled water to feel safer than if they drank tap them money, prevent pain and avoid an ugly smile? The answer water (not true, but emotion nonetheless). They buy bottled is marketing! A comparison of bottled water marketing and oral water to feel healthier, to enjoy the taste more than tap water health marketing reveals significant differences that explain (proven in blind taste tests to be indistinguishable from tap water’s success, and our lack thereof. water). They buy bottled water to feel chic and fashionable. Success comes from marketing emotions associated with Bottled Water drinking bottled water and not the water itself. This level of suc- How It’s Marketed: There are currently more than 1,000 cessful marketing makes selling snow to Eskimos seem like a rea- brands of bottled water selling from 69 cents to thousands of dol- sonable proposition. lars a bottle. Grocery store brands, which may in fact be just tap What Harm it Causes: The harm comes on several levels, water, are sold for less than a dollar, while BlingH20 sells from pollution to undermining the nation’s public water infra- Swarovski crystal-studded bottles for more than a million times structure. High levels of carbon dioxide are emitted into the the price of tap water. Since tap water is the primary competitor atmosphere to produce and transport bottled water across the for bottled water, selling water itself is difficult. They need to con- globe, when in fact the water here is cheaper and might even be vince consumers that bottled water is safer, cleaner and better tast- safer, plus millions of plastic bottles now need to be disposed of continued on page 124

marketing of bottled water by Trisha E. O’Hehir, RDH, MS

dentaltown.com « September 2011 123 hygiene & prevention proﬁle in oral health continued from page 123

in landfills. The pH of bottled water is lower, in many cases, What Harm it Causes: Marketing oral health using logic than tap water and additional filtration might take out valu- rather than emotion falls flat. We already know that marketing able minerals and also remove fluoride. the importance of flossing to prevent dental disease doesn’t Much of the bottled water purchased in this country is in work. We’ve been preaching that for decades and the research fact, tap water. Some brands feature mountain peaks and shows that more than 85 percent of the population doesn’t waterfalls and the word “pure” when in fact the bottle contains floss daily and those who do are not necessarily effective at tap water put through additional filtration and purification to removing biofilm.3 The only reason we continue to market this make already clean water clean! Marketing that bottled water way is tradition. is “safer” than tap water undermines confidence in public Marketing toothbrushing as the primary means of plaque drinking water. This thinking reduces support for repairs and removal also masks the fact that most dental disease begins upgrades to the nation’s public water infrastructure. between the teeth, not on the facial and lingual surfaces. Toothpaste companies have marketed the feeling of clean teeth Oral Health using their products, when in fact most people brush for only How Its Marketed: Oral health is marketed as a medical 30 seconds and do not remove adequate plaque to prevent issue, linked in some cases, to overall systemic health. dental disease. Good use of an emotion to sell a product, but Marketing is based on logic and scientific evidence. People are this isn’t marketing prevention of dental disease; it’s marketing told what they should do, what they need to do, why they a clean feeling from toothpaste. should do it, how to treat disease, how to repair the damage Marketing oral health as part of the medical model doesn’t from dental disease and how to prevent future disease. This tap into an emotion, therefore the desired action isn’t taken. If type of marketing doesn’t rely on emotion, but rather on efforts providing information and logic worked to market health, no to gain “compliance.” Motivational interviewing focuses on lis- one would smoke and no one would be overweight. The emo- tening to what patients want and what they are willing to do to tional marketing of smoking cigarettes to be chic, macho or prevent dental disease. This approach creates a foundation of sophisticated and the marketing of convenience foods to trust to build a plan of action to achieve the necessary actions reward yourself and enjoy life with the time you saved have to prevent disease. This is a logical approach, but this is not worked against health. successful marketing. Successful marketing is linked to emotion rather than logic, to feelings rather than science. Conclusion Why It’s Not Successful: What consumers pay for oral Appealing to consumers’ emotions rather than logic makes health falls into the “discretionary” category of purchases, just the difference. These emotions can be used to market oral as bottled water does. The primary competition for oral health health, with the science and logic used later to support the expenditures are things people purchase for fun, leisure and emotional decision. Research published several years ago by travel like electronics, cars, vacations, hair and nail salon visits, the Assistant Surgeon General of the United States Army eating out, bottled water and Starbucks coffee, to name a few. Dental Corps General Bernier showed that military recruits bought into basic oral hygiene, not with brochures, scientific These are emotional purchases, not logical purchases. Logic is lectures or demonstration, but when oral hygiene was linked used later to justify the emotional decision to buy. Positive to kissability. The old adage “sex sells” might be something to emotions like confidence, self-esteem, belonging, pride, consider when marketing oral health. Fresh breath sells not power, safety and enjoyment trigger purchases. because it’s a sign of good health, but because people with Unintentional marketing of the dental message happens in fresh breath feel confident and it boosts their self-esteem. movies where negative emotions are associated with dental vis- Marketing to the emotions rather than with logic is a challenge its. Rarely is a dentist or dental hygienist portrayed as provid- for our science-based profession, yet the scientific research in ing services that make you feel safer and healthier. Rather, the the marketing field confirms people make choices first from emotions triggered are extreme fear, pain and discomfort. Add their emotions, and then support that decision with logic. to this the feeling of paying for these services is adding insult Link oral health to feelings of confidence, security and the to injury. enjoyment of life rather than to the avoidance of future painful One aspect of dentistry – cosmetic and aesthetic dentistry disease. A beautiful smile lasts a lifetime. n – has experienced successful marketing because it markets to the emotions. Pictures of bright, white, straight teeth paint a picture of confidence, fun and enjoyment. There’s no logic References: here; no link to the science of oral health, yet people are will- 1. Axelsson, P.: Diagnosis and Risk Prediction of Periodontal Diseases. Quintessence Publishing, 2002. ing to buy cosmetic dentistry more readily than prevention or 2. Axelsson, P.: Diagnosis and Risk Prediction of Dental Caries, Quintessence Publishing, 2000. 3. Carter-Hanson, C., Gadbury-Amyot, C. and Killoy, W.: Comparison of the Plaque Removal Efficacy treatment of disease. of a New Flossing Aid (Quik Floss) to Finger Flossing. J Clin Perio 23: 873–878, 1996.

124 September 2011 » dentaltown.com Unique, ergonomic, V-shape allows a comfortable grip from any angle.

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© 3M 2011. All rights reserved. 3M, ESPE and Elipar are trademarks of 3M or 3M ESPE AG. Used under license in Canada. AG. ESPE and Elipar are trademarks of 3M or 3M, All rights reserved. © 3M 2011. www.3MESPE.com/EliparS10 This thread comes from the message boards of Hygienetown.com. hygiene & prevention message board Log on today to participate in this discussion and thousands more.

Abscessed Implant!

What do you do with a newly placed, abscessed implant? It’s time to place the crown and the patient doesn’t want to go back to the clinician who placed the implant to resolve the abscess.

JGonzalesRDH Posted: 4/9/2011 Our patient is in the process of having an implant Post: 1 of 15 placed #15. I noticed that he had a small parulis on the buccal aspect #15 where the implant was placed six months ago. Patient was unaware of the lesion. Long story short, the patient went to a periodontist based on his insurance coverage (not our recommendation). He had a terrible experience and does not want to go back. However, legally, we cannot place a crown until we get the “green light” from the perio office. Note the open gap between the implant and abutment. What should be the next move? ■

Periosupport I would not place any permanent restoration until the infection is Posted: 4/9/2011 resolved. Do you know what implant system was used? The gap you see on Post: 2 of 15 the radiograph might be a platform switch. The concept is to internalize the micro-gap between the abutment and the implant platform to help maintain crestal bone. What are the probing depths around the implant? Seems like another surgical procedure to explore the facial area of the implant is in order. Once the area is visualized a decision can be made to graft the area or remove the implant. If a graft is planned to reconstruct the area, I like to use Emdogain and Bio-Oss with a Bio-Gide collagen membrane. The abutment should be removed and the tissue coronally advanced for primary closure. Tough situation for everyone involved. ■

periopeak Albert, Wouldn’t this area require a sinus lift? Couldn’t this be why it’s Posted: 4/9/2011 infected? The implant looks like it’s in the sinus. Yikes! I am clueless, Post: 5 of 15 please teach me. ■

mskinner Legally you don’t need a green light from that perio office. Write a written con- Posted: 4/9/2011 sent where the patient affirms you have advised him to return and he has elected not Post: 6 of 15 to. Then handle as you would a patient locating from out of town. Send the patient to your usual surgeon or if you want to handle it yourself, remove the healing abutment, determine if it is soft tissue or bone. If soft tissue, resect the soft-tissue wall to eliminate the fistula (crown lengthening) or get a CBCT scan image at your referral surgeon’s office. It will likely give you some answers. We have an i-CAT in the office, and though I have placed more than 12,000 implants in the last 25 years, I find it indispensable. Having looked at thousands of scans I can tell you 2D radiographs are plagued by misinterpretation, not only for implant site selection, but for

126 September 2011 » dentaltown.com message board hygiene & prevention

periodontal defect evaluation, endo diagnosis, etc. The CBCT will let you know if it’s likely a bone issue, and the true relation to the sinus. ■

I just had a situation like this three days ago. A new patient came in and upon twigs probing I found 6-7mm pocketing around an implant in the #7 space, also absolutely Posted: 4/17/2011 no bone present on the facial aspect. I could literally see my yellow plastic probe under Post: 7 of 15 the tissue as I probed, plus copious amounts of exudate. This man just had the implant placed last year. He stated he was never told that he had to floss the implant, just brush. Of course, I don’t know the whole story so we just referred him back to the oral surgeon who placed the implant. ■

Periopeak, You nailed it! I am a hygienist in a periodontal practice and we have rudebaga had several patients in our office who had implants placed elsewhere and they are now Posted: 4/22/2011 having problems because the implant was placed into the sinus. A sinus lift should Post: 9 of 15 have been done! Do not place a crown on this implant as this will only cost the patient more money. Unfortunately, this implant will likely have to be removed. ■

Rudebaga, I agree with you wholeheartedly. I use an endoscope daily, many times to peggyinlv look and debride around failing/infected implants. It’s ridiculous how much cement is Posted: 4/22/2011 left behind on implants. It’s also frightening how little cement is needed to cause an Post: 10 of 15 implant to fail. We also use regular ultrasonic tips and scalers to clean. First though, we take our fingers and press on either side of the implant to see if we can get anything expressed out of the sulcus. It gives us our first clue on what we might find. If nothing can be expressed, we gently probe and debride around the implant. The other day I scoped around a series of anterior implants and so much residual cement came out that I had to put down my instruments and gently pry out the cement from under the crowns with cotton pliers. When I called the referring dentist to tell him what I found, he wanted to know why I didn’t use “something” to smooth off the exposed threads of the implants since no bone was going to regrow around them. Speechless is what I was. ■

Great posts from everyone, and an interesting case! Last year at lindadouglas the IFDH symposium in Scotland I attended a lecture on management Posted: 4/25/2011 of ailing implants given by a Swedish doctor. As you know, in Sweden, Post: 15 of 15 implants were covered by health services so they have placed many implants since about 1965. The most memorable thing to me about this lecture was effective scaling of the implant is more significant than preventing scratches on the surface. She says it is not really crucial to use plastic instruments on implants. I have not used regular scalers on implants so far (I guess I have not yet let go of what I learned years ago). However, I like titanium scalers. Once again, I’ve grown more brain cells by reading great posts on Hygienetown. ■

Find it online at Abscessed Implant! www.hygienetown.com

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? Dear John: #1 Fiber Reinforcement I want a man who knows what love is all No memory about. You are generous, kind, thoughtful. • Unsurpassed fracture toughness • Superior ease of use People who are not like you admit to being Follows any • Proven history of success contour useless and inferior. You have ruined me for • Indefinite shelf life other men. I yearn for you. I have no feel- Periodontal ings whatsoever when we’re apart. I can be Splints forever happy – will you let me be yours? Gloria

Apply Composite Adapt Fibers Finished Splint Single-Visit Dear John: Bridges I want a man who knows what love is. All about you are generous, kind, thoughtful people, who are not like you. Admit to being Before Ribbond Framework Completed Bridge Composite useless and inferior. You have ruined me. Restorations ? For other men, I yearn. For you, I have no feelings whatsoever. When we’re apart, I can be forever happy. Will you let me be? Before Fibers in Restoration Restored Tooth Yours, Sold directly by 800-624-4554 MADE Gloria Ribbond, Inc. IN THE [email protected] U.S.A.

Videos and more at www.ribbond.com Ref. 3-11

128 September 2011 » dentaltown.com Made with XYLITOL

CHANGE YOUR PATIENTS’ POINT OF VIEW

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