This article identifies several of the current controversies, provides information about each, and shares my personal opinions on each. Undoubtedly, it will irritate some who disagree with my interpretation of the state of the art, which I will try to identify.

EVIDENCE-BASED DENTISTRY/MEDICINE
This phrase, pioneered by the late American and Canadian physician, Dr. David Sackett, has caused enormous controversy among practitioners and academics since its origin in about 1991. The hierarchy of levels of evidence in dental/medical studies is not well known among dental practitioners, but has become a near religion among academics. They are listed from most to least adequate evidence as follows:

• Meta-analysis—combines selected research from many studies
• Systematic review—review of all relevant studies
• Practice guideline—statement produced by a panel of experts
• Randomized controlled trial—subjects received randomized clinical interventions
• Cohort study—follows populations prospectively throughout time
• Case controlled study—retrospectively follows patients with and without a control
• Case report—what happened to a patient.

Evidence-based dentistry (EBD) may be the most important controversy that I will discuss. As a teacher of statistics many years ago, I could prove almost anything one wanted to prove by applying various statistical tests to whatever data to prove the desired result. Be careful when reading the results of a study. When considering the so-called “evidence” on any topic, you and I must look deeper than the apparent conclusions to any study, such as: who did the study, who wrote the paper (the author or a ghost writer), who funded the study, when the study was written, are the investigators knowledgeable and clinically competent on the topic, are there some potential ulterior commercial motives for the conclusions, can you believe the statistical analysis, and—very importantly—are the investigators knowledgeable about “real-world” dentistry?

My Observations
One must consider all of the above and other points when interpreting the “evidence” on studies. Every month we, as a team, analyze the “literature” overall to determine on which research projects our organization, Clinicians Report (CR) Foundation, should spend our time, energy, effort, and nonprofit financial resources. Each month, in the hundreds of articles reviewed, there are only a few articles/studies that have logical and proven application to what you and I as clinicians do on a daily basis. In fact, many of the alleged “evidence-based” articles are unfortunately diametrically opposed to what experienced clinicians find in practice.

Figure 1. On the top is an SEM image of a zirconia-based ceramic fixed prosthesis at seating in a CLINICIANS REPORT (TRAC) study. The “evidence” in the literature at that time was very positive about zirconia-based restorations. The lower image shows the same prosthesis in the mouth 8 years later after enough time had elapsed to show that the external ceramic did not match the expansion contraction characteristics of the zirconia.

Figure 2. There is no validity to the allegation that articaine causes more paraesthesias than lidocaine. If you are still worried, use articaine only for infiltrations.

Figure 3. Rotary, reciprocal, and hand debridement of root canals have been shown to be equally effective or ineffective. Note the remaining debris in the canal shown here, instrumented meticulously with a rotary file.

Well-planned and executed studies by knowledgeable investigators, who are unbiased, noncommercially supported, and without ulterior motives deserve your attention. However, changes in clinical concepts and techniques should not be done until sufficient time has elapsed to confirm the results of the study by real-world clinical observation (Figure 1).

The remainder of this article includes my conclusions on the printed research on specific topics and the clinical observations that I see as I speak to tens of thousands of dentists annually. I will not list the hundreds of related references, since you, as I, have a computer and access to PubMed, Google Scholar, the Cochrane database of systemic reviews, and your conclusions on any of the topics may be different than mine. I suggest that you attempt to make your own conclusions on the confounded literature on some of these topics.

ARTICAINE VERSUS LIDOCAINE
Articaine is now by far the most used local anesthetic in dentistry. Research concludes that articaine, as currently marketed, is twice as toxic as lidocaine. There have been allegations of more patients having lingering paraesthesia and anesthesia when articaine is used for mandibular blocks versus lidocaine. Studies have not shown that to be true. Also, the observations of practitioners show about the same quantities of paraesthesia with articaine versus lidocaine.

My Observations
The controversy is unfounded. Articaine is twice as toxic as lidocaine. Use half as much anesthetic solution when using articaine. Use infiltrations for most clinical situations. If you are still worried, use only lidocaine for blocks (Figure 2).

ROTARY VERSUS RECIPROCAL VERSUS HAND ROOT CANAL DEBRIDEMENT
Research shows proper use of any of these 3 concepts provides relatively equal results. Rotary is the most popular but breaks the most files. Reciprocal is gaining in popularity because of the frequency of file breakage by some dentists when using rotary devices.

My Observations
This controversy appears to be unfounded. If a practitioner is having success with any of the 3 concepts and is pleased with the long-term clinical results, there is no reason to change. New techniques including high-power ultrasonic debridement of root canals (such as GentleWave [Sonendo]) are coming. This technique may improve the currently relative inability of any of the 3 current techniques to completely remove debris from root canals (Figure 3).

IMPLANT SURGERY BY GENERAL DENTISTS
This controversy is a major frustration to me personally. Some research shows the overall success of implants placed by surgical specialists is slightly more successful than implants placed by general dentists. I feel that is to be expected, since specialists usually place more implants and specialists do the studies on success of implants.

As an American Board of Prosthodontics certified prosthodontist and a longtime restorative dentist, I have accomplished implant placement for more than 30 years, taught hundreds of general practitioners (GPs) to place implants, and observed the effectiveness and clinical service of root-form implants as placed by both surgically oriented general dentists and specialists. In my opinion, most surgical specialists know the surgery in more depth, but know little about occlusion or prosthodontics; and, most general dentists know surgery relatively well and have significant knowledge about occlusion and prosthodontics. Each group has weaknesses and strengths.

Figure 6. This panoramic radiograph shows gross caries in the impacted second molar. The infection in the pericoronitis and swelling reduced the effect of the local anesthetic. Use of sodium bicarbonate to raise the pH of lidocaine has been long-proven to provide anesthesia, even in the presence of infection.

Figure 7. This is a clenching bruxer with steep canine rise and incisal guidance. Restoration of this person’s condition is diametrically opposed to restoration of a grinding bruxer, in which case there is usually no lateral or incisal guidance.	Figure 8. The patient had many radiation and chemotherapy treatments for multiple squamous cell carcinomas in his head. Teeth were removed and healing occurred only after many hyperbaric oxygen treatments. The bottom image shows numerous slightly radiopaque repair restorations done with Ketac Nano (3M ESPE), not amalgam.

A related challenge is that the percentage of Americans who have received implants is low compared to many other developed countries, and even lower than some developing countries. We need to serve more of the public with this life-changing concept by educating more dentists to do them.

My Observations
Surgically oriented, experienced general dentists can be taught in a few days how to successfully place (simple) single implants in healthy patients with adequate bone. I have taught that concept to hundreds of successful general practitioners for 2 decades. It has been estimated that 80% to 90% of implants placed fall into that category (Figures 4 and 5). When general dentists do such dentistry, they soon find some of the more difficult procedures are beyond their comfort zone, and they find themselves referring more than previously to surgical specialists. Who wins? There are 3 winners: the GP, the specialist, and most importantly, the patients. In my opinion, it is high time for manufacturers, GPs, and specialists to eliminate the “turf battles” and educate more dentists regardless of specialty, to better serve more of the American public!

BUFFERING OF LOCAL ANESTHETICS
Sodium bicarbonate buffering of lidocaine is used routinely in many areas of medicine to raise the pH of the anesthetic solution, reduce pain of the acidic solution on injection, have faster onset of the anesthesia, and have the anesthesia be more profound in areas of infection. Although these characteristics have been proven by research and observation in numerous areas of medicine, the concept is still used only minimally in dentistry. Onset by Onpharma and Anutra by Anutra Medical provide 2 methods to buffer local anesthetic with sodium bicarbonate. Manual buffering is also used routinely in numerous areas of medicine.

My Observations
Research has shown the positive characteristics of buffering local anesthetics. The reasons for minimal use in dentistry appear to be cost, required changes in clinical techniques, some reported untoward reactions, and satisfaction with current techniques and lack of buffering. In the presence of infection and the related inability to provide adequate anesthetic effect, buffering is a proven solution (Figure 6).

Figure 9. Properly done conservative periodontal treatment has been proven for decades to have the same tooth morbidity and mortality as conventional periodontal surgical treatment, especially in patients such as this 80-year-old.	Figure 10. The tongue is a reservoir for the organisms that cause caries and periodontal disease. Cleaning debris from the tongue with a scraper has been shown to be much more thorough than brushing the tongue.

Figure 11. This is a typical patient found in “areas of need.” Hygienists and assistants working under the guidance and supervision of fully educated dentist are very capable of doing many expanded clinical tasks on such patients. Mid-level practitioners are not the type of practitioner needed in areas of need.

THE “RELIGIONS” OF OCCLUSION: WHICH IS RIGHT?
We dentists primarily treat 3 major diseases/conditions in our daily practices: dental caries, periodontal disease, and occlusion. However, we do not treat them equally well. Caries is often overtreated, periodontal disease is pathetically undertreated, and occlusion is essentially not treated, except for some orthodontists who primarily treat malocclusion and not the often more serious conditions related to occlusion.

I have taught, researched, and treated the 6 pathologic occlusal conditions for more than 40 years (grinding and clenching bruxism, primary and secondary occlusal trauma, biocorrosive abfractions, and temporomandibular dysfunction). I find the subject in the literature replete with contradictions and highly confounded statements. You can read any conclusions you want from the literature with “evidence” to prove the point of the article. Where are we with this major controversy?

Although so-called “normal” occlusion can be identified and described, there are many variations to the norm within patients who have painless, efficiently functioning occlusion. It has been my experience that personalized occlusion has been developed by each individual patient by that person’s muscle function, tongue movements, the type of food consumed, oral habits, and chewing patterns. Each patient’s occlusion can be quite different from others.

My Observations
To attempt to make rules and overall statements about occlusion that fit every person is futile (Figure 7). To state that one concept of occlusion or one articulator is best for every patient is impossible. As an example, placing a steep, canine-guided occlusion in a mature grinding bruxer is inviting failure and near immediate restoration destruction. Such grinding bruxers need to have their occlusion restored in a modified and refined, relatively flat occlusion similar to the destroyed occlusion. Providing optimal occlusion for patients requires an educated and experienced practitioner to determine the peculiarities of any specific patient, and only then should the sequence of diagnosis and treatment be as follows: carefully analyze and characterize the specific patient’s occlusion; plan the treatment related to those characteristics; and accomplish the treatment, including restorations, occlusal splints, occlusal equilibrations, and any other occlusion modifications as related to those characteristics accordingly.

“AMALGAM IS DEAD” VERSUS “AMALGAM IS BEST”
This controversy has existed my entire career. It is doubtful that it will be solved in the remaining lifetime of anyone reading this article! Some of the research on this subject is highly emotionally charged and in the fringe areas of science. Many diseases and disabling conditions have been allegedly caused by use of amalgam. Conversely, the ADA and other groups continue to support amalgam use. However, the World Health Organization’s official statement is as follows (you may Google the entire document):

The Geneva meeting encourages a global “phasing-down” of the use of dental amalgam and actively supporting the introduction of dental materials alternative to amalgam. A global “phasing-down” of dental amalgam will contribute considerably to reduction of mercury use and release; meanwhile, a complete ban is not yet appropriate. The issue of equity in dental healthcare needs to be carefully considered.

From both the research and clinical observation standpoints, there is no inexpensive alternative to amalgam that lasts as long in moderate- to large-sized intracoronal restorations. Research shows that amalgam in such restorations lasts twice as long as the major alternative, resin-based composite. Composite serves well in small restorations. Therefore, amalgam is still the mainstay restoration in many developing countries and in treatment in low-income treatment facilities.

My Observations
Surveys show that more than 50% of American dentists use amalgam at least some of the time and for specific clinical situations. Many of these dentists claim that amalgam is still the most adequate material for deep box forms and other clinical situations. Yet dentists in numerous other countries use composite, resin-modified glass ionomer, and conventional glass ionomer for all operative dentistry situations (Figure 8). Some of their schools have not taught amalgam in more than a decade. It appears that use or nonuse of amalgam in the United States is a personal decision for individual practitioners. I have found that elimination of amalgam is possible and have not used it for about 20 years. However, my behavior has not been based on the alleged toxicity of amalgam as much as on the patient demand for tooth-colored restorations.

CONSERVATIVE VERSUS CONVENTIONAL PERIO TREATMENT
Although some individual periodontists do not fit this statement, I do not see a significant amount of conventional periodontal treatment being accomplished in the United States by GPs or many periodontists, as determined by our CR Foundation surveys. It is the observation of most general dentists that many periodontists are not doing as much conventional periodontal treatment and have replaced that treatment in their business model with implant placement. Can and should dentists involve hygienists more in conservative periodontal treatment for moderate to severe periodontal disease? My answer is a resounding yes! Research on this subject, done at the University of Michigan many years ago, showed that conservative techniques can be as effective as more radical surgical procedures. A conservative estimate of the percentage of these relatively untreated periodontal patients in a general practice is at least 35% of adults. In a typical US general practice, that percentage is at least 400 to 600 patients! Motivated and educated hygienists should be used for this untreated group.

My Observations
Conservative periodontal treatment by dental hygienists is one of the solutions to the great need for treatment of periodontal disease (Figure 9). In my strong opinion, this is a major and important responsibility for dental hygienists —not the often-promoted idea of getting them involved with restorative and other areas of dentistry. Who wins with conservative periodontal treatment? The patient wins most of all, but the practice has a new revenue source, and dental hygienists become more highly involved, motivated, and satisfied. Typical conservative procedures are listed below. The major, most proven procedure is frequent scaling and root planing with less effectiveness observed with some of the other procedures.

• Education about periodontal disease
• Frequent oral hygiene instruction
• Frequent (2- or 3-month) scaling and root planing
• Tongue cleaning once or twice daily (Figure 10)
• Alternating oral rinses, changing frequently
• Subsystemic antibiotics beginning in nonresponding areas 3 months after starting treatment and used for at least 9 months (doxycycline hydrochloride 20 mg, twice per day)
• Local antibiotics delivered to nonresponding pocket areas after 2 or 3 months of previous points above (most popular is Arestin)
• Providing the patient with a metal base repairable periodontal removable partial denture, after about 9 months of treatment, allowing easy replacement of teeth, as some may be lost in the future
• Laser use is still controversial but supported by some groups.

ARE MID-LEVEL PRACTITIONERS REALLY NEEDED IN THE UNITED STATES?
America has a well-defined, effective team of auxiliaries including assistants, hygienists, technicians, administrators, and office personnel. What is lacking? I see nothing. Can the clinical use of these current auxiliaries be expanded? Yes! Mid-level dental practitioners are the strong suggestions of some organizations, allegedly to solve the access to care problem. Would partially educated/trained mid-level practitioners go to “areas of need”? That has not happened to a significant degree in other professions. They want to live in areas of little or no need. By the way, what type of dentistry is present in these “areas of need”? Complex dentistry! What type of practitioner is needed there? You guessed it, fully qualified dentists!

My Observations
The following are just a few of the many techniques that can be delegated to current dental auxiliaries (Figure 11), most of which are legal in all states (check your local practice act for details).

• Athletic mouthguards
• Crown try-in
• Custom tray fabrication
• Desensitization of teeth
• Diagnostic data collection
• Educating patients
• Fluoride application
• Laser therapy*
• Local anesthetic delivery
• Occlusal splints
• Periodontal antibiotics
• Preventive appointment
• Radiographs
• Reline denture temporary
• Restoration placement*
• Scaling and root planing
• Snore appliances
• Sealant placement
• Whitening teeth in-office
• Whitening teeth at home

*Not legal in some states.

In my opinion, mid-level dental practitioners are a misguided and potentially dangerous solution for access to care for dentistry, potentially negatively affecting patients, dentists, and the profession at large, and not satisfying the access-to-care problem.

IN SUMMARY
Many controversies are present in dentistry. A few of the major and minor ones are briefly discussed in this article. Dentists are advised to look at the best evidence that is available in the dental literature, blend it with their own and their colleagues’ clinical observations and, only then, use their best judgment on whether (or not) to change their own clinical concepts and techniques.

Dr. Christensen is founder and director of Practical Clinical Courses (PCC), chief executive officer of Clinicians Report (CR) Foundation, and a practicing prosthodontist in Provo, Utah. He is a co-founder of the nonprofit CR Foundation (previously named CRA). Since 1976, the Foundation has conducted research in all areas of dentistry and published the findings to the profession in the well-known CRA Newsletter, now called CLINICIANS REPORT. His degrees include DDS from University of Southern California; MSD from University of Washington; PhD from University of Denver; and 2 honorary doctorates. Early in his career, he helped initiate the University of Kentucky and University of Colorado dental schools and taught at the University of Washington. Currently, he is an adjunct professor at the University of Utah School of Dentistry. He has presented thousands of hours of continuing education globally, made hundreds of educational videos used throughout the world, and published widely. He can be reached at (800) 223-6569 or info@pccdental.com.

Disclosure: Dr. Christensen reports no disclosures.

DIAGNOSIS AND TREATMENT PLANNING

Much of dental treatment is now elective. It has been estimated that elective procedures such as veneers, PFM crowns, bleaching, amalgam replacement, etc, generate as much as 50% of a typical general dentist’s income.  Currently, some practices are overwhelmed with patients and have far more treatment than they can do, while others are desperately looking for patients. One of the major keys to a busy practice is thorough patient education. In spite of constant education by the lay press and professional sources, patients do not know what dental practitioners can do. They do not know the procedures that can upgrade their facial appearance and their overall self-esteem. As a result, the dentist who does only superficial examinations, avoids patient education during the diagnosis and treatment planning appointment, and treats only the obvious broken or carious teeth will have difficulty fully realizing the potential of his or her practice.

I highly recommend using one of the several electronic patient education concepts available today. CAESY (A Patterson Company) has a beautiful interactive patient education series; Practical Clinical Courses has a well-organized, easy-to-use, concise DVD series that is oriented toward assisting with patient informed consent; and MedVisor is an interactive patient education system just coming on the market. These types of educational programs are making a significant difference in practices, where they are used at the diagnosis and treatment planning appointment as well as during subsequent treatment. When a patient has a few mandatory procedures that are needed immediately, most patients will accept the treatment after it is explained to them. If elective procedures are discussed and demonstrated during the same initial encounter as when the mandatory treatment is explained, it has been my experience that patients will accept the elective procedures after the mandatory treatment has been completed. This suggestion does not infer encouraging patients to accept more treatment than necessary, only to educate patients to the treatment possibilities available and help them make their own decisions based on the education provided.

ENDODONTICS

Automated endodontic therapy has made a major impact in dentistry in the past 10 years, but many dentists are still using the concepts they were taught in school years ago. As with any new technique, the initiation of rotary endodontic therapy was met with criticism and skepticism, since one of the originators of the concept was a rebel in endodontics and was the initiator of Sargenti paste in root canals. Nevertheless, the introduction of numerous excellent rotary endodontic devices has made this concept clearly superior to conventional endodontic therapy. It is anticipated that dentists will continue to change to rotary endodontics and the so-called “crown-down” endodontic procedure.

Gutta-percha has been the mainstay in endodontics forever and is still the major material used as root canal filler. However, new products are being investigated, used, and promoted by dentists, manufacturers, and lecturers. The most promising of these  potential gutta-percha replacements is Resilon (Epiphany [Pentron]) and similar products from other companies. This material is a polymer of polyester that looks and feels similar to gutta-percha. It plasticizes at a slightly lower temperature than gutta-percha, doesn’t become brittle like gutta-percha does, and is bonded into root canals, unlike gutta-percha.

Because of the aging population and increased retention of natural teeth, there is no question that endodontic therapy will continue to be one of the most active and income-producing areas in dentistry.

AESTHETIC DENTISTRY

The king of dental therapy continues to lead both in activity and income in the profession. As an indication of the importance of this area, veneer fabrication now comprises about one third of the gross dollar production of the American dental laboratory industry. I anticipate that the major emphasis of the public and the profession toward aesthetic dentistry will not stop, or even slow down, in the foreseeable future.

As a past president of the American Academy of Esthetic Dentistry, an American Board of Prosthodontics diplomate, and one who stimulated the movement toward this area of dentistry, I have some major concerns. The challenges are not oriented toward technical or material subjects. The challenges are ethical! The most frustrating challenges in aesthetic dentistry are clear. How much of the current aesthetic dentistry therapy has been explained to patients with proper, signed,  informed consent? Do patients really know that some of these procedures have a finite lifetime, even if they are accomplished at a high-quality level? Are patients being treated by practitioners who are educated to accomplish the procedures? Is the national “hype” on lay TV and in published commercial advertisements factual and informative or just for financial gain? Are the “degrees” or special designations some aesthetically oriented general practitioners promote legitimate?

It is evident from discussions with leaders in the profession, concerned practitioners, and mistreated, uninformed patients that aesthetic/cosmetic dentistry, a potential blessing to patients and the profession, is rapidly becoming a curse as well. It is time to do something about it!

On the positive side, aesthetic dentistry has been the profession’s salvation. If this emphasis had not come along,  then the volume of dentistry in the United States would be about 50% of what it now is. More dental schools would have probably closed. Aesthetic dentistry has made this profession much more creative, interesting, satisfying to patients and dentists, and, of course, financially rewarding. However, the negative signals are evident. If we let the current trend toward dollars and selfish motives run unabated, we will have enormous public outcry. Over the past 10 years, dentistry has fallen from the top of the Gallup poll on public esteem to the middle of the scale. Let’s stop that downward movement!

IMPLANT SURGERY

If there is one area of dentistry that has had fantastic innovation over the past few years, it is implant surgery. Implants are now the standard of care for many situations. Try placing a 3-unit fixed prosthesis between 2 virgin teeth and see how you will be treated in a court of law. If adequate bone is present, implants are state-of-the-art for everything from 1 missing tooth to an edentulous arch. I promote to patients at least 2 implants and an overdenture for edentulous mandibles as the primary treatment plan instead of a typical complete denture.

Root-form implants are now in 3 general size categories–mini implants (~2 mm in diameter), standard implants (~3.75 mm in diameter), and wide implants (~6 mm in diameter)–with sizes in between the 3 categories. Many patients do not have enough bone for a standard implant and do not want significant grafting. The mini implant has been accepted rapidly, as it has filled a significant need when adequate facial-lingual bone is not present. Imtec has actively promoted mini implants. I have placed mini implants in bone as thin as 3 mm from a facial-lingual dimension.  However, at least 10 mm of bone must be present from an apical-occlusal dimension for successful use of mini implants. The mini implants are proving themselves for retention of both removable partial dentures and fixed prostheses, and for resistance to chewing and retention when placed under complete dentures. I have personally used them for several years with remarkable success.

The wide, short implants are especially valuable when grafting is not desired in areas over the inferior alveolar canal or under the maxillary sinus, where the bone is wide facial-lingually (6 mm or more), but minimal occlusal-apically (~7 mm).

After proper education, more general practitioners should become involved with implant surgery in healthy patients who have adequate bone. Currently, most oral surgeons and periodontists, some prosthodontists, a few endodontists, and ~5% of general dentists place implants. To serve the American public well and in adequate quantities of treatment, many more practitioners should take the time and spend the money to become educated adequately in this area. I belong to 3 organizations that will excite and educate you about implant dentistry, and I encourage you to look into joining one of them. Call for information: (1) The Academy of Osseointegration at (800) 656-7736; (2) The Interna-tional Congress of Oral Implan-tologists at (888) 449-4264; and (3) The American Academy of Implant Dentistry at (312) 335-1550.

IMPLANT PROSTHODONTICS

Wonderful changes are taking place in implant prosthodontics. From recent surveys, nearly all general practitioners and all prosthodontists are accomplishing this area of dentistry. Manufacturers have simplified their systems significantly, and continuing education has enhanced the level of quality in this area. The result is that most practitioners do not hesitate to practice implant prosthodontics on a routine basis. Advances over the past few years have made this area predictable and gratifying to patients and to dentists.

Laboratory fees are still a problem. They appear to be too high in many areas. If the dentist has adequately placed an implant abutment at the impression appointment, there appears to be no reason why the abutment crown should cost the dentist and patient more than a standard crown plus the cost of the abutment. Placing the abutment takes about the same time as preparing a tooth. If the laboratory technician has made a custom abutment for a fee to the dentist, again, there appears to be no reason that the crown should cost the patient more than a standard crown plus the cost of the abutment. How long does it take to screw the abutment onto the implant? If costs are held to an affordable level, then both patients and dentists will benefit, because more implants will be placed.

It is evident that the trend toward more implant prosthodontics will continue, the quality of these prostheses will increase, and this treatment will be as common as a crown on a tooth is today.

OCCLUSION

I feel that occlusion is the most neglected area of dentistry. In my opinion, the reported 30% or more of the population that has bruxism and clenching and the enormous number of people who have TMD need our help. Fortunately, we are seeing more interest in making occlusal splints for those who need them. I encourage you to educate interested staff persons to make occlusal splints. They may be conventional, hard, full-arch splints, or the popular NTI (nociceptive trigeminal inhibition tension suppression system; Access Dental), or the Best-Bite. Both the NTI and Best-Bite devices are partial occlusal splints placed in the anterior portion of the mouth to reduce masticatory muscle activity significantly and thus reduce or eliminate bruxism, clenching, and TMD.

Learning a simple method and rationale for occlusal equilibration is also mandatory for optimum occlusal treatment, and it is doubtful if you received that information in your predoctoral education.

The resurgence of so-called neuromuscular occlusion is evident. Although this concept and mechanism has been around for more than 50 years, it has found a home and is being highly promoted commercially. This trend will continue. After many years of active involvement in occlusion, I find that the various “religions” of occlusion are diverse and that there is some truth in each group. The important point is that we as practitioners must select the occlusal concept that is best for each of our specific patients, even if it combines concepts from more than one “belief” in occlusion.

If occlusal splints were made for the estimated one third of your patients who need them, consider the significant service you have rendered to the public, and don’t underestimate the major income source that splint placement is to your practice. There are now lawsuits indicting dentists who have watched patients grind their teeth for years without suggesting or making occlusal splints. It is time for us to be proactive in suggesting and providing occlusal splints for our bruxing and clenching patients.

I see more interest in occlusion and potentially more activity in this important area, and I encourage you and your staff to become more educated and involved in this area.

OPERATIVE DENTISTRY

This area was supposed to die. Did it? No. It continues to increase in need because of the aging population and the retention of natural teeth. Resin-based composites have made some operative dentistry procedures relatively easy, predictable, and highly gratifying to patients and dentists. New restorative resins with lower polymerization shrinkage are coming. More nanofill resins are coming. Amalgam continues to be used at least some of the time by more than 50% of practitioners, and its use seems to be somewhat stabilized in quantity. Two new, 5-second-cure LED lights are now available from both  Kerr/Demetron and Ivoclar Vivadent. Electric handpieces are now a viable choice for routine tooth preparation. Nevertheless, operative dentistry remains the lowest income area of dentistry on a time-use basis. Learn how to accomplish it rapidly, well, and with significant staff help. Operative dentistry is enjoyable, highly service oriented, relatively simple, and when done correctly, nonthreatening to you because of minimal complaints from patients.

ORAL AND MAXILLOFACIAL RADIOLOGY

Is there any question about change in this subject? Digital radiography for periapical and bite-wing radiographs is rapidly becoming the norm. You can’t wait much longer. It is expensive and still in the developing stage, but it is wonderful, and when it is incorporated into practice, you wonder how you got along without it. About 5 major companies can easily be identified by your local dealers. Ask your local dealer which is providing the most adequate support and which brand has been the most reliable in your area. Then go for it! Plan on upgrading your system as the technology continues to develop. At the present time, the concept is great, but there is still a long way to go, and you must expect change. Don’t wait.

Digital panoramic radiography is in a tremendous growth period. Most of you don’t have it, but again, get ready! There are a few highly effective devices on the market, but they are expensive and will continue to be so. If you are interested in tomographic radiography as an addition to your panoramic unit, which you should be if you are doing implant surgery or implant prosthodontics, some of the brands can produce tomography and some can’t. Be sure to check. Two popular brands that can do tomography are Planmeca and Sirona. Digital radiography is here and growing.

ORAL AND MAXILLOFACIAL SURGERY

Although the extraction of teeth has declined, oral surgeons keep busy with third molar extractions and implants. At this time, general dentists still complete most of the regular day-to-day extractions. Oral surgeons are continuing to become more active in medical areas sometimes considered to be peripheral to dentistry, and that trend will continue.

ORTHODONTICS

This is another area of high activity and change. General dentists and pediatric dentists are much more active in orthodontics, obviously stimulated by the increased popularity of the Invisalign (Align Technology) concept. This relatively simple method to move teeth with minimal to moderate malpositioning is popular among nonorthodontists and some orthodontists. This is the first major breakthrough that general dentists have made into the previously impenetrable orthodontic specialty stronghold. It will continue with the introduction of other relatively simple concepts.

PEDIATRIC DENTISTRY

This is another area that was supposed to die. It has not done so. Pediatric dentistry is still very alive and active. Children love candy, and they continue to have developmental challenges as well as frequent accidents. Pediatric dentists are doing far more orthodontics than in the past. The highly perfected resin-based composites of today are being used in children for both posterior restorations as well as crown/veneer restorations on anterior teeth. Compomer, the most popular brand being Dyract eXtra (DENTSPLY), and  resin-modified glass ionomers such as Fuji II LC (GC America) are being used in posterior deciduous teeth, and some dentists are using the old standby, silver amalgam, in children. General dentists still do most of the pediatric dentistry, as is the case in most of the dental specialties.

PERIODONTICS

I have been told by periodontists that less periodontal therapy is being done by periodontists because of the significant increase in implant placement by periodontists. I suggest that periodontal therapy is one of the most significant needs in dentistry. Patients are suffering with periodontal conditions, and few are being treated. I suggest that dental hygienists should be assigned to identify patients needing periodontal therapy in your practice, and that they should take over conservative periodontal therapy for those patients who will not see a periodontist. The well-researched, conservative therapies are as follows:

• frequent scaling and polishing (every 2 or 3 months  instead of every 6 months),
• tongue cleaning with a tongue scraper (twice daily),
• oral antimicrobiologic rinses (once or twice daily),
• systemic antibiotics-doxycycline hyclate (Periostat), and
• local antibiotics (Arestin [OraPharma], Perio Chip [Dexcel Pharma], Atridox [Collagenex Pharmaceuticals]).

Educated hygienists can accomplish these conservative procedures easily for patients in a typical general practice who have ongoing periodontal disease  but will not see a periodontist. Periodontal disease is not going away, and in spite of about 5 alleged cures for it promoted during my career to date, none have been successful. Go for it!

PREVENTIVE DENTISTRY

A strong movement is observable in what is being called minimally invasive dentistry. I had the opportunity to speak to the World Congress of Minimally Invasive Dentistry recently, and I was impressed with the organization’s orientation toward preventing dental therapy instead of always picking up a handpiece. New remineralizing chemicals, such as MI Paste from GC, and other concepts in all areas of dentistry are actually making an impact in the profession. I predict that this movement will grow and have a significant influence.

The major impediment to minimally invasive dentistry is convincing dentists that they can still make a living preventing disease instead of treating it. I believe that it is possible.

PROSTHODONTICS, FIXED AND REMOVABLE

I was told by some dental administrators and prognosticators quite a few years ago that by the year 2000, there would be no more need for prosthodontics because of the coming impact of preventive dentistry and the demise of dental caries. They were wrong.

Currently, fixed prosthodontics is the single-most income-producing area of dentistry, with the amount estimated to be about one-third of the income of a general dentist. Additionally, there are still at least 40 million edentulous patients in America alone.

Implant prosthodontics will assist in solving some of the tooth loss problem, but many patients cannot afford a mouth full of implants. For those patients, I suggest at least 2 or more implants combined with an overdenture that the implants retain and support.

The new zirconium oxide-based crowns and fixed prostheses will, in my opinion, eventually replace the venerable PFM. DENTSPLY Cercon and 3M ESPE Lava are leading the entry of the profession into these strong, all-ceramic, fixed prostheses. The respective companies as well as independent researchers have research support for use of these prostheses up to 6 units long. Currently, CRA has a major study underway, planned and administered by Dr. Rella Christensen, that will shed light on the long-term serviceability of zirconia-based fixed prostheses. I feel highly optimistic about zirconium oxide-supported, all-ceramic crowns and fixed prostheses, and I am using them in practice where indicated with success.

Prosthodontics (fixed,  re-movable, and implant), as well as maxillofacial prosthetics, is one of the most active areas in dentistry at this time, and the affluent, aging population, with a mouth full of remaining teeth, a few missing teeth, edentulous jaws, or missing facial parts, ensures the continuation of need and increased expertise in this area.

TECHNOLOGY

You can go bankrupt buying the new gadgets that are coming onto the market on a frequent basis. Some of the technology is becoming nearly mandatory, such as business computerization, digital radiography, caries detection devices (KaVo’s DIAGOdent), intraoral cameras, electric handpieces, and digital photography. Other technologies are more elective, such as operating microscopes, bleaching lights, imaging, computerized shade selection, some lasers, air abrasion, and others.

I use the following reasoning to determine if I need a new technolog: do I currently have some device that does a given task as well as the proposed new technology, and is this new technology going to make my practice faster, easier, better, or less expensive to operate? If I do have something functioning well at this time, and the new technology will not make the practice faster, easier, better, or less expensive to operate, then I wait.

SUMMARY

What an exciting time to be in dentistry! The ongoing changes are enormous in quantity. The variety of procedures is overwhelming! The continuing entry of new technology into the profession is stimulating, if not daunting. The public need and demand for dental services is at an all-time high!

HoweverÛkeep in mind that as a profession, we have a service responsibility, and that means we should strive for an altruistic, honest orientation to serve the public and yet make a reasonable and respectable income for ourselves and our families.

Dr. Christensen is a prosthodontist in Provo, Utah, and is director of Practical Clinical Courses and co-founder and senior consultant of Clinical Research Associates. He is adjunct professor at Brigham Young University and the University of Utah. He can be reached at (801) 226-6569, info@pccdental.com, or by visiting pccdental.com.

To comment on this article, visit the discussion board at dentistrytoday.com.

This article will express my thoughts on every area of dentistry in alphabetical order and make predictions about what will happen in each respective area over the next year.

DIAGNOSIS AND TREATMENT PLANNING

Unfortunately, most dentists do not accomplish complete treatment plans. Numerous maladies may result. Piecemeal dentistry is received by patients. Numerous potentially dangerous conditions may be missed; patients can be confused about what portion of suggested treatment is mandatory and what portion is elective; aesthetically oriented procedures may be omitted or missed; occlusally oriented procedures may not be adequately coordinated; and new concepts or techniques may not be offered to patients. It has been estimated from various third-party benefit plans that about one half of the dentistry accomplished in the United States is aesthetically oriented.

I suggest that readers who do not accomplish a total treatment plan on patients consider the following points and place them into practice if applicable.

•Most patients want to know the total condition of their mouth when that information is offered to them. They should be told that the mandatory treatment will be differentiated from the elective therapy. Patients accept the mandatory treatment, and if they like the result of that treatment, many accept the elective therapy.

•The technical aspects of diagnostic activity can be delegated to staff members, allowing the dentist to concentrate on clinical treatment of other patients during that time. I prefer a 1-hour diagnostic appointment, where diagnostic data collection is accomplished by staff members, and the diagnosis and treatment plan are done by the dentist during the last part of the appointment.

•In the current aesthetic dentistry age, there is no more important appointment in all of dentistry than the diagnostic appointment.

Intraoral cameras are now used by most dentists, and the changes in these devices have made them indispensable instruments for diagnostic activity. If you do not have a digital clinical camera yet, several are available for a moderate cost. The immediate observation of images, combined with storage capability, make these devices indispensable.

ENDODONTICS

Rotary endodontics and the crown-down procedure are dominating this aspect of dentistry and will continue to do so. Those practitioners not familiar with the devices and the crown-down clinical concept should make these subjects a must for 2004 continuing education.

Nonmetallic posts with resin-based composite buildups have become the current techniques of choice for rebuilding endodontically treated teeth. These methods provide easy clinical procedures, aesthetically pleasing root stumps, and relatively strong tooth restorations. However, clinicians should remember that research shows metal posts provide more strength to endodontically treated teeth. Endodontics will continue to be a major need in dentistry, a significant income producer, and a procedure largely accomplished by general practitioners.

AESTHETIC/COSMETIC DENTISTRY

In the past 30 years, interest in this area has revolutionized dentistry. Patients want to look better, younger, more attractive, and more normal. They want white teeth. On the positive side of this interest, clinical activity in dentistry has been greatly increased because of aesthetic dentistry procedures. However, there has been a definite down side to aesthetic dentistry, including overtreatment to unsuspecting patients, excessive fees, used car salesman-type hype, and overt dishonesty about products and techniques on television, in lay publications, by dental speakers, and in dental publications. Nevertheless, the overall emphasis on aesthetic dentistry is good, and it will increase, we hope, with renewed honesty and logic.

It is anticipated that numerous aesthetically oriented techniques will increase in use, including all types of veneers, tooth-colored crowns and intracoronal restorations, bleaching teeth, orthodontics, and surgical changes in the face.

Aesthetic dentistry, despite the negative changes in the ethics of the profession it has brought, has saved the profession from takeover by managed care, and it is a wonderful addition to the activity of dentists and the beautification of the public.

IMPLANT DENTISTRY

If you are not restoring dental implants in your practice, 2004 is the time to incorporate that procedure into your practice. Numerous simple implant restoration systems and courses about how to use them are now on the market, and there is no longer an excuse to wait until the implant concept is refined to a greater degree. Additionally, if you are a general dentist who accomplishes a significant amount of surgery, there is no reason not to include surgical placement of implants in your practice. The risk of placing implants in simple locations is less than extracting impacted third-molar teeth, which are commonly removed by general dentists.

Implant dentistry, both prosthodontic and surgical, has stabilized at a moderate level. Cost to practitioners for implants has continued to rise, and laboratories usually charge higher fees for implant supported cases. Because of these relatively negative factors, I predict continued stabilization and low growth in this area, but I strongly suggest that practitioners realize the importance of implant dentistry and incorporate as much of this fantastic concept into their practices as their personal comfort allows.

OCCLUSION

Dentists are afraid of occlusion. Despite approximately one third of the population having bruxism/clenching and the resultant tooth destruction and the rampant presence of temporomandibular joint dysfunction, this area of dentistry continues to be practiced by a hardy, biologically oriented group of practitioners. Recent years have brought renewed interest in the long-available, muscular-oriented occlusion concept. Because of the commercial emphasis in this occlusion orientation, there will be continued interest in the area. However, there is extreme controversy about what concept of occlusion is correct, and I do not see any relief to that controversy.

After many years as a practicing prosthodontist, teacher, and researcher, and experimentation with almost all concepts of occlusion, I can candidly state that it is not the concept of occlusion that allows success; it is the knowledge and experience and the clinical skills and honesty of the clinician that are important factors to success with occlusion.

OPERATIVE DENTISTRY

Operative dentistry is an area that confused prognosticators, who predicted a few decades ago that dental caries would be eradicated by now. How wrong could they have been? Not only has dental caries not been eliminated, it has increased in the class V and class VI (incisal edge) areas. Granted, there have been some reductions in childhood caries. However, dental caries is still a very viable infectious disease that commands significant dentist time and expertise in every general practice.

It is anticipated that class I and II resin-based composite restorations will continue to be the simple posterior tooth restorations of choice of most patients despite the clinical success but aesthetic unacceptability of amalgam. Improvements in the polymerization shrinkage and wear resistance of resin-based composites are anticipated soon, increasing the acceptance and use of this material. Light-emitting-diode (LED) curing devices are now commonplace. Although most are still inferior to halogen curing devices, new developments coming soon will broaden the wavelengths provided by the LEDs and decrease the curing time of these devices.

The segment of the aging population that cannot or will not practice good oral hygiene needs restorations that provide caries prevention. Resin-reinforced glass ionomer used as a repair and/or restorative material will become more popular.

The concept of laser tooth cutting is trying to make an entrance into the mainstream of practice. However, significant improvements are needed to effect this use. Air rotor cutting is so easy and reliable that other modes of cutting teeth are not being sought actively by practitioners. The public has interest in laser technology because of the successful activity in eye surgery. Thus, lasers in dentistry have an immediate interest despite the need for further development.

Tooth-colored inlays and onlays comprise only a small amount of restorative dentistry. Improvements in these materials are making them more attractive to dentists, and slow but progressive acceptance is expected.

It is expected that operative dentistry in all of its forms will be with us for a long time, and that tooth-colored restorations will dominate and eventually take over the tooth restorative aspects of the profession.

ORAL AND MAXILLOFACIAL RADIOLOGY

Digital radiography is here! Those who have not discovered the convenience of immediate interpretation of radiographs, the storage and retrieval capability of digital radiographs, and the pleasure of no chemical solutions to contend with should look into digital radiography.

ORAL AND MAXILLOFACIAL SURGERY

Extraction of teeth has become a rarity in many areas of the United States, and this trend will continue. General practitioners accomplish most of the routine extractions, and specialists accomplish the more complicated procedures. There appear to be no major factors that will change that orientation. Implant surgery will increase somewhat among oral surgeons, where it is already a major portion of their practices.

I encourage oral surgeons to assist general dentists to become involved in simple implant surgery. As this change occurs, general dentists will find more patients who could benefit from implants, many of whom are beyond their capability, thereby increasing the overall use of implants. All 3 groups win—patients, generalists, and specialists.

ORTHODONTICS

Orthodontic activity continues to grow, motivated by the general trend for patients of all ages to accept aesthetic changes in their faces and smiles. More adult orthodontic procedures are being accomplished, and this will continue to increase.

Despite outcries from some orthodontists, some brave nonorthodontist dentists cross the turf battle picket lines to become involved with legitimate courses in orthodontics. Having taught occlusion in some of these legitimate multisession orthodontic courses and after observing first-hand the clinical results, I see a future for increasing involvement of nonorthodontists with orthodontic therapy after they complete acceptable orthodontic continuing education courses.

There is continued interest in use of computer-planned, sequentially used trays to move teeth. Although the concept has received criticism from some conservative groups or individuals, many practitioners continue to support and use the concept. It provides orthodontic movement without the unsightly display of metal.

Orthodontic therapy is needed or desired by a significant portion of the population, and demand for orthodontic therapy should continue to grow rapidly.

PEDIATRIC DENTISTRY

Once thought to be declining because of preventive concepts, this area of dentistry is alive and well. Increases in sugar consumption in all areas of the diet and the normal lack of oral hygiene instruction and mouth cleaning capability of children have probably contributed to the continuation of need for restoration of childhood dental caries. Additionally, some pediatric dentists are accomplishing at least some level of orthodontics. More parents are becoming aware that there are well-educated, skilled specialists available for oral care for their children, but the bulk of pediatric dentistry is still accomplished by general dentists.

Parents are interested in tooth-colored restorations for their children, especially for their anterior teeth. There is a major need for stronger, more aesthetically acceptable, relatively inexpensive, easy-to-place anterior crown or veneer restorations for pediatric anterior teeth.

PERIODONTICS

Periodontists have taken on implant placement with enthusiasm. Perhaps it is because conventional periodontal therapy can be painful and disfiguring, requiring continuing treatment through life, while implant placement is relatively easy, almost always appreciated, and successful most of the time. The need for periodontists who still want to treat periodontal disease is present. As determined from surveys I have accomplished of general practitioners, I have concluded that general dentists do not accomplish much periodontal therapy other than routine scaling, root planing, and polishing, and most of those procedures are in the realm of dental hygiene.

A cure for periodontal disease has been proclaimed several times during my career to date, and no cure has been routinely effective. Conventional treatment methods are still the choice of most periodontists and the few general dentists involved with comprehensive periodontal therapy.

The potential of laser treatment for periodontal needs has received unbelievable hype, much of which has not been confirmed in practice. Although lasers have potential and patient acceptance, most periodontally oriented dentists use conventional methods.

Implant surgery will grow in periodontics, but treatment of conventional periodontal diseases will still be largely in the hands of hygienists, some periodontists, and precious few general dentists.

PREVENTIVE DENTISTRY

The aging population and some other patients in a typical dental practice need preventive concepts that are easy to use and effective. At this time, topical fluoride rinses and gels appear to be the easiest and most reliable modes to apply preventive concepts to the adult segment of the population. In my own experience, about 10% of the patients in a typical practice could use some form of aggressive preventive therapy for dental caries. These patients include (1) the aged population with degenerating digital skills, gingival recession, and general lack of motivation, (2) bulimics, or (3) any age of patients with high caries rates. A formal appointment with a dental assistant or hygienist, depending on legalities, can be used to implement this fluoride therapy. An alginate impression is made, casts are poured, and a thin tray is made while the patient remains in the office. The patient is instructed on how to use the trays and fluoride for 5 minutes at least once per day with a 1.1% neutral sodium fluoride gel. A reasonable fee for this service makes it a financially viable procedure in the office and a great service for patients.

Fluoride toothpastes have become the major dental caries prevention method in the United States. Almost everyone uses toothpaste with fluoride in it. The profound dental caries reduction effect has had a major influence on the American public and the dental profession.

Dentists and dental staff members are encouraged to provide in-depth preventive dentistry instruction to patients.

PROSTHODONTICS—FIXED, REMOVABLE, AND IMPLANT

This area of dentistry is the single largest area of income to general dentists. It has been estimated that about one third of the income of a US general dentist comes from fixed prosthodontics alone. What has caused this increase in prosthodontic needs? It is obvious that the older population with increased life expectancy, discretionary funds to spend, and a desire to look and feel better has stimulated this growth. Also, current materials and techniques allow dentists to provide restorative services that are as aesthetically pleasing and adequately functional as natural teeth in many cases.

There is a significant evolution going on at this time. Although porcelain-fused-to-metal crowns are still by far the major crown and fixed prosthesis restoration, all-ceramic crowns and fixed prostheses are growing in use a few percentage points each year. The CAD/CAM developments of the past few years have made all-ceramic crowns and fixed prostheses competitive with porcelain-fused-to-metal restorations. This growth and acceptance should continue, and there is no reason to expect that fixed prosthodontic activity will not continue its rapid and continuous growth.

Removable complete and partial dentures are still a major activity in American dentistry. Developments of new tooth forms, better denture bases, and refinements in framework metals continue to offer excellent service potential for patients. However, in my opinion, the expertise of practitioners in these areas needs significant upgrading.

Implant prosthodontics is maturing, and laboratories and dentists are gaining more expertise in these areas. I am concerned to see the continuation of some very difficult and unpredictable techniques when more simple procedures are now available. Continued efforts to educate practitioners and labs in implant prosthodontics are needed.

Maxillofacial prosthetics is a small but important portion of prosthodontics. Clinical expertise is available in most of the larger geographic areas for those patients unfortunate enough to need these services.

All of prosthodontics will continue to grow and expand in influence.

INFLUENCE OF MANAGED CARE

Managed care in all of its forms has made a major impact on dentistry, and it is stabilizing with several categories of benefit plans, some shrinking and some expanding. Dentists must decide what level of income is needed to produce a realistic optimum quality of services in their practices, then participate only in those third-party plans that allow this quality level.

It is heartening to see the slow but continual decrease in dental HMOs. In my considered opinion, these organizations have little or no place in the dental profession. The small amount of services provided to individual patients and the cost cutting necessary for practitioners to survive financially while working in these groups have caused a significant challenge for practitioners. Patients who thought they had dental care plans have been disappointed to be required to go to “preferred providers” and receive minimal or no benefits.

PPOs are growing nationally, and they will continue to do so. If specific plans offer adequate funding of procedures for you to do your normal quality of dentistry, participate in them. If they do not provide adequate funding, get out ASAP!

Indemnity programs continue to decrease slowly, but most of them are adequate in funding to allow quality services. In general, these are still one of the most satisfactory types of third-party payment concepts.

Direct reimbursement is growing slightly, but it is a minor part of third-party payment in dentistry. I cannot understand why such a logical concept is not accepted immediately by companies looking for a dental benefit plan. Direct reimbursement is without doubt the best of the third-party benefit concepts for dentistry.

Dentistry can be thankful that the ingress of the undesirable parts of managed care in dentistry was timed nearly exactly with the introduction and growth of aesthetic dentistry, most of which is elective and not funded by third-party payment plans. The result has been that dentistry has not been consumed by managed care to the degree of our colleagues in the other parts of medicine. We are surviving the managed care takeover while retaining some semblance of control of quality and dignity in the profession.

SUMMARY

Dentistry is growing and serving the public better than ever before. In this article, the various divisions of dentistry have been considered, observing the current state of the art in each one and making predictions about the changes that are coming in the near future.

Dr. Christensen is founder and director of the Provo, Utah-based Practical Clinical Courses (PCC), an international continuing education organization for dental professionals initiated in 1981. He has presented more than 40,000 hours of continuing education throughout the world and has published hundreds of articles or books. He and his wife, Rella, are co-founders of the nonprofit Clinical Research Associates (CRA). Since 1976, CRA has conducted research in all areas of dentistry and published the findings to the profession in the well-known CRA Newsletter, which is now read throughout the world in 10 languages. Early in his career, Dr. Christensen helped initiate the University of Kentucky and University of Colorado Dental Schools and taught at the University of Washington. He has served as a department chairman, associate dean, and full professor. Currently, he participates on the postgraduate faculties of many dental schools, is an adjunct professor at Brigham Young University, and a clinical professor at the University of Utah. In addition to his education pursuits, Dr. Christensen practices in Provo, Utah. He is a diplomate of the American Board of Prosthodontics, a fellow and diplomate in the International Congress of Oral Implantologists, a fellow in the Academy of Osseointegration, American College of Dentists, International College of Dentists, American College of Prosthodontists, Academy of General Dentistry (Hon), Royal College of Surgeons of England, and an associate fellow in the American Academy of Implant Dentistry. Practical Clinical Courses can be contacted at (800) 223-6569 or via e-mail at info@pccdental.com.

Dentistry Today: You have often noted that general dentists should become more involved in periodontal care. With an increasing body of evidence suggesting that periodontal disease may be linked to various systemic conditions such as cardiovascular disease, do you foresee the general dentist taking a more proactive position in periodontal therapy in the future?

Dr. Christensen: At the moment very few general dentists treat periodontal patients. It is amazing to me that this is the case. I have a workshop each year that brings in one senior dental student from every dental school in the United States, and we observe their level of knowledge and their professional aspirations. We find that they know a lot about periodontics. I convene another group in July called The New Dentist Program, which involves one dentist from every state who has been out of school up to 5 years. I give them a quiz on what they know and what they are doing in their practices. I find that they are doing almost no perio in their practices. My frustration with this is they know a lot, but won’t do it. Even periodontists are becoming less active in treating periodontal disease because they want to do implants.

Dental hygienists and periodontists are the ones treating periodontal disease. I foresee the area of conservative periodontal treatment becoming more active in general dentistry. This increase in activity will probably be on the part of hygienists. I cannot seem to motivate general dentists to want to do perio. I have tried with articles and various personal commitments, yet there seems to be less interest in perio than I would like. I think that if dentists see a so-called profit center in general practice as being a hygiene-based conservative therapy orientation, this may do it.

The potential link between periodontal disease and systemic disease has been of academic interest, and we have all seen articles on this topic in both the professional and lay press, but it has caused almost no activity among general dentists. Some of the procedures I would include as conservative periodontal therapy are well known, and others are not as well known. Patient education is an obvious need. Oral hygiene instruction is necessary, but frankly, it is not too influential among people who have not cleaned their teeth for most of their lives. Tongue cleaning is new to most Americans, although it has been around for a few thousand years. It has been estimated that roughly 50% of people should be cleaning their tongue because of long taste buds and the scum that is left on the tongue, causing bad breath and contributing to generalized periodontal breakdown. Tongue cleaning really needs to be emphasized in conservative perio. Scaling and root planing is well known, but in my opinion, it is often done incorrectly. The dentist, or usually the hygienist, often scales 25 years of calculus off in one visit rather than using more frequent recalls, of perhaps scaling on 2- or 3- month intervals, removing the calculus a little bit at a time. Multiple visits do not hurt the patients, and they are maintained as patients rather than frightening them away. I suggest a revised form of scaling and root planing that is incremental and progresses slowly over several months.

An area that is not as well known, but  which is becoming quite influential in general practice, includes the use of systemic antibiotics. Currently, the main product used is Periostat, which is 20 mg of doxycycline hyclate administered twice a day for up to 9 months. This drug has shown significant positive influence in periodontitis or peri-implantitis patients. I suggest including Periostat in conservative periodontal therapy. There are many rinses on the market now, but the most well known is 0.12% chlorhexidine gluconate. I suggest using this for a couple of months twice a day, and then following it with other agents, such as one of the herbal solutions, the most popular being Tooth and Gum Tonic (Dental Herb Company). Then, follow up with other solutions, such as Listerine, chlorine dioxide, or stannous fluoride rinses. Alternate the solutions every couple of months. Another conservative periodontal therapy is local antibiotics. There are three products that are popular: Atridox from Collagenex, which is doxycycline hyclate; PerioChip from Dexel Pharma, which is chlorhexidine gluconate; and Arestin, which is minocycline hydrochloride. The three of them can be alternated in pockets that are 4 to 5 mm deep. In most states, they can be applied by hygienists.

I have noted that many of the people referred to periodontists are not pleased to undergo surgical therapy, but they are more willing to undergo conservative therapy. Periodontics doesn’t seem to excite general dentists, and this feeling probably will not change. The periodontal need is enormous, but general practice interest is minimal, and even periodontist interest is waning. Dental hygienist treatment potential is high, and conservative therapy is becoming more popular. Since conservative techniques can be delegated to staff persons, it is a source of income as well as a service to patients. Conservative periodontal therapy should grow.

DT: In many clinical situations, implants have become a highly predictable treatment for replacement of missing teeth. However, improvements in endodontics, periodontics, and prosthodontics, including tissue regeneration and bone augmentation, now allow the clinician to save teeth and roots that once were considered hopeless. How do you foresee the role of implants versus tooth/root retention procedures in the future as the treatment of choice in these situations?

Dr. Christensen: I am involved personally with both implant surgery and implant prosthodontics, even though I am a prosthodontist. The advent of implant dentistry is probably the most exciting and significant advancement in the more than 40 years I have been a dentist. However, only a few general dentists involve themselves with implant surgery. Most general dentists will accomplish implant prosthodontics. This concept is contrary to most other developed countries, with the exception of Canada, which is similar to the United States. In Western Europe, South America, and Asia, general dentists do the bulk of implant surgery.

My own belief about tooth retention has really changed since implants have become more widely and successfully used. I am more hesitant to retain teeth that are not sound since I know that implants perform well. I recently made a video on this subject, noting the clinical failures I have encountered by being too heroic in keeping suspect broken-down teeth. I entitled that video, “Dr. Christensen’s Most Frequent Failures and How to Avoid Them.” I have about 60 clinical situations in this video. One of my primary  mistakes has been being too heroic about keeping a broken-down tooth root, including some hemisections. Although I have accomplished many of those, I have had some notable failures. If I encounter teeth that are questionable and I am accomplishing comprehensive dentistry on the patient, I often choose to extract the tooth and place an implant. However, I know that the typical dentist would rather keep the broken-down tooth, or extract it and do conventional dental therapy. There will probably be more retention of teeth due to improvements in endodontics, periodontics, and prosthodontics, but I would really like to see the increased use of implants in those situations where the retention of broken-down teeth is questionable.

DT: Digital technologies are playing an increasing role in dentistry. Has the growth of digital radiography and photography met your expectations? What do you foresee for the future of digital technology in clinical dentistry, particularly in North America?

Dr. Christensen: I am probably a good example of the potential for digital technologies to develop within the profession, since I am a more mature dentist in terms of age and have changed almost totally to digital technology. However, many dentists in my age range and even younger have not done so. Age of dentists is still a determining factor, but it will not be for too much longer. Digital radiography has had slow, although progressive, growth in North America. Reasons for the less-than-expected growth are high cost, difficulty of integrating the concept into the practice, time involvement of incorporating it into the practice, and the cost of converting previous radiographs to digital format. Frustration with the service from some of the digital radiograph companies were very high at first, due to lack of adequate service and lack of support of dentists. More recently, there has been relative satisfaction, particularly among older dentists, with conventional radiography.

Our most recent Clinical Research Associates comparison of digital devices is posted on the CRA website at www.cranews.com. It allows an actual comparison of the digital devices with conventional radiographs. We used several CRA evaluators in the study and had them observe a comparision between typical conventional radiography and digital radiography. This comparison showed that neither digital nor conventional radiographs are adequate in showing initial dental caries. I was appalled. Some of the digital devices were so bad we couldn’t even detect lesions that were near pulp exposures. Others were as good as, but not better than, D or E speed conventional film. We found that if you are changing to digital, you are doing it for other reasons than better quality radiographs. Either type of image, digital or conventional, showed only about one half of the depth of the actual carious lesions when the teeth were dissected. Their diagnostic ability could not be compared with the radiographs of the 1960s—in the 1960s what you saw on radiographs was what was present on the teeth. Use of a reduced amount of radiation since that time is what has caused the depreciation in radiographic diagnostic ability.

I predict a slow but continued growth of the digital radiography concept because of decreased radiation, immediacy of image observation, storage and retrieval capabilities of the information, and the overall general conversion to digital concepts.

In contrast, digital photography is growing rapidly in the profession. It is very  easy to become proficient with this concept. In many continuing education audiences  I find as many as 60% of dentists use digital photography. It allows excellent patient education opportunities, storage and retrieval of images, immediacy of image viewing, and overall simplicity in producing photographs at a relatively moderate cost. Overall, I predict slow but sure domination of digital integration into all areas of dentistry, but I see the photography leading, with radiography being second showing slow but progressive growth.

DT: Dental materials have certainly evolved quite rapidly in recent years, especially composite resins and ceramics. However, certain clinical problems still exist with these materials. Many people have predicted the demise of conventional materials such as amalgam and metal alloys in favor of “tooth-colored” materials. How do you perceive the relative role of amalgam and metals versus tooth-colored materials in the future, including your forecast for how resins and ceramics will continue to evolve?

Dr. Christensen: This subject continues to be of high interest to dentists and patients. The profession is on the brink of significant improvements in composite resins. Soon we will see lower shrinking resins; we have some with less than 1% shrinkage under evaluation currently. Soon, there will be materials available with more wear resistance than in the past. Polymerization shrinkage and excessive wear have been the two major challenges in resin technology, and improvements in these areas will give justifiably greater emphasis to tooth-colored restorations. These changes will also help polymer crowns achieve acceptance. Some of the polymer crown materials have been disappointing, and only a few have been clinically acceptable. Polymer crowns  need significant improvements, but I don’t think these improvements will be hard to achieve. We have studied five brands of polymer crowns for 4.5 years, and belleGlass and Sculpture Fiberkor have been consistently good products.

I feel that ceramics will continue to dominate the crown market. Lower wear of opposing teeth by ceramic crowns is becoming a reality, but breakage of ceramic materials is still a significant negative factor. At this time, judging from reports from the major laboratories, over 70% of crowns are still PFM; about 92% are tooth colored; and only about 8% are gold alloy.

When considering amalgam versus composite, based on what I see represented by  thousands of dentists in continuing education audiences, resin-based composites are becoming more popular. For small to moderate restorations, the typical American dentist is currently placing composite resin. In the larger restorations or for patients with financial concerns, they are placing amalgam under false pretense, assuming that amalgam is a less expensive restoration. In our evaluations of the economics of amalgam, in most practices amalgam  is a “break even” procedure. Therefore, to say it is less expensive is closing one’s eyes to the facts. It is less expensive because the fee has not been raised to a level where it provides income to a practice. In a public health orientation and where the practitioners are salaried and high overhead is not a problem, amalgam does have a more forgiving nature than composite and it serves well. The difficulty of the composite versus amalgam procedure for experienced dentists is quite equal for the two materials. In terms of the alleged biologic challenges, composite wins.

Taking a look at surveys showing fees for both procedures, the fees charged for both composite and amalgam are too low in relation to many other routine procedures. For example, if we look at a similar time involvement for other procedures, such as single canal endodontic therapy, we find that the latter brings in four or five times the gross income than either amalgam or composite in a similar amount of time. For the future, I have no reservations saying that use of resin-based composites will increase. In crown and bridge, ceramics will reign until resin-based composites  for crowns have made significant improvements.

DT: The controversy about the impact of managed care in dentistry remains at center stage for many dentists. Has managed care negatively affected the practice of dentistry to the degree many once predicted it would? Has there been any positive impact? What is your vision of the future in terms of how dental care is paid for?

Dr. Christensen: Managed care is finding its place in the dental profession. It is not overwhelming the profession as it has in other areas of medicine, but it is definitely a significant portion of dentist income. However, most dentists have found that quality dentistry and economic survival can be found primarily in fee-for- service dentistry. Some young practitioners have suffered financial disasters with dental HMOs. Similarly, the average 20% fee reduction necessary in PPOs has caused even mature practitioners to have severe financial challenges. As an example, assuming a dentist has a 65% overhead, a 20% fee reduction leaves only about 15% before-tax profit. When about 50% overall federal, state, and local taxes are deducted from the 15%, before-tax profit of about 7.5 cents on the dollar of gross income remains for a PPO participant to spend on his or her family. This is pitiful, and it is evident that a dentist cannot participate on a long-term basis in such plans without burning out. I have seen this among many young dentists. They participate in HMOs or PPOs for awhile, thinking that they will obtain adequate income to support their families, but that has not happened in many practices.

Who benefits in DHMO programs? Not dentists, not patients. The HMO companies are the recipients of the financial benefits. Who is gaining in the PPO area? A few patients who would not receive treatment if they were not participating in a PPO. In my opinion, this is the only remotely positive aspect of managed dental care. But are dentists gaining financially? No. Looking at statistics for the year 2000, which is the latest data we have, dental plan enrollment in the United States was as follows: PPOs roughly 40%, indemnity plans roughly 27%, HMOs 19%, and referral plans about 14%. Interestingly and thankfully, dental HMOs dropped 8.3% in enrollment in 2000. However, dental PPOs went up 21%, and dental referral plans, which represent a relatively small part of the market, went up 126%. Dental indemnity, which has been the legitimate portion of managed care for most typical dental practices, sadly went down 18.5% in 2000. According to Harold Childs at the University of Connecticut, “Dental PPOs are now growing at 30% to 40% per year, and will go up to between 60% and 70% of the total.”

Looking at California, which has one of the highest percentages of managed care in the country, at least 65% to 70% of dentists in that state will accept managed care. For California Delta in the year 2000, preferred PPOs grew to 22%; premier indemnity dropped from 66% to 63%; and the Delta Care HMO dropped from 17% to 15%. So, the trend in California is for PPOs to grow and DHMOs to decline. Managed care is somewhat stable in the United States at this time. But as I look at what has happened in dentistry because of DHMOs and PPOs,  I see very little good that has come from either concept, except for a few patients who may be receiving rudimentary care in one of the plans, who would not otherwise receive it. I predict that because of the elective nature of much of dentistry, freedom of choice dentistry will continue to be a significant portion for those dentists who seek it. My advice to dentists is avoid the DHMOs like the worst cancer you can imagine. If you desire to provide quality oral healthcare with freedom of choice for patients, avoid PPOs. Carefully select indemnity plans that are not PPOs in disguise—we are seeing more and more indemnity plans that are dropping a percent or so and thereby becoming PPOs in disguise. Encourage local and national companies to choose direct reimbursement or direct assignment. Thankfully, these concepts are growing, although they are still a small part of payment for dental services. If companies only knew what direct reimbursement would do for their employees, they would go for it.

DT: What is your view of the future of dentistry, including your prediction for the major areas of clinical dentistry in terms of growth?

Dr. Christensen: Overall, the future of dentistry is extremely bright, better than ever in my career. If I were starting out again, I would make the same career decision without a moment’s thought. The overall population ratio is changing to favor dentists. In 1990 there were 59.5 dentists per 100,000 people in the United States, but in 2000 it was 58.4 per 100,000. The publication Managed Dental Care predicts that in 2005 the ratio will drop to 58:100,000; 2010 to 57; 2015 to 55; and by 2020 it will drop to 52 or 53. This ratio is obviously going down, and this means more patients per dentist. One potential negative consequence of this is that there will be fewer dentists to buy practices in the future. For a long time I have encouraged dentists to not depend on the sale of their practices to support their retirement.

Looking at specific areas of dentistry and the trends, the area of diagnostics is increasing in need because of the necessity for diagnostic activity for elective dental procedures. Endodontics has increased significantly, and when endodontics and fixed prosthodontics are combined, they comprise half of the income of general dentists in this country. Aesthetic dentistry is king. Implant dentistry, both prosthodontic and surgical, is stable, but I would certainly like to see an increase in this area by having more general dentists involved. Occlusion is an area waiting to be born—bruxing and clenching affect one third of the international population, and occlusal splints are necessary. Occlusion is an untapped area. Operative dentistry, in spite of predictions it would die, has a higher need because of the aging population. Oral and maxillofacial surgery is up, because the older people get, the more surgical procedures they require. Orthodontics is ready to literally blow up—only 25% of orthodontics is adult currently, and I predict this could go to 40% if adult -oriented procedures are further incorporated into general practice, which is happening now. Pediatric dentistry was supposed to die, but it has turned on again. You just can’t keep kids from eating candy or keep their parents from feeding them various cariogenic foods. Periodontics is not a highly active area.  As I discussed, this area needs rejuvenation. We can’t get general dentists to accomplish periodontics. The treatment need is there, but we need to motivate dentists and patients into conservative periodontal therapy. In the area of preventive dentistry, about 10% of the typical general dentist’s patient population needs heavy preventive therapy, ie, chemotherapy and radiation therapy patients, bulemics, senile individuals with caries, juveniles with caries, and tobacco chewers. Many of them need heavy fluoride, which is a win-win situation in terms of economics for the dentist and hygienist, and it is certainly a service to the patient. Prosthodontics—fixed, implant, maxillofacial, and removable—were predicted to die. When I helped start a dental school 30 years ago, I was told not to start a prosthodontics department because there would not be any prosthodontics by the year 2000. Now the combined area of prosthodontics is probably providing upwards of 50% of the general dentist’s income. This area will continue to grow.

Except for my concerns about managed care, I don’t have a negative thing to say about dentistry. The future of the profession is very bright.

Dr. Christensen is cofounder and senior consultant of Clinical Research Associates and director of Practical Clinical Courses. He has lectured throughout the world and presented over 40,000 hours of dental continuing education courses. He has published hundreds of articles and books and developed several hundred videos and DVDs. He maintains a practice in Provo, Utah. He can be reached at (801) 266-6569, info@pccdental, or www.pccdental.com.

The field of endodontics is undergoing a continual evolution in terms of materials and techniques, as well as growth in the number of patients who can benefit from endodontic treatment. In order to gain insight into the current and future status of this important clinical area, Dentistry Today interviewed Clifford J. Ruddle, DDS, a well-known leader in endodontic innovations, clinical technique, and education. In this interview, Dr. Ruddle shares his views on aspects of endodontics that should be of particular interest to general practitioners.

Dentistry Today: How would you categorize the growth in endodontics and, in your opinion, what has driven this growth?

Dr. Ruddle: There has been massive growth in endodontic treatment in recent years. By the early 1960s about 3 million teeth were endodontically treated in the United States annually. In the early 1990s, US dentists were treating 40 million cases per year, and currently the profession is performing over 50 million endodontic procedures each year. This endodontic growth is extraordinary and can be largely attributed to the ever-increasing acceptance of proven concepts, significant improvements in technology, and better trained general dentists and specialists alike. Clearly, this unfolding story would not have been possible without the general public’s growing selection of root canal treatment as an alternative to extraction. Over time, patients have become more comfortable voting for endodontics because of the change in perception that pain can be managed, one-visit endodontics is generally possible, and treatment is more predictably successful.

DT: Has this rapid endodontic growth created unforeseen problems and, if so, what are the challenges we need to meet?

Dr. Ruddle: The incredibly rapid growth in endodontics can be described as the good news/bad news dilemma. The good news is hundreds of millions of teeth are salvaged through combinations of endodontics, periodontics, and restorative dentistry. The bad news is if we treat 50 million cases per year and if the failure rate is just 10%, then there would be 5 million treatment failures per year. Extrapolating over the past 3 to 4 decades reveals that the number of failing endodontically treated teeth is massive, and could approach tens of millions!

Clearly, many previously treated endodontic cases currently need re-treatment, many more teeth have already been nonsurgically re-treated, others have been surgerized, and a large number of failures have been extracted. Failures are neither good nor bad, they just are. Mao Tse Tung wrote that the foundation of success is failure, with the important caveat, if we accurately discern the cause of failure. The challenge is for dentists to fully embrace proven concepts, become more proficient, and take advantage of the significant procedural refinements that have occurred during the last decade so we can fulfill the public’s higher expectations for predictable results. When the best of what endodontics has to offer is intelligently integrated, then the naturally retained root will be recognized as the ultimate dental implant.

DT: What are some of the controversies that potentially sabotage endodontic success, and how can these issues be resolved?

Dr. Ruddle: When one evaluates the current status of clinical endodontics as a healing profession, one is struck by the vast differences in how endodontics is understood and practiced from country to country, state to state, city to city, office to office, and even practitioner to practitioner within each office. Yet, rational treatment approaches are available, precise treatment techniques have been perfected, and success rates approaching 100% are measurable. The differences in how endodontics is practiced relates to different belief systems, which have led to legendary controversies. To make my point, if one reviews the dental literature, one will find that there is virtually no agreement on a variety of fundamental issues. Let me give you a few examples.

There is no universal agreement as to what are the best techniques and methods for performing vital pulp testing. There is ongoing controversy regarding the size of an access cavity and the strength, temperature, and type of irrigant, as well as its potential to clean. Ongoing debate continues regarding working length and patency files, the sequence of canal preparation, and the ideal percentage taper that ensures a root canal system can be three-dimensionally cleaned and obturated. There is no agreement on sealers or what is the best, most effective technique to pack a root canal system. There is still plenty of controversy among clinicians as to whether a failing case should be re-treated nonsurgically, surgerized, or extracted. With opinions so divergent on core issues, imagine the heightened confusion that exists for dentists trying to identify, assimilate, and integrate the best and most relevant new technologies and instruments.

All of these controversies make for exciting and turbulent times in clinical endodontics. Conclusions made in the dental literature must be balanced by clinical experience and long-term follow-up. A random review of countless endodontically treated cases begins to reveal the edges of the truth about those factors that influence success. Successful cases leave clues that can potentially guide our clinical actions. On the contrary, the avalanche of endodontic failures provides irrefutable evidence that our unresolved controversies perpetuate clinical breakdowns and decrease success rates. In the final analysis, science and basic research can illuminate our clinical endeavors, but ultimately it is by our clinical actions that our success as a healing profession is measured.

DT: For so many years the endodontic armamentarium remained much the same, then suddenly, made enormous change. Can you identify the greatest innovations that have recently occurred in the field of endodontics?

Dr. Ruddle: In my opinion, the greatest innovations in endodontics occurred, more or less, in the decade of the 1990s. The most important innovations have been the utilization of the dental operating microscope, ultrasonic technology and related instruments, nickel-titanium (NiTi) rotary shaping files, and mineral trioxide aggregate (MTA). Each of these innovations has dramatically impacted endodontics and significantly contributed to more predictable success.

DT: Let’s look at the microscope first. Could you tell us how you got interested in microscopes, how the use of microscopes has evolved in dentistry, and explain the clinical advantages of using a microscope?

Dr. Ruddle: One of the true leaders in the field of endodontics is Dr. Noah Chivian, an endodontist from New Jersey. At the American Association of Endodontists (AAE) 1988 annual meeting, Noah, who already was a microscope user, had a booth on the exhibit floor and was demonstrating the advantages of enhanced magnification and light utilizing a microscope. Because I had already been using a headlamp and magnification glasses since grad school, this seemed like the next logical step. At this meeting, I purchased my first microscope, and within a few weeks was using it, albeit rather awkwardly, on patients of record. Over the next 2 years, as my skills steadily improved, I tried several different kinds of microscopes, always looking for the scope that could provide the best optics, had features that would improve my documentation capabilities, and was endo friendly.

During this period, I met an endodontist named Dr. Gary Carr from San Diego, California. We began to work together to explore how we could better use this technology clinically. We spent countless hours sharing information on how we could refine existing procedures. As we were both using the microscope in our clinical practices, the next step was to integrate this technology into our respective teaching programs. In fact, the first endodontic microsurgical course given internationally was conducted in my teaching center January 25-26, 1991, to a group of 10 endodontists. What made this particular course significant was the introduction of the microscope and Gary’s new method for performing root-end preparations utilizing ultrasonics. Ultrasonic root-end preparation in conjunction with the microscope went on to revolutionize the field of surgical endodontics. By August 1995, quite a few endodontists had already incorporated the microscope into practice and many more were beginning to use the microscope, and AAE wanted to look at this technology in terms of whether microscope-assisted procedures should be taught in graduate programs. To answer this question, the AAE invited all of the postgraduate endodontic chairs from North America to Chicago for a 3-day symposium on the use of the microscope in clinical endodontics. The AAE called the course “Teach the Teachers” and invited Drs. Syngcuk Kim, John West, Gary Carr, and myself to be the teachers. At the end of this symposium, the AAE chairs voted unanimously that all postgraduate endodontic programs would integrate the microscope into their teaching programs, such that every graduating endodontist would become proficient in the clinical use of the microscope by 1998.

With regard to the clinical advantages of using a microscope, there are many. There is an old expression, “If you can see it, you can probably do it.” The microscope has allowed us to finally visualize things previously unseen, and has driven the development of new armamentarium, which has significantly refined endodontic procedural techniques. Beyond improved vision, other advantages are better posture and ergonomics, less stress and fatigue, enhanced ability to document, more effective case presentation and teaching, better diagnostics, greater staff pride and retention, and for the doctor, new-found enthusiasm, satisfaction, and practice growth.

DT: The second endodontic innovation you identified was ultrasonics. Can you describe when ultrasonics started, how it evolved, and its role in clinical endodontics?

Dr. Ruddle: Ultrasonic technology has been in dentistry for many decades. However, its role in clinical endodontics was limited because traditionally most ultrasonic units were magneto-restrictive and provided inadequate power, and the ultrasonic instruments were too large to work safely within the root canal space. Then came piezoelectric ultrasonic energy, which provided the needed range of power, and in combination with new instrument designs, significantly elevated clinical possibility. Clinicians are discovering that the utilization of ultrasonic technology improves vision, as there is no bulky handpiece head to obstruct vision and procedural access, and precision has greatly improved because of better instrumentation.

The evolution of ultrasonic technology occurred with the advent of the microscope. As an example, ultrasonic instruments had long been available but were not optimally designed. This problem created possibility for a solution. I began working with a high-quality machine shop called San Diego Swiss Machining, and in 1996, we invented three unique ultrasonic features, which were patented and significantly improved clinical outcomes.

First, we made all the nonsurgical lines of ultrasonic instruments contra-angled to improve procedural access into the roots of all teeth. Second, we made the distal working portion of the instruments with parallel-sided walls to improve access and vision. Third, our instruments were made abrasive to improve sanding and cutting efficiency. These three manufacturing features had never been utilized on any nonsurgical ultrasonic instrument distributed in the world.  DENTSPLY Tulsa Dental distributes these ultrasonic instruments under the ProUltra trademark. Over time, microscopes in conjunction with ultrasonics have driven many microsonic techniques in the field of nonsurgical retreatment.

DT: What are the various clinical applications where ultrasonic technology improves endodontic procedural success?

Dr. Ruddle: A partial list of ultrasonic endodontic procedures today would include removing restorative segments following sectioning procedures, eliminating pulp stones, troughing for extra canals, chasing calcified canals, exposing previously missed canals, and activating intracanal irrigants. In the field of nonsurgical retreatment, ultrasonic applications include eliminating core materials from the pulp chamber, retrieving posts and broken instruments, and removing obturation materials like gutta-percha, silver points, carrier-based obturators, and brickhard resin pastes. Additionally, ultrasonics is used to vibrate MTA and serves to adapt this material so we can seal canals that are immature or blunderbuss, or have been zipped, transported, or perforated because of iatrogenic or pathologic events.

DT: The third major innovation you have identified that has significantly improved clinical endodontics is NiTi rotary files. Can you describe when NiTi was introduced and how it has evolved?

Dr. Ruddle: The first NiTi rotary instrument came to market in about 1992. Dr. John McSpadden’s company distributed this 0.02 tapered file utilizing Dr. Ben Johnson’s idea of creating a rotary file with three radial lands and a taper similar to the carriers used with the Thermafil obturators. Although these instruments began to change how we looked at preparing canals, there were problems associated with breakage. In 1994, Ben introduced a more durable line of files, which became known as the ProFile 0.04 tapered series. Soon followed the ProFile 0.06 tapers and the Orifice Shapers. These instruments all contained three radial lands and fixed tapers, and the files cut in a gentle planing or scraping action. Ben broke the paradigm of ISO 0.02 tapered files by making these greater tapered files and is generally regarded as the father of NiTi rotary files. Other rotary file lines came along, each with its purported advantages, such as Lightspeed developed by Dr. Steve Senia, Quantec by Dr. John McSpadden, and GT files by Dr. Steve Buchanan.

DT: Can you describe the advantages of using NiTi rotary files?

Dr. Ruddle: There are many advantages for utilizing NiTi rotary instruments for shaping root canals. Traditionally, canal preparations have been performed using a series of stainless steel files, oftentimes in conjunction with gates glidden drills or peeso reamers. During use, the potential for blocks, ledges, external transportations, and/or strip or apical perforations is always present. Advantageously, NiTi rotary shaping files have nearly eliminated these iatrogenic events. Other important advantages of shaping canals with NiTi files are improved efficiency,  the opportunity to schedule more “one visit” endodontic procedures, and improved profitability. Additional advantages of using NiTi files are fewer postoperative flare-ups, the ability to open canals more easily and with less effort, and the creation of more consistent and uniform canal shapes. All these advantages create a win-win for the doctor and the patient alike.

DT: With all the advantages using NiTi rotary instruments, why are many clinicians reticent to embrace this important technology?

Dr. Ruddle: The reasons for not utilizing NiTi rotary instruments vary, but the greatest concern I hear is the fear of instrument breakage. On further questioning, I usually find that most of the broken instrument upsets were caused by failure to follow the directions for use for specific instrument lines, failure to adhere to the specific international protocols for rotary files, and failure to try this technology first on extracted teeth.

Another concern that clinicians express is that dentistry is advancing so rapidly on so many fronts that it is a challenging task just to keep up, let alone try to investigate, learn, and incorporate the newer technologies, instruments, and techniques. Although it is not always wise to be the first to adopt a new technology, it is also not desirable to be the last. Strategically, clinicians often ask when should  they change. From a practical standpoint, the longer a clinician waits to embrace a proven technology, the harder it is to change. If we wait too long, the gap becomes wider and harder to bridge. Change usually is made most effectively in small, controlled increments. This step-by-step approach to learning helps each clinician move toward their potential and serves as the blueprint to building greater practice success.

Finally, some clinicians express concerns about embracing NiTi rotary technology because of cost. It is true that there is a monetary investment associated with purchasing a new torque control electric motor, purchasing the instruments, and the costs associated with training. However, these costs are completely offset by the numerous advantages I previously mentioned. The reduction in chair time alone is a compelling argument for the use of NiTi files. When clinicians express strong concerns related to costs, I recommend they add $40 to $50 to their fee to offset this cost, and then more confidently start each case with a brand new set of files.

DT: What about all the new NiTi file lines that have recently come to market? Could you explain why there is a need for more rotary instruments?

Dr. Ruddle: There are several new lines of files that have recently become available, all of which are quite different in design and performance. Over several years, as we have used NiTi files, taught rotary preparations, and invited clinical feedback, we have learned that dentists are looking for four features. The features are  improved efficiency, better flexibility, greater safety, and importantly, simplicity. One survey of international opinion leaders rated the ProTaper file system as coming closest to fulfilling these features. Synergistically,  more creative and sophisticated instrument designs  in conjunction with advanced machining techniques have taken NiTi rotary files to the next level, and have dramatically benefitted clinical performance. Even with all the current improvements in file design and machining, the profession will continue to develop new, more innovative instruments as we pursue the endless journey toward a more perfect file.

DT: Earlier, you identified the four greatest endodontic achievements of the 1990s. We have discussed microscopes, ultrasonics, and NiTi rotary instruments. Could you discuss mineral trioxide aggregate (MTA) and describe its applications and clinical benefits?

Dr. Ruddle: MTA, commercially available as ProRoot, was developed by Dr. Mahmoud Torabinejad, who is department chairman of postgraduate endodontics at Loma Linda University. ProRoot is a material that creates an extraordinary breakthrough for pulp capping, packing certain canals, and managing radicular repairs. ProRoot can be used in canals that exhibit reverse apical architecture, such as immature roots or iatrogenic transportations. Importantly, ProRoot is the material of choice when repairing perforations both nonsurgically and surgically, and is commonly utilized in retrograde preparations to seal canals. Remarkably, cementum grows over this nonresorbable and radiopaque material, thus allowing for a normal periodontal attachment apparatus. Although a dry field facilitates visual control, ProRoot is generally not compromised by slight moisture, and typically sets brick-hard within 4 to 6 hours, creating a seal as good as or better than the best materials used today.

DT: Would you be willing to predict some of the future developments we will see in clinical endodontics?

Dr. Ruddle: Endodontic diagnosis and treatment will significantly improve in the years immediately ahead because of a greater understanding, appreciation, and codification of the fundamental knowledge. Central to the continued growth and success of clinical endodontics will be technologically driven advancements. Pulpal diagnostic schemes will emphasize full-mouth testing and measure each pulp’s vascularity. Clinicians who want to maximize success will routinely use the operating microscope. Handpiece heads will become smaller, affording better vision. Access burs will be refined, developed, and simplified to help us more consistently and safely meet this objective. Ultrasonic technology will continue to grow and play an ever-increasing role in all aspects of endodontic treatment.

The role of hand instruments will continue to diminish, but importantly, better metals and designs will allow clinicians to more readily explore and negotiate canals. NiTi rotary instruments will continue to evolve, simplify, and afford greater safety. Some of the NiTi improvements will be related to innovations in electric motors, which will include feedback features that will optimize performance. Sensors will scan files, analyze stresses, and prognosticate breakage. Intracanal irrigants will improve, appear radiopaque on working films, and the future endogram will phenomenally impact diagnostics. Further, irrigating devices and canuli will provide more efficiency and desirable options while promoting safety. Fully tapered microbrushes will clean canals and more optimally finish preparations. Sealers will improve, become more dimensionally inert, biocompatible, osteogenic, and readily facilitate the efforts of the restorative dentist. Although there has been much interest in replacing gutta-percha, it will continue to be the obturation material of choice for the next several years because it readily fulfills the many traits deemed critical and essential. Importantly, gutta-percha delivery methods will improve, simplify, and increase the potential for 3-D obturation.

Despite all the promises in the future for greater clinical satisfaction, clinicians must still work on the fundamentals that provide success. The one thing that has never changed in the history of mankind is root canal systems and their infinite range of anatomical variability. The one thing to remember is that proven concepts tend to endure whereas instruments and techniques come and go. There is an old expression for wise clinicians to consider: “Give a man a fish and he will eat for a day. . .Teach a man to fish and he will eat for a lifetime.”

Dr. Ruddle is founder and director of Advanced Endodontics, an international educational source in Santa Barbara, Calif. He is an assistant professor of graduate endodontics at Loma Linda University and an adjunct professor of endodontics at University of the Pacific, School of Dentistry, in San Francisco. Dr. Ruddle is the author of two chapters in the new 8th Edition of Pathways of the Pulp, “Cleaning & Shaping the Root Canal System” and “Nonsurgical Endodontic Retreatment.” He is internationally known for providing endodontic education as a lecturer and through his clinical articles, training manuals, and multimedia products. In addition, Dr. Ruddle has recently completed a new Clean Shape Pack video. He can be reached at (800) 753-3636 or www.endoruddle.com.