Grounded. For about 20 years, I have spent time at least once a month sitting at Boston Logan International Airport or Manchester-Boston Regional Airport in New Hampshire waiting to get on an airplane and go off to a dental conference. Armed with a battery of meetings to see the latest and greatest new dental technologies or teach groups about making intelligent purchase decisions related to my findings, I spent my non-clinical time following this passion. Along the way, I got to meet the who’s who in dentistry, pick their brains, and make friends around the world. Since March, I, along with most of you, became an expert in Zoom and tried to carry on my quest in this virtual world. I have had a difficult time getting information on new products due to manufacturer shutdowns and layoffs; things are in limbo. In fact, in March, there were a few new projects that were announced, and to date, I have no idea what happened. Of course, as I said, a lot of my information comes from face-to-face meetings and demonstrations, which are currently not happening.

This is not to say that nothing is new. First of all, there has been a surge of online patient communication tools emerging under the category of “teledentistry.” As explained in my previous column, this is not just an advanced use of Zoom, Skype, and FaceTime. There are HIPAA-compliant portals that handle these patient and dentist-to-dentist communications. As we are now open, there are still clever uses of these services for marketing, consultations, patient screenings, and secure collaborations. It will be interesting to see how many of us continue using these platforms.

We have all increased our disinfection and sterilization protocols. At chairside, we are using wipes, sprays, fogging, UV-C lights, air purifiers, external suction, and more. As I tell my patients, although we are creating a safe environment for them (and likely the safest place they have been all day), a lot of this is for our own safety. If we are confident in the environment, they should be too. In July and August, many of our patients stated that the dental office was the first excursion they had made from their houses except for going to supermarkets.

This has led to a proliferation of equipment sales online from such “reputable” sources as eBay. Figuring out what to use requires a bit of scientific study. It is unlikely that a $200 air purifier from Amazon is as effective as one costing 10 times more, such as the Surgically Clean Air Jade room unit (scadental.com). In fact, just the UV-C bulb plus the filters retail for a total of over $200, so who knows what is in these inexpensive units, not to mention the amount of air exchanged per hour, which is often rated by the companies without the filters inside their products. There’s a lot to think about here.

One area to look at is disinfection. I am not an expert on pathogens, but during my downtime, I found a few people who are. One is Leslie Fang, MD, who practices and sees COVID-19 patients at Massachusetts General Hospital in Boston and is on the faculty at Harvard Medical School. You might also recognize him as author of The Ultimate Cheat Sheets: The Practical Guide for Dentists as well as a faculty member of DOCS Education. The other is John Burd, PhD, who, along with his work with diabetes and having been awarded the American Association for Clinical Chemistry’s Edwin F. Ullman Award for Technology Innovation, is the founder of Wonder Spray (thewonderspray.com). Both have been teaching the use of hypochlorous acid as a solution that can be fogged in a room to safely disinfect every surface before and after seeing each patient. It can actually be used to fog your staff members and you, as well as clothing and covers, between appointments. Plus, in a dilution to 50 ppm, it can be used directly on surgical sites and in water bottles for handpieces and ultrasonics to create a partially disinfected spray. Do some research on this product and process.

Keyboards and mice are another area that has been scrutinized during this time. Offices spend a lot of time and create environmental waste covering these with plastic barriers. I came across Man & Machine, which makes totally sealed keyboards and mice, both wired and wireless. They can be wiped, sprayed with all disinfectants, and even washed in a sink. Some of the keyboards also come with a “skin” that can be removed and autoclaved (just the skin, not the keyboard). There is an extensive selection on the company’s website, man-machine.com.

This time might also be a chance to reassess the idea of digital impressions as well as one-visit dentistry. Certainly, the disinfection of impressions and trays can be eliminated, as well as the “hazards” of shipping and handling. And if you think it through, keeping the entire crown production in your own facility keeps external pathogens under your control.

If you take extraoral photographs, how do you cover or disinfect a camera? I suppose an underwater setup from Nikon or Canon would be a possibility but fairly bulky and expensive. To the best of my knowledge, there is only one disinfectible camera that is used in dental offices, and that is the Shofu EyeSpecial, now in its fourth version (C-IV) (shofu.com/en).

Each of us has our own comfort level, and some dentists have said that it is not really necessary to do all of these things. If you have invested in any of these or other products or processes, it is essential that you show these off to your patients. You can even call it a marketing expense, as I have found that patients are quite impressed as well as reassured that you are doing everything possible for their safety. No matter what you are doing, please stay safe and use common sense.

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Over the past few months, most of us have been interacting with patients and staff via phone calls, texts, emails, and video chats. We have often asked patients who had urgent issues to use their smartphones to send a “selfie” or photo of their problems, often of a broken tooth or lost crown. Many times, we were able to talk them off the ledge and reassure them that the problem was not as urgent as they had assumed. And, as we know, the tongue seems to magnify that “giant hole” or piece of tooth or filling that disappeared. Some did require a trip into the office, while others were able to be stabilized with over-the-counter cements/fillings or medications. Many practitioners used Zoom, FaceTime, Skype, or other phone apps that allowed a face-to-face consultation and discussion and to perhaps make a plan for when the offices opened for “nonessential” treatment. Taking this a step further, the primary doctor might have decided to make a referral to a specialist and forwarded this information, along with the photos and patient information, using these same pathways. There is a basic issue with this approach: None of these portals are secure, and they are contrary to HIPAA rules. It seems that due to this unique circumstance, rules were relaxed, and fines were not imminent.

What this did accomplish, though, is that it created in patients and providers more familiarity of this method of communication and triage. Many of us are now using these same pathways as a common method for patient/office communication. This whole process is now back under scrutiny and has to be addressed. It has been simply stated in the HIPAA recommendations that emailing patient information is not compliant or secure. Many states have rules in place stating that any information from attorneys, accountants, banks, or medical providers has to be sent through secure email portals. You have all received an email stating that General Hospital or Mr. CPA has sent you a message—just click on this link to read it. When you do, a screen comes up asking you to set up a password and brings you to the “messages” page. Your reply securely goes from there back to the initiator. There are many variations on this theme, but the idea is that the messages go through an in-between place that is secure. The office must subscribe to these services and set up accounts for the staff, usually for a monthly or annual fee. These services also allow for collaboration between multiple accounts: for example, when multiple specialists are required to develop a treatment plan. As far as video conferencing, it is debatable how secure some of these common portals are. They do require password protection, but as we have seen recently, they can be easily “hacked,” leading to some uncomfortable intruders, and, of course, medical information can be seen and stolen. Just as there is encrypted email, there are totally encrypted video channels that are labeled “teledentistry.” These products are far more than just encrypted video chat software. They have multiple functions for group consults, record sharing, referrals, and more complex consults. The earliest player was MouthWatch (mouthwatch.com), which created a platform that incorporates its affordable intraoral camera (in addition to any images) to give real time doctor-patient communication that allows for live consults with specialists or even with the dental lab.
As the quarantine evolved, many insurance providers agreed to reimburse for remote exams, some for a limited time. There is actually an ADA teledentistry code (D9995). This is not always reimbursed, but if charged in conjunction with a limited oral evaluation (D0141), many of the insurance carriers do pay for the exam, assuming the patient has proper coverage. Dental offices can, of course, charge a reasonable fee for any service irrespective of insurance.

Moving out of the crisis arena, as we get back to “normal” practice, this concept can be used in many ways. These virtual visits can still be used to screen emergencies by the person answering the phone to schedule the patient more efficiently. But virtual consultations for anything from answering questions to actual smile design consults can be done with several options. These have been around for a long time, but the concept was previously hard to explain to patients. Now everyone is familiar with virtual meeting products, such as Zoom, and understands how they are useful. This can also be a vehicle for postoperative questions in general as well as for reviewing treatment plans. Very often, we schedule a block of time with a patient to review some details of a plan and answer patient questions. As teledentistry removes the time and costs required for room- and PPE-preparation procedures, it can be a great method of followup. A visit can be made even more spectacular using, for example, screen sharing. The patient at the remote location can be shown photos, intraoral images, and even radiographs for further explanation. Two of the companies, MouthWatch and Dentulu
(dentulu.com), have inexpensive USB intraoral cameras that can be lent or actually sold to patients to allow a close-up look at the followup for healing or even new problems. Keep in mind that, although remote, we still have to be sure to give accurate information as liability extends beyond the walls of the practice.

There are now many companies that have these secure portals for patient interaction. There are too many to list here, but they can be referenced on the Dentistry Today app or found online at dentistrytoday.com.
This is indeed a reset of our practices.

…there were too many products to cover here in one column, so you will have to keep an eye out here as w

The Chicago Midwinter Meeting in February did not disappoint with new product introductions as well as enhancements of existing products. I can only touch on some highlights here, which summarize 3 days and over 30,000 steps on my Fitbit. It is difficult to assess a new product on a meeting floor with tabletop demonstrations, so I have a lot of work to do in the coming months to report accurately on what I have seen. Of course, new impression scanners, mills, 3-D printers, and software caught my eye first, but there are many other aspects of dental practice that must be reported. In addition to this meeting, there was a simultaneous show, LMT Lab Day, at a different location. This year, the show was spread over 2 exhibit halls and several corporate showrooms, which caused anguish to anyone who wanted to see everything. The lab show includes many classes by lab technicians, clinicians, and manufacturing experts. Luckily, there is another LMT lab show later this year, which will be held in October in Philadelphia. Get more info at lmtmag.com/labday.

SmartMirror (Dental SmartMirror, Inc)

Goccles (Pierrel Pharma) The new SmartMirror (Dental SmartMirror, Inc) from Israel debuted, which, in simple terms, is a dental mirror that is also an intraoral camera with WiFi connectivity and a microphone allowing the operator, patient, and observer to get a close-up view of live procedures with both video and image files. The perimeter of the mirror is also lined with bright LEDs that illuminate the intraoral area. This is a must-see product. More information is available at smartmirror.dental.

A new innovation in early oral cancer detection by Italian company Pierrel Pharma called Goccles (goccles.com) was also being shown. Instead of using a special light source, the operator wears green goggles and uses a standard curing light to illuminate an area. In addition, there is a filter that attaches to a smartphone, allowing the operator to photograph an illuminated area. An app is also on the way. The company’s literature and research are similar to that of other light systems, so the practitioner has to determine if this is valuable in the practice.

Using a different optical technology, GreenMark Biomedical (greenmark.bio/products) showed a new upcoming product/technique for early caries detection. A patient rinses for 30 seconds with LumiCare Caries Diagnostic Rinse, a “water-based solution containing patented fluorescent sub-micron starch particles that have been functionalized to target and adhere to the subsurface of early-stage carious lesions after penetrating through surface porosities.” After a 10-second water rinse, using a standard blue curing light and the orange filter from a standard curing light worn as glasses or a shield, the practitioner can see “subsurface carious lesions illuminate quickly, identifying porous pre-cavities.” These areas can be treated with minimally invasive procedures or remineralization techniques. The crystal ball here is that this same nano-technology should be useful for delivering fluorides or calcium phosphate (or even other therapies) directly to these areas. They are currently waiting for FDA clearance, so stay tuned.

An interesting company from the LA area called Dentulu (dentulu.com) showcased an app that helps patients find a dentist with an Uber/Lyft-type interface. Going beyond this, it offers home or office visits for certain treatments and is utilizing a simple home-use intraoral camera that can send images securely to a practitioner for new problems or postoperative followup. The teledentistry aspect is not new, as MouthWatch has been using this technology for several years and is also rapidly moving forward in this space. To see what the company is up to, go to mouthwatch.com.

In other news, 3Shape (3shape.com) has entered the single-visit-dentistry world by partnering with Ivoclar Vivadent (ivoclarvivadent.us) on the latter’s newly reintroduced PrograMill One milling system. The press release from 3Shape states “The single visit dentistry bundle includes the award-winning 3Shape TRIOS 4 intraoral scanner, TRIOS Design Studio chairside software, and the ultra-compact 5-axis PrograMill One milling unit. The fully integrated setup creates a seamless, super-fast and predictable – scanning > design > milling – same day workflow for dental professionals.” In addition, 3Shape has also partnered (through Henry Schein) with Amann Girrbach on the latter’s new PL900S mill, giving the dentist more options. In addition, at Lab Day, I found 3Shape’s new model E4 tabletop lab scanner that can copy a model in under 10 seconds!

Additionally, 3Shape was also busy integrating 3Shape TRIOS with Bellus 3D Face scan software (bellus3d.com). “The aligned result can be used in 3Shape Dental System lab software for the design of fully facial-driven restorations that reference your patient’s individual smile and lip line for superior results and patient care,” according to 3Shape. This unique scan can be accomplished with an iPhone or iPad—take a look at the website to be dazzled.

As I said, there were too many products to cover here in one column, so you will have to keep an eye out here as well as online. And by the way, download the new Dentistry Today app on your smartphone. You will get cutting edge information daily, including my updates. 

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…we are seeing a lot of new digital impression systems coming into the marketplace….from familiar…[and] new manufacturers….

The last quarter of 2019 was very busy with new product introductions as well as an interesting computer issue that will affect every office. This “issue” is Windows 10. As of January 14, prior versions of Windows are not supported. You might think that this is not a big deal; after all, how often do you call Microsoft for Windows support? That is not the big story: They will no longer update the operating system with security enhancements. As you know, there are new malware and ransomware attacks, viruses, etc, that not only make your systems unusable but also expose your data to the outside world. We all have sensitive patient information in our systems. A breach is a HIPAA violation, and the penalties are staggering. Those of you who have not looked at the upgrade to Windows 10 could be in for a big financial surprise. Most of the older computers and workstations cannot be upgraded from, for example, Windows 7 or 8. In the simplest terms, the system requirements are larger, and the processing power is more demanding. I am not saying that it is impossible to run the upgrade, but computers will not run properly if they are not configured or if certain components are not upgraded. This could mean replacing every computer in the office and then reconnecting all of your hardware (digital radiography and intraoral cameras, for example) as well as reinstalling your practice management systems. Some of you might be willing to do it yourself, but just the time involved in reconfiguring even a small office with 3 to 4 treatment rooms, a front desk, an office, a server, etc, is a daunting task. I have been asked to look at some IT company proposals, and they ran from $25,000 to $80,000 in “just a simple GP office.” Take a hard look at what you are running, and do not ignore this as the fines will make that upgrade investment look like, as they say, chump change.

Speaking of computers, I have had a chance to work with some new keyboards and mice that are totally waterproof and disinfectable. There isn’t a very good technique to wipe these down between patients. Offices tend to use things like Saran Wrap or blue sticky barriers, at least on the mice. I was given a couple of wired and wireless units to use in my office, and we did our best (as requested) to try and destroy them. We sprayed them with everything we had and submerged and scrubbed them in the sinks, and they are still working. Check out Man & Machine’s products at man-machine.com.

On another front, we are seeing a lot of new digital impression systems coming into the marketplace at initial costs of under $20,000. Some are from familiar companies, while others are from new manufacturers hailing from Denmark, France, Belgium, Korea, China, and more. As I look at each of these systems, my initial thoughts are that they all seem to scan, but you are usually only getting basic scan software or the ability to use a third-party program like Exocad. As said, they all seem to scan (at least based on a typodont that I tried at a trade show) and all are “open,” meaning that you can create a standard file, such as an STL file, that can be used by any laboratory or open software. Many of these will be sold by independent distributors, and others will be sold direct. There are users’ groups for some of these new products online that are either hosted independently or through social media sites, like Facebook. As more practitioners use these products, more peer-to-peer feedback is generated for improvements that the manufacturers and distributors see instantly, and they often implement changes quickly. The larger companies, of course, make changes based upon user feedback, but some of the smaller ones have upper management monitoring and responding directly to the users, thereby speeding up development.

Despite this “competition,” the legacy companies are constantly improving hardware and software and also have thousands of cases that have been done as well as thousands of users giving constant feedback through many channels, including large user meetings. One interesting situation in the marketplace is that Midmark has now taken over the True Definition Scanner (formerly 3M) and is working on improvements that will be introduced shortly. They have been showing the product at the past few meetings.

Finally, a few years ago, I wrote about using buffered local anesthetic with sodium bicarbonate. Many dentists have used this idea in their practices, but it is a bit cumbersome to implement. Two companies, Anutra (anutramedical.com) and Onpharma (onpharma.com), have systems that simplify the process. The latter company went through some corporate changes and was off the grid, but it is now back (and, as they say, better than ever) with the original founders running the show. Originally, it was only used with lidocaine; they have now added use with standard carpules of articaine, prilocaine, and mepivacaine. Buffering, if you are unfamiliar, shortens the time it takes for the patient to get numb, leads to a more comfortable injection, and (anecdotal) provides the patient with more profound numbness. There are clinical references and more information on both companies’ websites; they are eye openers if you are unfamiliar with the process.

This month, the Chicago Dental Society’s 155th Midwinter Meeting will take place; historically, many new products have been launched there. I have my running shoes ready for this show and will be reporting on any interesting developments at the show both here and online at dentstrytoday.com.

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There are many [podcasts] out there….Some are full of technical information, some are like Ted Talks, and others are just entertaining with some good dental information thrown in.

One of the best (and sometimes worst) ways to learn about new technology and dental procedures is by scouring Internet resources. Our own website (dentistrytoday.com) has a lot of information in both text and video formats. Some content comes directly from manufacturers, while the bulk is from clinicians. During the course of a day in my practice, I sometimes sneak away before a patient is seated and look for an instructional video or information on a procedure. Many times, I am directed to YouTube, where you could probably duplicate your entire dental school education. Some examples are protocols to cement certain restorations; how to insert an overdenture attachment chairside; and indications and instructions for the use of silver diamine fluoride. (Teaser: I will have a lot of new information on this interesting product/process in the near future.) Many of these videos are put up by individual dentists, hygienists, assistants, or lab technicians as a sort of public service. Everyone wants to be an Internet star! Of course, there are great videos and some questionable ones, and all are of varying quality.

For years, people have published podcasts. There are many out there, and if you have a long commute and don’t want to hear the the day’s news, they are quite interesting. Some are full of technical information, some are like Ted Talks, and others are just entertaining with some good dental information thrown in. I will mention a few here, but a search for “dental podcasts” will direct you to lists and reviews of many. There is a lot of crossover on the Internet, as some of the groups publish on their own sites and mirror on Facebook. Do whatever is easier for you—a similar search on Facebook or Instagram will fill your bucket. There are several formats, with some being dissertations from one person and some having guest presenters, while most seem to use an interview format. Some of them are targeted toward clinical issues, some toward practice management, and some focus on wealth management, and others still are general and even social. Here are a few that I follow and invite others to try. (Note that this column, as with all sections of Dentistry Today, are easily found on dentistrytoday.com. I may update this column online with direct links to podcasts if there is interest.)

I must say that my dear old friend Dr. Howard Farran really knows how to dig deep into an interviewee in his podcast, Dentistry Uncensored with Howard Farran. I have carefully avoided Howard over the years as I want to keep my deep, dark secrets from the world.

One of the most popular podcasts is The Thriving Dentist with Gary Takacs, which looks at the business side of dental practices with great insight. The Dental Hacks Podcast, hosted by Drs. Alan Mead and Jason Lipscomb, is a no-holds-barred look at dentistry with a bit a humor and sarcasm. Dr. Tarun “T-Bone” Agarwal, one of the premier experts on digital dentistry and sleep apnea, entertains on T-Bone Speaks Dentistry. Want to make your fortune? Check out The Dentalpreneur Podcast with Dr. Mark Costes. One of the newest podcasts is Dr. Chris Phelps’ Dental Slang Podcast, in which the interviewees tell how they explain dentistry to patients and each other in our own code and give helpful clinical and management hints in the process. And don’t forget that the ADA has a couple of interesting podcasts: Tooth Talk and the non-clinical Beyond the Mouth.

There are numerous groups on Facebook, a few being offshoots of these podcasts. One example is Dental Hacks Nation! Most are private groups that require registration, but you really don’t know who is looking at the posts. A lot of the text, photos, and videos are quite graphic. (Facebook has a filter that obscures potentially graphic content; click the warning message to diplay the post.) Since many of these forums are international, you get to see interesting cases and techniques that you never really thought about. And as you remember from some of the wild pathology cases and photos you saw in dental school, some of these actually appear in people’s offices and clinics around the world. A few of these forums are designed to show failures, which are always eye-openers. However, I am always afraid that some may be from clever Photoshop users who have nothing better to do than to start trouble, but the majority are honest. A fun one is an implant-failure group with a name I cannot print here, but just search “implant club” on Facebook to find it. A wonderful group is Dental Clinical Pearls, which is moderated—an important factor in keeping it top-of-the-line. The cases and discussions are high-end, and many of the members post techniques with detailed information and excellent photos. Also check out the new group led by Dr. Sandy Pardue, Dental Gumbo, which includes practice management discussions and tips.

The problem is that some forums create their own “experts.” As I said, everyone wants to be a star, so there are some people who post very often and appear to be the latest key opinion leaders. People are followed based on the fact that they have over 1,000 posts. Some are genuine teachers, while others are merely showing off their knowledge base—you have to filter this. Still, it is interesting to see a variety of approaches to dental issues. On the other end, there are dentists like Dr. Bill Strupp, who continue to amaze everyone with superb gold restorations. In one recent post, Bill showed a buccal pit gold inlay that had been in place for 40 years. Of course, I have a few patients with buccal pit amalgams that have been in at least that long, but they aren’t as shiny!

Generally, I find that although many of the interviews or talks are from names you know, a lot are just everyday practitioners talking about their experiences, successes, and failures. There are a lot of you out in the trenches who have no desire to rack up thousands of air miles traveling to lecture but have a lot to tell us. Also, many of the posts are from dentists who have run into difficult clinical and diagnostic situations and are looking to colleagues for help. The speed at which an answer can be obtained is often surprising: sometimes while a patient is still in the chair. Private practice can be a lonely place, and it is great to realize that we are all trying to get to a common patient care goal and that there is a virtual camaraderie out there.

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The bottom line is, if you are considering a 3-D printer, know what you can actually make efficiently in your office and how much you will actually use it.

Last month, the annual meetings of the ADA and the FDI (World Dental Federation) were combined and held in San Francisco as the ADA FDI World Dental Congress 2019. For those not familiar, FDI represents more than a million dentists worldwide. As usual, many new products debuted in a large array of manufacturer displays. There were also 5 days full of continuing education with top presenters speaking on topics ranging from restorative dentistry to technology to wellness. It is a bit sad that many of you missed this opportunity. Although the ADA reported more than 30,000 attendees, there were only about 11,000 dentists and 4,000 assistants. Perhaps it was due to the fact that this was the week following Labor Day; I was told by many dentists that their families had commitments (eg, the first week of school), which might have been a deterrent.

Of course, my focus was on the new technology. All of the digital impression scanners presented improvements in functionality as well as new software. A few newcomers also graced the meeting. One of the new product introductions came from Carestream Dental, which launched its new CS 3700 scanner. Its increased speed, unique shade matching, and new intuitive software created a buzz.

I describe this space as an ongoing Kentucky Derby in dentistry. As I watch the products, changes come almost monthly, and honestly, as soon as one manufacturer introduces a new feature, the others follow rapidly. At this time, all the intraoral scanners create files for dental restorations and procedures. The elder statesmen (Dentsply Sirona, Planmeca, 3Shape, Align Technology, and Carestream Dental) have proven their accuracy with thousands of restorations as well as clinical studies. One of the most important aspects of this technology is the ability to create an accurate full-arch scan with precise cross-arch measurements from second molar to second molar. One of my early simple tests for this aspect was to create a full-arch scan and send it digitally to a laboratory and have them create a hard nightguard; then I would see if it “drops in” with no real pressure points. Although not scientific, it is an inexpensive test to perform before investing thousands of dollars. There are, of course, many new companies with units from all over the world being introduced at, in some cases, significant price differences. When I spend time at a show booth looking at the new products, creating a scan on a model often looks impressive. I cannot make a judgment at that time, though, as I really need to see legitimate studies and, if possible, create some restorations in my own practice. In earlier times, I rotated various systems on loan through my office and took a digital and a PVS impression to get a clinical sense of accuracy there—not in a sophisticated lab—just as any GP would do. I sometimes had the luxury of 2 scanners and could scan a crown prep twice and compare results. Margins, contacts, and centric occlusion were easy to check with explorers, floss, and articulating paper, and I continue to do this with newer products to report back to my readers and course attendees. The advice at this time is to at least get a demo in your office and do a case or 2. Look at the ease of use and the actual handling of the wand; examine the software; and, even at this early level, get a sense of the customer support. Also, find a laboratory that will do a totally digital workflow for you. Currently, the easiest product to receive is a full-contour zirconia crown with a model, for your testing. There is usually an additional charge for the model, but keep in mind, this is part of your investment in the ultimate end results for your patients. One of the first things that threw me in my earlier days was receiving a case from a lab with a little box that contained a crown and no model; I had to raise my right hand and say, “I believe.”

One of the other areas at the meeting that added to digital restoration confusion was focused on 3-D printers. There was an array of units ranging in cost from $3,500 to $20,000. There is a lot of talk by manufacturers on the methods used to print a product. SLA, DLP, DLS, etc, caused a lot of head scratching. To simplify, the questions should be how fast, how accurate, how many pieces at a time, and how large can they be and what materials are available. The latter will help determine what you will actually do with the printer. More important is the fact that you cannot just buy a printer and “attach” it to your scanner. There is software that is necessary to design the appliance, and you must consider who in the office will do this and how much time will it take. Then there is “post-processing.” The printer doesn’t just pop out a finished product; there are sprue-like pieces that have to be cut/grinded off. The printed piece has to go through one or 2 washes. Then many materials must be cured by light, and sometimes by heat in an oven. Finally, someone must polish it for delivery. A couple of companies, Micron Dental (microndental.com) for example, do not just sell you the printer: They also have all of the finishing components and are quite honest about all the steps needed and how much time and manpower is involved. One company, Structo (structo3d.com), showed the Velox, which has a little carousel inside the unit and automates all of the steps of printing, washing, and curing (but you still have to cut the sprues and polish). Those of you using guided surgery for implants will be able to print your own surgical guides, but make sure you understand the entire process—it is not a one-click solution (yet). There was a lot of talk about being able to print dentures right in your office at a cost of, perhaps, $25. Again, this requires designing, printing, and finishing, which takes time and manpower. And there are still limitations on what materials are FDA approved for long-term use in the mouth. The bottom line is, if you are considering a 3-D printer, know what you can actually make efficiently in your office and how much you will actually use it.

Of course, the understated point here is “Do your homework.” Take some courses either at workshops or online. The resources are out there for you to make an intelligent purchase decision.

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When an office uses digital chart notes, there are usually templates that are far more thorough than the paper charts, which had entries like ‘#5 MO composite.’

With all the discussions on advanced dental treatment with new technology, there is an underlying issue that affects many of us. Some of us take insurance assignments, while others are fee-for-service and let the patients fend for themselves. I am in the former. Recently, it seems that the insurance companies are tightening things up with more requirements and restrictions. Technology can be quite helpful in dealing with them. I have often wondered about the math, though. When I started practice in the 1970s, most dental policies had a $1,000 or $1,500 maximum. The premiums were often paid by employers, or the patient had a minor contribution. In those years, a patient could get a lot of treatment and at least 2 to 3 crowns if the insurance paid 50% of these $500 to $700 fees. Premiums have gone up with inflation, so what about the maximums? Many are still $1,000, and a few get up to $2,000 (aside from some higher-end policies). In my simplistic analysis, the premiums have gone up, but the exposure of the insurance companies has not increased over these 40 years. Am I missing something? (End of soapbox.)

Preoperative image of a fractured molar. (Image courtesy of A.G. Khan, DMD, Billerica, Mass.)	An image of a prep with a buildup. (Image courtesy of Dr. Khan.)

One of the crackdowns reported by many dentists is that the insurance companies are often denying crown buildups. There is some blame on our end when a dentist puts a dab of Vitrebond (3M) on the prep and calls it a buildup. The insurance companies are asking for documentation. This starts in your charting, which is hopefully digital (so it is legible). When an office uses digital chart notes, there are usually templates that are far more thorough than the paper charts, which had entries like “#5 MO composite.” Everyone has his or her own version of the template, but one of the first entries must be the reason for the restoration—for example, an old, leaking amalgam with recurrent decay. The radiograph will, in most cases, verify this; thus, a preoperative radiograph is a must. When you are using a digital system, you can assure the patient that this radiograph is, in lay terms, being taken in at least one-tenth or less time of the old x-rays. In actual numbers, the film was usually exposed for about 0.2 seconds, while in digital it is closer to 0.02 seconds. The patient understands when you say “One of the old x-rays equals 10 of the new ones” or whatever numbers you feel are legitimate. The next pre-op image should be a photo using either an intraoral camera or an extraoral one with retraction and a mirror. If the camera is at your fingertips, there is plenty of time for you or your assistant to take this image at the beginning of the procedure, perhaps while the patient is getting numb. That image should be stored and dated in the practice management system and—this is very important—tagged with the tooth number. Many people take a lot of images, and most practice management systems allow you to search for an image by tooth number or pull up a tooth’s history the same way. When creating the tooth buildup in this new insurance world, there has to be verbal documentation of the process, and there should be visual documentation as well. It won’t take much time to get an intraoral camera image of the tooth after the old restoration is removed (to show what is left of the tooth) and another image after you do the actual buildup. The chart note should clearly state that there was not enough tooth structure for proper retention and that we used, for example, etch, bond, and core materials; a glass ionomer; a bioactive base; etc. Even with all of this, some companies don’t pay for buildups unless the tooth has had endo­dontic treatment, and others will not let you bill the buildup the same day as the crown (let’s hear from the one-visit-dentistry docs on this one). Still, the digital documentation is critical.

And just to belabor the story, there are also requests for post-insertion x-rays. (I feel a mistrust here, probably due to the low percentage of offices that are abusing the system.) Again, we must reassure the patients that this is a necessary verification of the fit of the restoration, although many of us already take an image before cementation to check the margins. This is all just one example of digital documentation we can and should do. One point is important here: I am not stating this information and saying the insurance companies are telling us to take these images. They are very important for a proper record and should be done anyway. Of course, it takes extra time, but if there is a camera in the treatment room, and it integrates with your imaging system, it really only takes seconds. The images are also good to have if a patient has an issue down the road: You can look over what was done, and, of course, if there are any accusations, you are well covered. Taking this whole discussion a step further, why not take before and after intraoral images for all restorative procedures? Some of the cameras, as we have noted, have caries-detection modes, which not only photograph the prep but could also surprise you. And most patients are totally impressed when you show them an “ugly, old silver filling” and then show them the beautiful, white tooth. It is a practice builder, and patients think you’re amazing; it’s far more impressive when patients see this transformation than when you show them that you’ve filled a root to the apex.

As a working GP, I am faced with this every day. The staff in my office is on top of things, and we have all of the bells and whistles for eligibility, coverage, etc, but they are the ones on the front lines listening to the patient complaints (or compliments) regarding billing a coverage. We workers “in the back” must do what we can to help that whole situation.

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Show Me the Way

Perpetual Change

Make Me Smile

Digital impressions took an interesting step. In addition to improving current products, companies are looking to expand the use of these devices beyond restorative processes.

The largest dental show in the world is the International Dental Show (IDS), held every other year in Cologne, Germany. It is a unique experience where you can see new and upcoming products from around the world well before they arrive in the United States. The design and size of manufacturers’ booths can only be described as amazing. In addition to the array of products, many of the manufacturers served food and beverages, some had live music, and one actually had a roulette table. Although there were no official CE courses, there were many product demonstrations, including live dentistry (some right in the booths), as well as short talks. Of course, as an international show, all of the exhibitors wore flag pins of the countries representing the language(s) they speak. IDS 2019 ran for 5 days and exhibited 2,327 companies from 64 countries. More than 160,000 trade visitors from 166 countries were in attendance, and the exhibition space was 1.8 million square feet! The next IDS—the 39th International Dental Show—is scheduled to take place March 9 to March 13, 2021.

Several products and processes were shown in prototype stages to give us a glimpse of our future. Among the most interesting to me was some expanded use of 3-D printing. Lithoz (lithoz.com) presented a 3-D printed zirconia crown. I would have to call this a proof of concept, as the cost and time of actual printing was far from cost effective, but it looked great. The company’s printers mainly print ceramics, and they showed some very intricate printed products. The other prototypes at the show that raised a lot of eyes were clear aligners shown by EnvisionTEC and the French company 3D-TOTEM (3d-totem.fr/en) (but only if asked). Currently, the process of creating aligners is performed with printed models and “suck-down,” clear acrylic. If we could skip that step, the process would be faster; cheaper; and, perhaps, something for in-office manufacturing. To me, the most impressive find was Graphy (itgraphy.com), which had a resin (Tera-Harz T85DAL) it claimed could be used with almost any printer. I took a sample around to some of the printer companies, and they were quite impressed. I will be following this closely. If a lab or office was to use this resin, they would, of course, need software not only for the design of the aligners but also to set up the orthodontic case. One company from France, Orth’Up (c4w.com), demonstrated this type of software, and the product costs well under $8,000. To quell this excitement, a lot of time (and training) would be required for an in-office solution in terms of designing and printing, and it would probably require at least one employee to take charge of the whole process. Still, just as one-visit dentistry requires a period of time for ROI, it seems feasible.

Digital impressions took an interesting step. In addition to improving current products, companies are looking to expand the use of these devices beyond restorative processes. TRIOS 4 (3shape), iTero Element 5D (Align Technology) and Planmeca Emerald S all added caries detection to their scans. All 3 of these scanners can transilluminate the teeth, and TRIOS 4 can also do an additional scan using fluorescence. The iTero Element 5D does this simultaneously during a 3-D scan, while the other 2 need a different head and a second scan. The results look similar to the Air Techniques CamX Spectra, Acteon SOPROCARE/LIFE, DEXIS CariVu, and Digital Doc LUM products. I would be remiss in not mentioning here one of my favorite transillumination products, the AdDent Microlux Transilluminator, which, by the way, lists at less than $300 (addent.com). Other features of these 3 scanners include programs that do comparisons of prior patient scans. This is a powerful diagnostic and patient education tool, showing things like advancing occlusal wear, increasing abrasion/abfractions, and more. Other software has been added, such as smile design, orthodontic analysis, advanced bite registration (including TRIOS’ recording of lateral excursions), and more.

Just prior to the IDS, Dentsply Sirona introduced Primescan, the totally revamped scanner that replaces the popular CEREC Omnicam. This booth was one of the most crowded from dawn to dusk while the new scans flew across the arches. It was also quite impressive: It has the ability to clearly view into a deep sulcus, improved margin marking, and a very good “ignore” function for soft-tissue artifacts. Carestream Dental gave a sneak peek at the new CS 3700 scanner, while Straumann showed a new version of the Dental Wings Virtuo Vivo scanner (which has direct integration with ClearCorrect). GC America showed an updated Aadva, and a few new, unreleased prototypes were in from Vatech and KaVo. VOCO continues to develop its new scanner that is purported to be able to see through tissue. Also, 3Disc showed its new Heron, and several others will be flooding the marketplace, promising a lower cost. The most notable “newcomer” is Medit. The company has been selling its Medit i500 scanner in the United States at a cost well under $20,000 for more than a year. This scanner is fast and accurate and has improved its software, thanks in part to a relationship with exocad and, soon, Straumann CARES. I must say that there were many people at Medit’s booth from competitive companies who wanted to see what the buzz was all about.

There is much more to review here, including more advances in 3-D printing from companies we are familiar with, such as VOCO, Planmeca, and Kulzer, as well as new models from Formlabs and SprintRay. The larger industrial 3-D printing companies, such as EnvisionTEC, Asiga, 3D Systems, and others, also have numerous units for in-office use. Stay tuned for more details on these and other new and upcoming technology products.

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Perpetual Change

There were eye-opening products that are being used by dental labs now that are actually driving the entire dental industry to new processes and products.

The recent Chicago Midwinter Meeting had, as usual, new product introductions from existing companies and new exhibitors as well as existing products trying to catch the attention of attendees. There were a few surprises; one was a bit disappointing.

For years, Oral Health America (OHA) hosted its annual fundraiser at the opening night of the meeting. This charity, which started in 1955, helped the underserved population of children by donating services and products. Its Smiles Across America program coordinated schools, governments, care providers, and corporate and community sponsors to fight against tooth decay. In addition, there was an initiative to make people aware of the dangers of chewing tobacco. The industry looked forward to this black tie event, with a who’s who in the dental industry attending, including not only the top lecturers but the heads of every major dental company. It was sometimes referred to as “The Dental Prom.” Corporations and individuals donated money, services, products, and more, as well as put items up for auction at the event, which generated hundreds of thousands of dollars for this charity. Abruptly, OHA closed its doors in January and, as a result, cancelled this event. The first disappointment is that this wonderful service has been discontinued. And the loss of this event took away an amazing social night where all of corporate dentistry could sit together as one.

Back on the floor, as expected, the digital impression/CAD/CAM arena had several advances and new product introductions. In the impression scanning/CAD/CAM world, there were several new players, including Medit i500 (Medit) (medit.com), Heron IOS (3DISC) (3disc.com), and QuickScan IOS (Denterprise International) (denterpriseintl.com). These and a few others have broken the price barrier, coming in at under $20,000. GC America (gcamerica.com) also continues to improve the Aadva IOS scanner, which is priced in the same range. A quick response came from 3Shape (3shape.com), which launched the TRIOS 3 Basic at $23,500. It is a wired unit, scans in color, can create an STL file for export, and uses 3Shape’s AI scanning, but it is lacking a few of the advanced software products that are found in the original system. They can be added on at a later date.

Launching its new CS 3100 mill and design software, Care­stream (carestreamdental.com) created a new full system for one-visit dentistry. This new mill can create very detailed restorations using the incorporated Exocad Chairside CAD software and is quite fast. Carestream also officially launched its new CS 9600 cone beam unit. It is quite different from other systems, as it uses a new video camera patient-positioning system, which not only makes this step quite easy but also allows the unit to perform “face scans.” There are also several other details, including software enhancements that were added as a result of customers’ requests that make the scan process easier.

Air Techniques (airtechniques.com) introduced a new cone beam, the ProVecta 3D Prime, to add to its radiography portfolio, which already includes the unique panoramic ProVecta S-Pan (which selects from 20,000 image fragments to create one image) as well as the popular phosphor plate system, ScanX. One of the ProVecta 3D Prime’s novel features is a unique, 130-mm × 85-mm, jaw-shaped, anatomically adapted volume that encompasses all treatment areas without imaging non-relevant anatomy.

Glidewell Laboratories (glidewell.io) showed its fully developed IO system, glidewell.io, which can deliver one-visit dentistry. Using the iTero Element scanner (Align Technology) (itero.com) with Glidewell Laboratories’ proprietary design software (fastdesign.io Software) and its new milling unit (fastmill.io In-Office Unit) is quite fast and precise. The mill is modeled after Glidewell’s larger units that are used in the commercial laboratory process.

Speaking of iTero, there was a glimpse of some new enhancements that were about to be launched at IDS 2019 in Cologne, Germany, in March. The new iTero Element 5D (Align Technology) is expected to add features like caries detection with transillumination. Its near-infrared imaging (NIRI) technology lets you scan the internal structure of your patients’ teeth in real time. There are also enhancements of its Time Lapse software (that can show differences between scans over time) as well as the ability to use the unit as an intraoral camera. This column precedes the official launch, so watch for details.

The biggest buzz, though, was from Dentsply Sirona (dentsplysirona.com), which launched the Primescan, replacing the Omnicam. This is not an upgrade; it is a totally new design of the camera and the mobile cart. Some of the many features include new autoclavable tips (with internal heating); faster and higher resolution scans; the use of Artificial Intelligence, which, among other things, automatically removes superfluous information like cheeks and tongues; and the replacement of the trackball and keyboard with an enhanced swiveling monitor. The website has a lot more information, and many of the users have been posting videos on social media platforms like Facebook, showing clinical examples of the power of this new system.

Planmeca (planmeca.com) has made some software improvements to its new Emerald scanner and its Romexis software, which is a total solution for all of its products.

This now gives us 4 complete systems for one-visit dentistry, and 3 of them have direct integration with their own cone beams. Still, some practitioners want to have totally open systems and would prefer to choose their own options. This can be a challenge, as it is not simple to buy the components and get them to “talk” to each other. Benco Dental launched a service (onevisitbenco.com) that presents a menu allowing a practitioner to choose from a list of scanners, software, mills, and blocks and will put it all together. This gives the office one source for support and service.

There was an array of 3-D printers at McCormick Place, but many more were at a parallel meeting in Chicago, the LMT Lab Day show. There were eye-opening products that are being used by dental labs now that are actually driving the entire dental industry to new processes and products. Between this lab show and the IDS show, we will have a lot to cover in upcoming columns here.

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Get Ready

How many times have we heard the phrase “I want to improve my smile”? In many situations, the patients’ idea of what they want might be totally different from our natural response. Sometimes it’s as simple as wanting a whiter smile. The definition of “white teeth” to many patients is also far different from ours. Some of these patients are still bleaching their veneers in hopes they could be a little whiter. Other patients are concerned with “crooked teeth” that are “getting worse.” Their definition of crowding is often quite different from ours. Luckily, with the proliferation of aligner products and processes, we can often accommodate these patients with a simple, limited case. And, with a little bleaching in the final retainer, they fall in love with us.

A new idea has come from Dr. Brian Harris of Phoenix called Smile Virtual Consult (smilevirtualconsult.com). This simple system allows a patient to take a photo with his or her cell phone, answer a few questions about what he or she wants to improve, upload it, and then receive a video reply explaining aspects of possible treatment.

There are many situations that require combinations of the aforementioned processes. Before the advent of digital dentistry, we took photos, made study models, used lab wax-ups, and got a little help from Photoshop-type products, and we were able to do case presentations. Using the labs’ templates that were made over the wax-ups, we were able to deliver satisfactory end results. There were issues, though, that required time to create these projections and make modifications. If the wax-up had to be changed or the photo images were not quite what the patient had in mind, it was back to the lab and another patient visit.

Ten years ago, Kulzer launched a website, tryavenussmile.com, that allowed a patient to upload a photo and then “try in” a few smile designs. SciCan also had a great simulation program called Image FX, and several companies offered a Photoshop-type service that allowed you to send a photo and receive a digital simulation in return. These systems were very dangerous, as the simple computer manipulation often rendered results that were impossible to recreate and often led to a disappointed patient who stated that the end result “was not like the picture you showed me.” A transition came with Dr. Lawrence Brooks, a dentist in Massachusetts who created a dental lab called Smile-Vision (smilevision.com) that requires both photos and study models (or now digital scans). His lab prepares wax-ups, which are then superimposed onto the photos with a much more accurate proposition. He can also prepare clear overlays, prep guides, and temporary templates, ensuring the final result. Many other labs follow this process.

Much of the designing was (and is) based on the “golden proportion.” We looked to experts who almost seemed to be mathematicians, calculating things like “The width-to-length ratio of the centrals should be approximately 4:5,” “When viewed from the facial, the width of each anterior tooth is 60% of the width of the adjacent tooth,” “Interproximal contacts must follow ‘the 50:40:30 rule,’” and so on. The face also has to be analyzed as to its shape and relation to the teeth form (square, tapered, ovoid, etc) while using more math like “The width of the face should be the width of five eyes,” “The distance between the eyebrow and chin should be equal to the width of the face,” and so on.

We now have several computer programs that can take all this data that you or a lab can use to design a patient’s smile. The wax-ups are virtual, and now with 3-D printing, an overlay can be created quickly and inexpensively (in your office) that will sit on the patient’s teeth to see how things will look. Years ago, I would take an A1 composite and just place and shape it over the teeth to give the patient a rough idea of where we were going. This new technology is much more specific and realistic. Planmeca now has Romexis Smile Design software that can render a simulation in minutes. 3Shape Smile Design is also an option that uses an easy-to-see template and creates a new look that can then go forward into the 3Shape restorative system.

The most comprehensive system for smile design was created by Dr. Christian Coachman of Brazil and called DSD (digitalsmiledesign.com). The website has educational videos, which are among the best I have seen, and DSD offers seminars around the world that detail the journey. The math previously mentioned has been considered, but the cases start with a specific series of patient videos that allow you to see function, phonetics, facial analysis, and more. Photos are pulled from the videos to create more views to get a 3-D functional analysis. You can do your own design or have them do it for you. There are partner labs, such as The Aurum Group (aurumgroup.com), that can create prep guides, temporary templates, and more, giving the patient a totally predictable result. Even if you don’t think you need to use this service, the information on this website is eye-opening.

A totally different idea was just introduced by a company called Kapanu. Their program uses an amazing simulation they call Augmented Reality, where the patient can see transformations in real time on a computer screen or tablet. He or she can toggle the before and after images on the screen, with the arch split left and right, showing before and after views simultaneously. The website (kapanu.com) shows this dynamic process. The system was so intriguing, Ivoclar Vivadent acquired it early in its development and rebranded it as IvoSmile. According to Ivoclar Vivadent, “The main objective will be to determine how the usage of ‘Augmented Reality’ can facilitate dental diagnostics, case analysis, and treatment therapies.”

Everyone will have to find his or her comfort zone on how far to let computers run the treatments. It is surely an interesting journey we are on.

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