Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.

Although endodontists make their best faith efforts to relieve patients’ pain as quickly as possible, they may not be able to do it fast enough. The treatment may take time to heal or, even worse, they may not be able to begin treatment right away. In either case, endodontists have a number of tools at their disposal to help make those patients more comfortable.

Sometimes it is simply not avoidable. Even in the face of agonizing pain, some patients may just have to wait for their ultimate treatment and can only be seen for an initial visit.

“Generally, what will happen is endodontists or oral surgeons or specialists––or general dentists who are making time to see patients for emergencies––sometimes [only have] enough time for an emergency visit,” Nicholas Pappas, DDS, MSD, an endodontist from The Woodlands, Texas, says. “When I make my schedule, I have certain spots for emergencies, certain spots for treatment and evaluation. We do our best to be able to accommodate any type of emergency. However, if we cannot see a patient immediately, we are trying to see that patient the following business day. So from my personal experience, if we have a patient [who is] in pain, the longest they’re waiting is a business day.”

However, some practices make every effort to deliver treatment, in an effort to help patients alleviate pain.

“It’s our practice’s philosophy that if somebody comes in in extreme pain, I’ll never turn them away without providing some type of help,” Ryan M. Walsh, DDS, MS, Diplomate of the American Board of Endodontics, and endodontist at Advanced Endodontics of Texas in Keller, says. “And most of the time that involves initiating treatment of one type or another. If it’s something where the tooth is going to be clearly extracted, most of the time I will call an oral surgeon or…the referring dentist and let them know, ‘Hey, this has to be extracted right away.’ Rather than me starting any treatment, let’s get to the endgame first. But what you have to first determine is where the pathology’s coming from––or where the pain’s coming from. Is it an endodontic infection? Is it a periodontal infection? Is it an infection at all? Is it just an inflammatory response? Is there deep decay? Is there a crack or a fracture causing it? …Those things could change the way I manage this patient and/or help determine what’s the best course of treatment, long-term, and the best course of treatment, short-term.”

Patients can present with several pain profiles, any of which call for a different pain management regimen.

“From an endodontic perspective, it is important to diagnose the source of a patient’s discomfort,” Dr Pappas says. “For example, irreversible pulpitis, nerve pain, can be manageable if you’re keeping stimuli away from it, meaning we’re not eating ice cream, we’re not drinking cold water, we’re not chewing on that side. When there’s possible necrosis, that pain might present as the dull, constant ache. Spontaneous discomfort––pain that wakes a patient up at night––that typically is not going to be something that you can manage by taking away a stimuli…. The problem with necrosis is that that pain can be constant and can’t be turned off.”

The most obvious way to treat pain is through medication. It may be something as simple as analgesics, nonsteroidal anti-inflammatory drugs, or it may be as potent as an opioid. However, Dr Walsh prefers opioids to be the last thing he prescribes.

“I try to use opioids as the last line of defense, because I think so much pain can be treated and managed without it,” he observes. “Our leading pain experts suggest that over-the-counter medications work better than opioids in controlling endodontic pain. So being able to use something that has no addictive potential, has no intoxicating or mind-altering effects, and treats endodontic pain more effectively, that’s a win-win.”

That’s not to suggest that opioids don’t have their place in reasonable pain management strategies, but given the effectiveness of over-the-counter medication, opioids tend to be the last thing suggested.

“I still prescribe opioids in cases where, if it’s an acute apical abscess or an acute infection, the pain has not been controlled with over-the-counter medications,” Dr Walsh says. “I still think there’s a time and place for opioids. I just think we have to be selective about when we use them, as opposed to using them as our first line of defense.”

No matter the protocol, it all starts with knowing the patient and his or her needs––and their history.

“Generally, when we prescribe medications, it’s usually when we’ve seen the patient and completed a proper medical history,” Dr Pappas says. “I feel it is important to see a patient and prescribe a regimen that is appropriate for their medical history. Secondly, it’s important to administer the right medication for that diagnosis. For example, if we have a case of irreversible pulpitis where the nerve is vital, an antibiotic is not necessarily effective or necessary. Now, if we diagnose the nerve as being necrotic, an antibiotic could…be indicated if there’s a sign of swelling or fever, et cetera. Generally, what I like to start with is over-the-counter medications, specifically acetaminophen and ibuprofen. [Results from] recent studies have shown that a combination of acetaminophen and ibuprofen, when taken together, can work as effectively as an opioid. So as we try to scale back our prescriptions of opioids, we’ve actually found that over-the-counter medications, when taken together, have extremely potent effects.”

Painkillers are not the only medications used in the quest for pain management. The problem is a war that must be waged on several fronts.

“I would not say antibiotics are used for pain management, per se,” Dr Walsh says. “Antibiotics are used as the name would suggest––to help reduce bacteria in the body. I think there’s a time and a place for those in endodontic treatments as well. I think of endodontic pain as having a triad of causes and a triad of treatments. In other words, we have bacteria (or we potentially have bacteria), inflammation, and pain. And so, if we can effectively manage the bacteria and the inflammation, both by treating it endodontically and by using over-the-counter [medications], most of the time the third leg of that triad, the pain, is controlled all on its own without really having to use a lot of pain medication to control it. So if we can control the sources of the pain, it usually is much more manageable.”

Regrettably, endodontists must be on the lookout for drug seekers. Fortunately, it is not as prevalent a problem as it used to be.

“Drug seeking is still out there, but I’ve seen it diminish over the past 5 to 7 years, probably because of internet-based tracking software,” Dr Walsh says. “For instance, Texas has a pharmaceutical management database where we have to enter the patient’s name and other identifying information to see how frequently and how often they’ve been prescribed medications from other providers. So by going to these digital platforms, I think that kind of puts dentists in connection with physicians who may also be prescribing and when.”

Obtaining pain medication from an endodontist, Dr Pappas observes, may not be drug seekers’ first choice, because access to endodontists is not an easy route.

“Endodontic offices are generally not the first thought in a patient’s mind when experiencing dental pain,” he says. “Since most of our patients are sent via referrals, it can be fairly laborious for a drug seeker to end up in our chair. Therefore, most drug seekers are looking for easier access, such as walk-in clinics and urgent care facilities . So I personally do not see much drug seeking; however, it does happen.”

Medication isn’t the only tool that can be used to mitigate patients in pain.

“I'll look for pain that’s caused by a certain stimuli, meaning patients complain of pain while chewing or when drinking cold water,” Dr Pappas says. “My first step would be to try to avoid any of those stimuli. Sometimes there’s pain associated with swelling or fever, so in certain cases, cold compresses can help just relieve discomfort. But generally, there’s nothing better than getting to our office for definitive treatment as soon as possible.”

Of course, the best way to alleviate pain is to remove the source in the first place.

“We take as kind of a hallmark of our practice that if you’re in pain, you will get treated that day, not just managed,” Dr Walsh says. “One of the things we have at our disposal is local anesthetics to numb the location of the pain, which not only helps the patient feel better, but sometimes can break the pain cycle and allow them time to get more over-the-counter medications on board to effectively manage the pain when it returns. Sometimes even breaking the pain cycle, allowing the patient to get some sleep and some mental recuperation, will help in the pain management protocol.”

Ultimately, it is in the patient’s best interest to deal with their problems sooner rather than later, which can prevent a small problem from growing into a big one.

“From a practice management perspective, we’re built for emergencies,” Dr Pappas says. “So sometimes a little bit of hesitation can just delay the patient getting into the chair. Always feel free to give us a call, because definitive treatment cannot be administered until I have seen a patient. So the sooner we get involved, the sooner we can help.”

Dental pain can be torturous, and endodontists see a lot of it. Happily, they have many tools at their disposal to help patients alleviate their pain.

Articles

Dealing with dental patients who must wait for treatment.

Managing Patients in Pain 

Study Shows Sensor-Adapted Dental Clinics Reduce Stress for Autistic Pediatric Patients. Image: © University of Southern California


A new study from the University of Southern California (USC) has demonstrated that dental clinics that use visual, auditory, and tactile adaptations, reduce stress for pediatric autistic patients. This study, which was done by researchers at Children’s Hospital Los Angeles, gave dental cleanings to autistic children in both standard clinics and adapted settings. These adapted settings included blackout curtains, a slow-motion visual effect which was either an underwater scene or abstract colors, nature sounds and quiet piano music, and a butterfly wrap to provide children with a hugging sensation.

Results were measured using electrodes placed on the child’s fingers to measure electrodermal activity which provide a physiological measurement of the fight-or-flight response in the brain. Researchers also measured results through observation of distressed behaviors like crying, biting, and clamping down.

The quality of care between the control environment and the adapted environment was the same. Children entering the adapted environment had decreased stress levels even before treatment, according to lead study author Leadh Stein Duker, assistant professor at the USC Chan Division of Occupational Science and Occupational Therapy.

“So many interventions try to change the person,” Stein Duker says in a press release from USC. “Instead, this intervention sees children for who they are–it does not try to fix or change them–focusing the intervention to modify problematic environmental factors as a way to empower the child and family to engage successfully in occupation.”

This study was done to address the reality that autistic children are often presented with unique, sensory challenges at the dental office, which can be a barrier to care. Stein Duker and Sensory Adapted Dental Environments (SADE) aims to find new ways to eliminate these barriers to boost efficacy of dental care for this patient population.

“Because it’s a fully-powered study, we were able to identify some other very exciting things,” Stein Duker says. “For example, our data showed that children’s physiological stress dropped as soon as they entered the adapted dental cleaning room before the actual cleaning even began, and that level of physiological stress predicted behavioral distress during the cleaning.”

this study also aims to help close an ethnic disparity gap, with 72% of parents of the children enrolled self-identifying as Hispanic. To ensure fidelity, the SADE research team had bilingual members to communicate with participants and families.

The research team hopes to expand in the future by implementing SADE studies for typically developing children with dental fear and anxiety, and, eventually, researching preliminary data for adults with intellectual developmental disabilities and/or autism.

“Regardless of population, my advice to dental professionals and parents alike is to work together to find ways to improve the overall clinic experience,” Stein Duker says in the press release. “There are weighted x-ray bibs in every single dental office that may help calm the child; they can wear sunglasses; they can wear a beanie hat covering the ears to muffle noises–all of these are completely free and easy adaptations that have the potential to improve the clinic experience for those with sensory sensitivities, without negatively impacting dentists’ ability to provide care.”

This new study from the University of Southern California demonstrates that dental clinics that make small sensory adaptations in the treatment room are better equipped to care for autistic pediatric patients. 

Study Shows Sensory-Adapted Dental Clinics Reduce Stress for Autistic Pediatric Patients

Signs That a Tooth Just Can’t Be Saved. Image: © Alex Mit - stock.adobe.com


Sometimes it’s just unavoidable: no matter the clinician’s efforts, a tooth just may be unsalvageable. Knowing when that tooth is irretrievable can sometimes be obvious, but other times the signs may be subtle, and the endodontist will have to rely on experience and skills to recognize whether a tooth can be saved.

The most obvious sign that a tooth just can’t be saved is when a root fracture exists.

“These findings are known as ‘J-shaped bone loss’ in a tooth that has had a root canal, especially if there's a post in place, especially in a patient that is a bruxer,” Brooke Blicher, DMD, an endodontist at Upper Valley Endodontics in White River Junction, Vermont says. “There's nothing else that this could be. And unfortunately, root fractures are one of those things that we just don't have interventions for. There are things that have been proposed in the literature, but I always tell patients that we don't have strong enough materials that can glue things together in a way that can support root structure, and reinforce this in a long-lasting way.”

Ryan M. Walsh, DDS, MS, Diplomate, American Board of Endodontics and endodontist at Advanced Endodontics of Texas in Keller, Texas, observes that cases are more readily diagnosed with the advent of better imaging.

“They seem to be more prevalent now than they were in the past, and maybe that's because we're better diagnosticians or we have better imaging,” he says. “But we tend to see those quite frequently. And often, we won't know for sure until we see a radiograph or a CBCT, and even then, we can't conclusively diagnose a fracture without opening the tooth and getting into it. Sometimes to definitively diagnose a vertical root fracture, we must already be inside the tooth and clinically see that fracture line extending into the radicular tooth structure.”

Fractures can exist anywhere on the tooth, and while they may not mean the end of the tooth above the gumline, root fractures will seal the tooth’s fate.

“Fractures come in many different shapes and sizes,” Dr Walsh says. “Crown fractures versus root fractures. Is it a split tooth or a cusp fracture? All those things go into the long-term prognosis of the tooth, and if the fracture is fully maintained within the crown or the chewing portion of the tooth, the long-term success is favorable. It's only those cases where it starts to extend down into the root structure and down below the bone that things really become a challenge to not only do a root canal, but to predictably save the tooth, long-term. Any time the fracture is extending into the root structure of the tooth below the bony support, I recommend extracting the tooth, because the long-term success is poor. I also don't want the patient to incur any other adverse impacts, such as additional bone loss or compromise adjacent teeth at the expense of a tooth that has a poor long-term success.”

“It's really the end,” Dr Blicher adds. “If there's any fracture into root structure, it’s going to get bigger over time due to biting forces, leading to a split tooth. The earlier we get these teeth out, the better. I hear from my periodontal and surgery colleagues that root fractures lead to dramatic levels of bone loss in very short periods of time, so the sooner we can get these teeth addressed and out of there, the more options the patient is going to have as far as doing an implant.”

While root fractures are a very clear indicator that the tooth can’t be saved, there are other, more subtle indicators to be cognizant of.

“Even if there are deep caries, maybe we can save this tooth,” Dr Blicher says. “It really depends on several factors: Why is this patient getting such deep caries? Is it home care, dry mouth, or a systemic health issue? What's going to be the longevity? Is saving the tooth the right thing for this patient? Can this patient tolerate the treatments needed to save the tooth?”

The signs may not immediately indicate tooth loss, but it should remain an option, and it may be a decision that the patient prefers.

“I recently had a patient with a combined perio/endo infection,” Dr Blicher recalls. “He had an endodontic infection and a periodontal disease on the same tooth. These coalescing infections are harder to treat. In theory, it might respond to treatment, but the prognosis is reduced, the treatment might take a few visits, and periodontal therapies might be needed. Even still, the periodontal disease might limit long-term maintenance of the tooth. This patient travels all the time, and treatment with a reduced prognosis was too much for him to risk. He wanted to keep his highflying lifestyle and didn't want to have to worry about something failing, so we opted for extraction instead.”

Modern imaging technology helps dentists diagnosis these problems more efficiently.

“A major reason that my partner and I take CBCTs on most patients that we're working up for endodontic treatment, are incidental findings,” Dr Blicher says. “Things like undiagnosed root fractures, perio-endo infections, and resorption can really doom a tooth if we don't address them. Incidental findings can really change our treatment plans and make us less likely to recommend saving a tooth, because it's not going to reliably work, or the risk is going to be intolerable for that patient.”

It’s never a bad idea to ask for a second opinion or specialist’s expert eye.

“I don't know that there's a lot that's overtly missed, because some types of endodontic infection can mimic a vertical root fracture,” Dr Walsh says. “Any time a general dentist suspects a root fracture but can't conclusively diagnose, I feel it's worth referring to the endodontist for further imaging and/or further clinical evaluation to determine if it's truly a fracture. If it's just endodontic pathology mimicking a root fracture, the long-term success is favorable if we can treat the endodontic pathology. However, if we get inside the tooth and discover a deep root fracture, then the prognosis is poor and I would recommend extraction, but I don't think there's a lot of overt cases where dentists are missing things like this that are clearly non-restorable teeth.”

If a tooth is unsalvageable, it’s time to deliver the bad news. No matter how it’s done, it requires tact and finesse. For instance, Dr Walsh lays out the long-term costs and consequences of living with such a tooth.

“I like to think of it in this perspective: sure, we can treat that tooth for you, but the long-term success is poor,” he says. “How much time, money, and effort do you want to invest in a tooth that ultimately will need to be extracted? You don't want it to be maintained in the mouth at the compromise of potentially adversely impacting adjacent or opposing teeth. I think the best long-term success would be extracting the tooth and replacing it, rather than trying to maintain it.”

The more information of patient has, adds Dr Blicher, the better decision they can make.

“Part of it is just laying it out there for the patient and being honest and objective,” Dr Blicher says. “But part of it is having them as part of my exploration and discovery, so I know they're on board. As I go through my diagnostic workup, I’m explaining everything. I have a really detailed, informed consent discussion with patients, and I'm always giving them options. Even if a tooth is, technically speaking, salvageable, I'm telling the patient about their options for extraction or non-treatment, including their risks and benefits, to try and make this a tenable decision for them to make. I'm a specialist, so I'm really only equipped to offer endodontic care. But I'm talking about the whole picture with patients because it matters, and it's also a way to build relationships with patients that I don't have a lot of time with. I spend a lot of time talking with people.”

Communication is also very important with the referring doctor, as they are the ones who must continue the patient’s care.

“We always call the general dentist’s office because many general dentists extract teeth and nowadays many place implants,” Dr Walsh says. “I always like to talk to the general dentist first, because they're the quarterback of the team, and are the lead restorative expert in the case. If they'd prefer to refer it to an oral surgeon or a periodontist, I'm happy to provide that referral, but I always want to touch base with the general dentist first before referring them to anybody else's care.”

“I don't do any extractions in my office,” Dr Blicher adds. “I always briefly review with patients their replacement options, and that's what I put in the note back to the dentist. I say, ‘We briefly reviewed the options of not replacing versus fixed options versus implant replacement versus removable.’ As an endodontist who doesn't do extractions, I have that ability to go through the broad scoping details of treatment options while deferring to the experts. Ultimately, what comes next depends on the referring office I'm working with. Some offices prefer that I send patients directly back to them, and then they either extract teeth or they make referrals from there. Some offices ask for direct referral to oral surgeons. In my community, we are lucky to have some great oral surgeons and periodontists that I'll refer directly to. Even if a tooth is, technically speaking, salvageable, it's ultimately the patient's choice what they want to do. I always want to make sure that I communicate that to the patient that the ball's in their court. I'm not here to sell them on a root canal or saving a tooth. I want them to reach that decision on their own.”

The signs are there. Sometimes they are obvious and unavoidable. Other times, it requires further examination to make an unfortunate diagnosis. Whatever the case, it is up to the patient to decide whether they want to save a tooth, and it’s up to the endodontist to help guide that decision.

Endodontists can provide insight and care on when a tooth cannot be saved. Experts weigh in on knowing when to refer, extract, or ask for a second opinion. 

Signs That a Tooth Just Can’t Be Saved

Bruce Bryen is a certified public accountant with over 45 years of experience and is a part of Baratz & Associates CPAs. He specializes in deferred compensation, such as retirement planning design; income and estate tax planning; determination of the proper organizational business structure; asset protection and structuring loan packages for presentation to financial institutions. He is experienced in providing litigation support services to dentists with Valuation and Expert Witness testimony in matrimonial and partnership dispute cases. He is also a financial writer for several dental journals. You may contact him at 609-502-0691 or at 

Details are critical when it comes to dental practice valuations, and so is great communication.

For the dental practice evaluator and for the dentist who needs the dental practice valuation as quickly as possible, there is sometimes a miscommunication between the 2 as one is trying to find information and the other is waiting for the information to be forwarded to him or her.

The evaluation of the dental practice can’t begin until the dental practice data is in the hands of the evaluator. Discussions may be taking place and verbalizing may occur, but the evaluator will want something in the file to rely upon when the conversations have been completed and the written report is in the process of being written and then checked for accuracy before being forwarded to whomever retained the evaluator.

Sometimes it happens that the dentist has been shopping for the cheapest price and quickest turnaround of the valuation process so that the entire process is slowed down because of the timing of responses that the dentist receives when analysts are having conferences with the dentist while he or she is trying to determine who to retain for this important job. Deadlines for discovery, depositions and pretrial hearings have specific times and dates when the court demands completion of the assignment to appear for his or her review and expression of an opinion. If the deadlines are not met, the ire of the court may be present, and the plaintiff or defendant will have no excuse that may be acceptable.

Does the dentist understand the urgency of the matter?

It is probable that the dentist is having a court room experience or other situation where the urgency of the matter is not known by him or her. This is because it is probably one of the first times that the dentist has been in a situation where someone is telling them what must be accomplished and when it is due. The dentist in his or her professional life is usually the one who is telling the patient what must be done and when the next visit will occur so that the project can continue.

The attorneys and evaluators are used to deadlines but the typical situation for the dentist is one of caution when working with the patient and understanding patient lapses in time for completion as well as forgotten or missed assignments needed for completion by the patient before the next visit with the dentist or hygienist. Lawyers, consultants, and dental practice evaluators will continue to work through the evening and on weekends to finish their responsibilities for the dentist and the attorneys, but dentists are not used to working at night, on weekends or holidays for anyone. This becomes a test of the attorneys and other consultants convincing the dentist that this is for real and that there can be penalties and other consequences to the dentist if things are not completed on time.

The evaluator and the attorney should have experience in the type of case that is being heard by the court so that the dentist has the best that he or she can afford for the presentation:

It is good for the dentist to interview a few attorneys, consultants, and dental practice evaluators prior to choosing which is the best for him or her and the type of case that they were involved with that may be going to the court room. An example would be that a personal injury attorney is not the one to represent a client who may be going through a divorce proceeding. An expert dental practice evaluator who cannot complete an assignment where an appearance in the court room to testify is part of the scope of the requirement for completion is the wrong person to be involved with litigation involved with a partnership dispute.

Being careful with friends who have good intentions but who offer to do something for free or at a deeply discounted price because they are friends is a warning sign that the attorney or evaluator is the wrong person to choose for representation if that person has little or no experience with what is being adjudicated. Remember to keep your friends close but not to engage them. Find someone who you have interviewed and has good credentials in the field of endeavor that you need for the valuation.

You don’t want to be embarrassed or your evaluator to be humiliated by a lack of knowledge with the subject matter. Worse than the embarrassment is the loss of money when the court decides who gets what from the arguments the judge has just heard. It makes no sense to wait until the last minute to retain those who will be needed when there is normally adequate time to prepare for the case to be presented to the court. The evaluation of the case can also speed up the settlement discussions once each side has something worthwhile to review in writing. This is where a good evaluator is worth a lot more than his or her charge since a settlement is worth a lot more than the cost in that it can result in settlement discussions where a trial is not needed, and a written settlement agreement is accepted by the parties and then endorsed by the parties to the case as well as the court.

Sometimes the dental practice evaluator must be retained who is out of the geographic area in which the dental practice is located. If that evaluator is the best one found, a little extra for travel, meals and lodging that is amortized over the rest of the life of the dentist but gets the best result for the dentist is a cheap price to pay for a victory.

Who else can the dentist rely upon for help and security with the matter?

Since almost every case involves money, someone who typically can be relied upon for additional support is the dental CPA. He or she offers a security blanket and a feeling of trust since they most likely have a good relationship with the dentist. The day-to-day contact with the dental CPA is usually that of the most contact of any advisor and someone who the dentist has relied upon before for important financial decisions.

When it comes to selecting the right dental practice evaluator for your valuation, a little patience and homework can go a long way.

Hurry Up and Wait for the Best Practice Evaluator

Jiffy™ Spin Disks, the latest addition to Ultradent's restorative dental product lineup, is a shaping and finishing disk system designed to provide an efficient instrument set for high-quality restorations.

The disks are thin enough for interproximal finishing and shaping. The disks are coated for aluminum oxide and available in grits ranging from coarse to fine. An additional diamond grit disk makes the system capable of gross removal and rapid interproximal shaping. 

Compatible with both ceramic and composite dental materials, Jiffy Spin disks are described as an affordable system that allows for a seamless transition starting with the diamond disk and moving on from coarse to fine disks to complete restorations with lasting shine. 

Ultradent Announces New Jiffy Spin Disks

Solmetex Acquires Impladent. Image: © Solmetex


Dental waterline safety and amalgam separator company Solmetex has announced its acquisition of Impladent. This acquisition will add Impladent’s OsteoGen® Plug, a regenerative socket preservation solution, to Solmetex’s platform, as well as expand their portfolio of offerings for dental practices and dental service organizations, per a press release from Solmetex.

Through this acquisition, Impladent aims to grow into new markets, according to president Andrew Valen.

“We are eager to partner with Solmetex to help launch our next phase of growth and accelerate expansion into new markets with new products,” Valen says in the press release. “After nearly 40 years operating as a family company, we are confident that Solmetex is the right partner at the right time to take Impladent to the next level.”

Solmetex, which focuses not only on dental waterline products but also modern dental isolation technology, will work with Impladent to grow together.

“We are proud to partner with a leader and innovator in regenerative dental technology,” Solmetex CEO Gene Dorff says in the press release. “We believe the addition of Impladent to our offering will unlock meaningful growth in new areas. I look forward to the opportunity to collaborate with the Impladent team and execute on our plans for future expansion.”

The financial terms of the this acquisition were not disclosed, per Solmetex.

Solmetex will acquire Impladent to expand regenerative product offerings into new markets in the United States and globally. 

Solmetex Acquires Impladent

A new partnership between onDiem and the American Dental Hygienists' Association (ADHA) is designed to provide additional benefits to dental hygienists.

Eligible dental hygienists who both find work through onDiem and sign up as ADHA members will be able to receive discounts on their ADHA memberships along with up to $3,000 each year in onDiem Care Benefits which can be used for a range of health and wellness expenses.

“We’re passionate about helping dental hygienists not only find jobs, but also the kind of flexible work and protections that enable them to avoid burnout, build financial stability, and enjoy fulfilling careers in dentistry,” says Joe Fogg, Founder and CEO of onDiem. “We’ve partnered with the ADHA—the consistent advocate for the dental hygiene community at the federal, state, and local levels—to help dental hygienists feel cared for, and to expand their access to all the perks and benefits of an ADHA membership.”

The membership discounts are made available due to matching deductions from onDiem, according to a press release. The onDiem Care Benefits provide up to $250 each month for costs including things such as child and elder care, gym memberships, wellness retreats, copays, prescriptions, deductibles, and more.

“At the height of the pandemic, we were proud to help our dental hygienists continue to find ways to deliver essential care across the country—in the midst of great personal risk and uncertainty,” adds Dawn Ann Dean, RDH, MSDH, ADHA 2022-2023 President. “As the ADHA celebrates its 100th anniversary this year and embarks on a new century, we’re excited to partner with onDiem, a company that shares our vision and values.”

For more information on the partnership visit 

 official onDiem-ADHA partnership website

The new partnership is designed to help dental hygienists cover membership dues and health care expenses.

American Dental Hygienists’ Association and onDiem Announce New Partnership

The Trap-Eze Plaster Plus™ is a specially designed, disposable sink trap that can effectively capture plaster, wax, floating materials, polishing compounds, abrasives, pumice, steel wool and the latest environmental concern—microplastics. The product, recently launched by Buffalo Dental Manufacturing, joins a popular line of plaster traps from the company, with this latest version designed to help out the environment.

According to the National Geographic website, “Microplastics have been detected in marine organisms from plankton to whales, in commercial seafood, and even in drinking water. Alarmingly, standard water treatment facilities cannot remove all traces of microplastics. To further complicate matters, microplastics in the ocean can bind with other harmful chemicals before being ingested by marine organisms.”

Dental practices commonly release microplastics into municipal wastewater from procedures such as removing and adjusting restorations, or by milling and grinding crowns, inlays and onlays. The amount of microplastics generated per procedure is small, but it occurs frequently, states Buffalo Dental Manufacturing.

Although it is not known exactly what percentage of global microplastic pollution originates from dental offices and dental labs, it’s possible to reduce that percentage with the Trap-Eze™PlasterPlus trap. Recently added to the company’s popular line of plaster traps, the new, patent-pending product not only captures microplastic particles, but also wax, floating materials, polishing compounds, abrasives, pumice, and steel wool that can cause drain clogs.

The Trap-Eze™ PlasterPlus is made in the USA and includes the following features:

Designed to slow water discharge flow rate and allow sediment to settle out of wastewater

Fast and easy trap replacement and installation

Disposable—No permanent traps to clean or messy liners to replace

For use in dental offices, clinics, and labs

For more information, or to order the Trap-Eze™ PlasterPlus, visit 

, call 800-828-0203, or send an email to sales@mailBDM.com. Distributor inquiries welcome

Buffalo Dental Manufacturing’s latest offering effectively captures plaster, wax, floating materials, polishing compounds, abrasives, pumice, steel wool and microplastics.

Trap-Eze Plaster Plus Can Help Reduce Dentistry’s Role in Microplastic Pollution

Laura Dorr is the former executive editor of DPR's Modern Dental Network and a regular contributing author.

Although a dentist’s immediate focus may be on perfecting restorations or remedying periodontal issues, none of these tasks would be possible without first having a business in which to do so. As much as many dentists may just want to focus on the dentistry, the business side of things is a predominant factor in practice success.

Running a successful business requires a combination of good customer service, smart decision-making, and savvy business acumen. This means structuring your business—and your investments—to meet practice requirements without wasting overhead on things you don’t need. In addition to a dentist’s responsibilities in the operatory, a Bankers Healthcare Group survey found that 76% of dentists—regardless of practice ownership status—play an active role in practice financial decisions.

Being involved with financial decisions means that learning how to make the 

 decisions is a key skill. But this can be a more onerous task than expected, particularly in today’s saturated markets for dental technology, products, and services. Which solution is the right one for your practice? Determining that can take some time, consideration, and support to avoid entering into a contract you can’t wait to get out of.

Having the right support team is the first step in ensuring the business deals you enter into are ones that truly benefit your practice. This process begins the second that dentists leave school and decide where they’re going to practice. And, subsequently, this is also one of the first opportunities for things to go wrong and bad deals to be made, particularly if a new dentist is joining a practice as an associate.

“If you’re going to work for somebody, if you’re an associate, your contract is really important,” says Bruce Bryen, CPA, CVA, a dental practice valuation analyst at Baratz & Associates, PA. “Many contracts contain noncompete agreements. The noncompete has traditionally been a really important thing for the practice to have power over the associate.” 

Although noncompete clauses are rarely legally enforced, Bryen says that doesn’t mean they should be ignored. According to the American Dental Association, potential associates should examine the prohibitions, including the geographic scope, duration, termination clauses, and ultimate potential liabilities if the noncompete is broken.

 A too-stringent noncompete agreement can be the first bad deal a dentist makes.

“The attorney is very important in the beginning,” Bryen says. “The lawyer will tell you whether or not you should do it and explain what’s reasonable and what you’ve got to look out for. This is incredibly important. You should also get the support of a financial advisor or a dental CPA [certified public account]. And be sure to find one who understands the ins and outs of the dental field [because] it is different from other industries.”

Bryen emphasizes that although up-front costs of retaining professional support sometimes deter dentists (particularly younger dentists who are deep in student-loan debt), investing in assistance early can have substantial financial benefits in the long run. Retaining the right people ensures that you’ll get the best contracts and enter into deals that will be beneficial—and not contain any surprises down the road. In 2019, 13% of practice owners reported being entirely hands-off in financial decision-making and instead relied on financial advisors, partners, or even office managers.

Bringing in experts makes sense. “When you buy a house, you hire somebody that’s going to tell you what’s wrong with it,” Bryen says. “It’s no different when entering into a contract or investing in a practice or upgrades; you’re paying someone to find the issues and explain them to you. They’re the ones who are going to help you stay out of trouble. To them, the issues will be obvious while they may not be to you. They can sort out all the potential problems that you might not even have considered.”

Kevin Walker, DDS, founder of Dental Debt Solutions LLC, a marketplace for student loan refinancing for dentists and dental specialists, agrees. He adds that it’s important to consider choosing an attorney familiar with dental contracts.

“Dentists can go wrong with business deals if they do not have the proper legal representation,” he says. “Do not choose legal representation based on who is the lowest price. Choose legal representation based on their experience specifically dealing with the business [or service] you are trying to buy.”

Effectively managing money is critical to practice profitability, and having experts who support you can be the difference between success or getting sucked into a deal you don’t need or can’t afford.

“When it comes to investing, I always suggest to [dentists that they interview] multiple professional money managers and select the one they feel most comfortable with,” Walker says. “Investing is complicated, and every individual has different future goals. After practicing dentistry for a year or two, find out if you want to be an owner or not. That will be very important information to talk about with your financial advisor so you can plan accordingly.”

Dentists are champions at detail-oriented tasks but sometimes have trouble seeing the bigger picture. After all, if you’re spending your day focused on the nuances of color matching and the practice seems to be running along smoothly, it can be hard to find time to take a closer look at the broader scope and identify areas for improvement. This makes dentists susceptible to too-good-to-be-true offers when it comes to upgrades such as practice-management systems or the latest technology.

“It’s important to remember that salespeople are cheerleaders,” Bryen says. “You may need new practice-management software, but they can make you think salt is pepper. And you don’t need all the bells and whistles; you need to identify what you actually need the software to do for you.”

This is where many dentists go wrong, Bryen explains. Practice owners need to establish what the shortcomings are of their current systems and choose a new one that can address those issues—without going over-the-top. In short, you really need to understand how your software is working for you and how a new system would benefit you before you can make a switch. This can be challenging in today’s market because the complexity and rapid advancements in software and technology often leave dentists without a clear view of what developments or features are critically valuable to their practice and which ones are extraneous. Often, according to a salesperson at least, all these features will be absolutely essential to your practice—but the shiny marketing brochures may be promoting features that aren’t necessary for you.

“You probably don’t need the practice-management software for everything the salespeople are telling you,” Bryen says. “You need it for specific things—for your appointments, your accounts receivable, insurance. Some of the bells and whistles are just packaging, but it can be easy to get distracted by them. And then you’re going to be paying for things you don’t need.”

It’s important to ask questions before entering into contracts with any vendor. How will the transfer of data be handled? What sort of fees will that incur? What sort of backups will a cloud-based vendor provide, and what happens if recovery is necessary? Ensuring that protections are structured into any initial agreement or contract can save a lot of conflict and money down the road, should one of these situations arise.

Dentists should be wary of contracts with vague terms or long-term commitments that don’t include outlined plans for updates or evolution. When it comes to the fast-moving world of technology, a company should have plans in place for upgrades or updates to the technology and the underlying infrastructure. Does the vendor have a documented track record of both maintenance and development? Are they up to date on the latest Health Insurance Portability and Accountability Act (HIPAA) and confidentiality requirements? If the company is stagnant without development plans, you’re going to get stuck in the mud for the duration of your contract along with them, potentially setting your practice back indefinitely in terms of expansion and productivity.

When it comes to information technology or software providers, contracts should clearly include what sort of customer support is provided, security, network monitoring, and threat protection. If a company doesn’t offer support in these areas, you’re setting yourself up to handle any potential problems solo—which can quickly spiral out of control if HIPAA violations come into play.

Understanding the intricacies of things like HIPAA protections and in general how your business functions can also help prevent falling into pitfalls such as investing in pricey consultants to come in and improve the practice. Although it’s never a bad idea to get outside help when needed (ie, having the right people in your corner), a lack of understanding about the issues that need to be addressed can result in big bills for simple solutions.

“I’m always amazed when I see practice-management people come into a practice,” Bryen says. “They’re there for a week, and it’s $50,000. And I think some of this happens because dentists don’t understand how their practice runs. Maybe some of these consultants have good names in the industry, and maybe they’ve been around a long time, so you feel good with that person. And that’s fine if it is what your practice needs. But oftentimes, this isn’t necessary if you take the time to understand your business.”

It’s also important to understand market values and how much a service or investment should cost. After all, if something seems too good to be true, it often is.

“Dentists should watch out for deals that have too high or a too low of a price,” Walker says. This is just good advice across the board, but it also comes into play when entering an agreement to purchase a practice. “For example, if a business has been listed for many months, there’s a reason why the business hasn’t sold yet, whether that be the price is too high or [some other reason].” 

Perhaps most importantly, don’t enter into a deal that you don’t fully understand. Dentists should understand what they are getting for their money. Fees and pricing should be transparent and predictable with no hidden costs, expected support should be detailed, and opportunities for development or improvement down the road should be included. Dentists should consider scalability, reliability, and the vendor’s ability to actually fulfill its promises before diving into any major agreement. Do your research, shop around, and don’t be afraid to ask the vendor questions.

One way for dentists to figure out what investments and deals are worth the money is simple: Look at what other dentists are doing. Clinicians can learn a lot from each other, both clinically and on the business side.

“If you’ve gone to work for somebody before you open your own practice, you see what they have and what worked and what didn’t,” Bryen says. “If they’re [old-fashioned] and they don’t have anything state of the art, that’s a bad thing. And you’ll be able to see the shortcomings and make decisions in the future that can avoid those.”

Maybe these shortcomings are something they didn’t have but should or a technology that was superfluous. Either way, keeping an eye on what is happening in other practices can help a dentist make better decisions for their own.

Although determining what deals are worthwhile can be intricate, it isn’t all doom and gloom. Agreements that help improve your business, such as necessary technology improvements or cutting-edge technology that improves patient care, can be incredibly beneficial.

Knowing what is going on in the industry can also be helpful. Staying current on the most recent technology trends, emerging research and technology, and scientific advancements can help dentists make informed decisions regarding what investments they should make within their practice. With 20% of dentists reporting that they upgrade or purchase new equipment every year, staying abreast of the latest trends is critical in leading the pack and providing the highest level of patient care.

“You need to have some things that are state of the art to have a functioning business that attracts patients,” Bryen says. “Things as simple as [having] computers in the operatories and being able to schedule appointments chairside. These are great investments that improve patient care and streamline your business. You want to have as much modern equipment as you can because doing things manually—or not doing them at all—will hurt your practice. If it’s not up to date, it takes too long to get things done.”

In 2019, 32% of dentists reported taking out loans to finance equipment upgrades or practice expansion, and 50% said they had secured a loan to buy or open a practice.

 Although taking out loans innately comes with risk, Walker and Bryen both contend that it’s a calculated risk—one that can create incredible returns, particularly when purchasing or opening a practice.

“Buy your own business!” Walker says. “This allows many advantages not just financially, but in lifestyle. It’s important to have a good work/life balance, and owning your own business allows you to do that. I always suggest thinking of the future and living below your means, but I think it’s important to treat yourself from time to time as you worked so hard to get where you are in life.”

And this balance is often worth the gamble.

“There’s always a risk when you’re borrowing money to invest in a practice or an upgrade,” Bryen says. “But the financials will tell you an awful lot, and if you go back and review them, you’ll get an idea of the bigger picture. And remember, when you’re looking at things surrounded by your advisors and it’s time to go to the bank to borrow the money, you’ll have so many people pointing out the different facets of the business deal that you should feel pretty confident about the whole thing.”

1. National survey from Bankers Healthcare Group examines dental practice investments. News release. Bankers Healthcare Group. May 15, 2019. Accessed May 10, 2023. 

https://www.multivu.com/players/English/8440255-bankers-healthcare-group-dental-practice-investment-survey/

2. Everything dentists should know about non-compete clauses and restrictive covenants. American Dental Association Accessed May 10, 2023. 

https://www.ada.org/en/resources/careers/employment-agreements-the-devils-in-the-details/non-compete-clauses-and-restrictive-covenants 

How to avoid getting stuck in a bad contract or signing up for something you can’t use.

Business Deal Red Flags for Dentists

Don’t miss the chance to learn about the latest in endodontics, implants and glass ionomer dental restoratives and sealants, and earn 3 free continuing education (CE) credits along the way, during 

 Specialties in Dentistry Virtual Event on June 23.

Attendees can work with experts on the fastest growing dental specialties. The virtual event kicks off at 10 am ET on June 23 with an introduction from John Flucke, DDS, Chief Dental Editor & Technology EditorDental Products Report.

For the link to the event page (i.e. To Register, 

Bryan Kariya, DDS, Transcend Dental Clinic in Huntsville, Alabama, will teach a course titled “Digital Full Arch Implant Workflows” that will address options for digital implant capture, necessary records for facilitating digital design, restorative options for provisional and final restorations, and more.

The second course of the virtual event will be “The Chemical Magic of Glass Ionomer Restoratives and Sealants,” taught by dental materials expert Douglas Young, DDS, EdD, MS, MBA, Professor Emeritus, University of the Pacific. Dr Young will review how to properly use glass restoratives with, and without, the use of silver diamine fluoride (SDF) using minimally invasive methodology to bridge the gap between remineralization and traditional restoration.

The final course, byBrett Gilbert, DDS, FICD Diplomate, American Board of Endodontics, will focus on endodontics. Dr Gilbert’s CE session is titled “Overcoming Common Pain Points in Endo: Perforations, Locating MB2, and Negotiating Calcified Canals.”

The course will use multimedia visuals to illustrate and demonstrate techniques through the dental operating microscope to help you overcome common pain points in endodontic procedures. Learn tips and techniques to help you prevent these iatrogenic occurrences such as perforation on access. Additionally, attendees will learn about describing and demonstrating techniques, armamentarium, and the mindset to successfully negotiate calcified canals.

 for the June 23 CE event. Sponsors for the event include Axsys (Course 1), GC America (Course 2), and Enova (Course 3).

Virtual event courses taught by experts on endodontics, implants and dental materials offer 3 CE credits, chance to learn about the newest advances in dentistry. 