Dr. John Flucke is in private practice in Lee’s Summit, Mo. He also serves as technology editor for Dental Products Report magazine and keeps an active blog filled with thoughts and tidbits on the world of technology at blog.denticle.com.

Dr. John Flucke

Keeping Personal and Practice Data Safe in the Wake of the American Dental Association Hack. Photo courtesy of Chor muang/stock.adobe.com. 


None of us wants to learn the unfortunate news that our office has been hit with a cybersecurity attack. In addition to the effects it can have on our business and potentially, our income, there is also the matter of protecting patient data. Not only is protecting that data the right thing to do, but it is also required by law. Cybersecurity incidents can be a harrowing ordeal. While there is no way to completely guarantee you will never be affected by one, there are some good rules to follow which will help make you less susceptible.

Given the recent hacking of the American Dental Association (ADA) office as well as the increase in cybersecurity threats due to the ongoing issues in Ukraine, I turned to the person and company that I trust for my own practice’s cybersecurity.

Here’s some insight from Steve White, Senior Partner and Vice President of DDS Rescue.

Dr John Flucke: Given what we know about the cyber-attack at the ADA offices, what are your initial thoughts?

Without knowing exactly what files the hackers have accessed, we can only make assumptions. Based on these assumptions, each individual ADA member should take extra steps to ensure their personal and their practice’s data is protected.

JF: Given the current situation, what are some immediate steps that ADA members should take to protect themselves and their practices?

The first concern that I have is the personal data that may have been caught up in this hack—data that can be used for personal identity theft.

To be safe, you should assume that the hackers have the password to your ADA account. Even if you have never used your ADA password anywhere else, you should immediately change your passwords, especially any and all passwords associated with anything financial such as your accounting software, banking, investments or retirement accounts.

In fact, this is a good time to go through all of your passwords and employ best practices for proper password management. Password complexity and expiration policy should be enabled and enforced by Group Policy when possible. Here are a few password don’ts:

Don’t reuse passwords. If you do, a hacker who obtains access to 1 of your accounts will be able to access all of them.

Don’t use a regular dictionary word as your password. If you do, at least string several together into a passphrase.

Don’t use standard number substitutions. Do you think “P455w0rd” is a good password? N0p3! Cracking tools now have those built in.

Don’t use a short password—no matter how weird. Today’s processing speeds mean that even passwords like “h6!r$q” can be cracked quickly. Your best defense is the longest possible password.

You should also enable 2-Factor Authentication, also referred to as Multifactor Authentication, to all applications and websites that offer this as an option. Two-Factor Authentication sends a 1-time code to your cell phone to validate that it is you who is attempting to login. When enabled, a hacker will need both your password and your cell phone to successfully login.

JF: I have received notifications that both my cell phone number and my email address have appeared on the dark web. Besides identify theft protection, are there any other steps that we should take?

You bring up a good point. With healthcare being such a high-priority target for cyber-attacks of all types, having an active identity theft protection program, such as LifeLock or Identity Guard, are not only a best business practice, but also just common sense.

In addition, a professionally run Dark Web Assessment should be conducted now and subsequently on an annual basis to see what personal information may be out there. You don’t have to have a full cyber-attack to have information leaked that can be used to create an online clone of you or your practice.

JF: Is there any chance that any of the information that the ADA hackers may have could increase the likelihood of an office having a cyber-attack?

Not individually, but as a group, possibly. The chances that the ADA attack could lead to a single office becoming an individual target of a cyber-attack are slim. Having said that, it should be assumed that the hackers do have all the members’ email addresses. That brings up the possibility of using these addresses to do an email Phishing attack.

Over 90% of the successful ransomware attacks in dental come into the practices through emails camouflaged as a company or individual that the recipient trusts.

Each office needs to develop sound defenses against this type of attack by understanding that there is no single step that can be taken to prevent a ransomware attack. A multilayered approach is necessary.

The step that all members should immediately take is making certain that you are using a professionally managed email service. A no-charge email provider is neither Health Insurance Portability and Accountability Act (HIPAA) compliant nor a strong enough defense to decrease the chances of a successful ransomware attack.

A professionally managed email service, such as Google G-Suite and Microsoft 365, provide a layer of encryption to your stored emails that is required to be compliant. In addition, these email service providers are 2 of the best at filtering out dangerous incoming emails. They both provide continuous updates to their service to filter out malicious emails before they can reach your network.

JF: You mentioned a multi-layered approached. What are different steps and how do the members learn more?

The steps that should be taken vary widely from administrative to technical. Some are easily identifiable, such as your email provider; another is if your staff has had sufficient training. Everyone in your office, doctors included, need to be properly trained in how to avoid triggering a ransomware attack. A qualified healthcare or dental cybersecurity provider should provide this annual training as part of their normal services.

The additional protection layers are technical in nature and are managed in the final—and most important—step, which is a professional network security risk assessment. We have found that the majority of offices across the country do not know that having a proper risk assessment is a major HIPAA requirement—one that needs to be done every 12 months and is the first thing that the Office of Civil Rights will ask to see should you ever be audited.

In addition to ensuring you are HIPAA-compliant, a proper risk assessment is the best tool to identify the layers of defense that your practice presently has deployed and what layers of defense should be added or upgraded to be both compliant and properly defended against a cyber-attack.

It is advised that this risk assessment be run by a third party, and if done properly, will not interfere with the workflow on your network.

DDS Rescue runs this assessment on my practice each year. You can learn more about a proper risk assessment by visiting their website, DDSRescue.com or by phoning them at 800-998-9048.

Articles

What to be concerned about and what steps to take to protect your dental practice from cyber-attacks.

Keeping Personal and Practice Data Safe in the Wake of the American Dental Association Hack

The human body is the most complicated and impressive machine I can imagine. You probably feel the same way. In the early technology days of the computer network, the original designers of what would eventually become the Internet were designing and building a command-and-control system for the U.S. Military. It was in the days of the cold war and military minds were very concerned about a “decapitation attack”. The concept was a very real fear and dealt with the possibility of Russian first strike that might cut off the decision-makers from the rest of the armed forces. To help prevent this, the network designers designed the network so that all the computers were connected to all of the other computers. This meant that if 1 computer went down, the network would simply “re-route” the electronic traffic around the damaged system. As long as there were at least 2 systems online, the communication continued uninterrupted.

The computer network experts considered this a genius move. Yet, the human body had been using the concept of collateral circulation and redundant systems since the first human evolved from pond slime.

The human body is a masterpiece of engineering. It can take tremendous beatings and continue to thrive. It can be attacked by a huge number of pathogenic living organisms and win the battle. If it comes into contact with an organism it has never seen before, it can quickly start up an investigative process that can find the enemy’s weaknesses and then exploit them to destroy that enemy.

It is composed of many redundant systems that work independently of the others to ensure that if a critical process is damaged or lost, things can continue on, and the human organism can continue to survive. It can even endure the loss of critical parts or limbs and keep on living.

Part of that amazing ability is, for lack of a better description, the design and system layout. Putting organ systems like the kidneys on opposite sides of the body means that if an accidental injury happens to one side of the body, the contralateral side still can function. The redundancy is incredible and fascinating.

Another part of that amazingly functional machine is the actual shape and placement of anatomical parts. The eyes are placed slightly inside the skull with bone around them to prevent damage from the outside environment. Joints are composed of smooth articular surfaces on both the socket of a joint and the bone head that fits into it to ensure easy and pain-free movements.

All of these things work together, to make that amazing symphony of biological systems work in absolutely perfect harmony. Of course, nothing works in a vacuum and as I’ve already stated, the human body fights a lot of battles. The body is a microscopic war zone of agents attempting to speed up its demise. Between outside biological insult and the ever-present risk of damage due to accidents and injury, the body does not stay pristine very long.

As all of us know, the oral cavity is a difficult place to manage. In fact, it is 

 difficult to manage that I don’t think we give ourselves enough credit for how well we, in the profession, affect its outcomes. The combination of bacterial attack on both the dentition and periodontal systems as well as the potential for accidental injury, make managing the oral cavity a dicey process at best.

As we all know, recreating mother nature is an incredibly delicate balance and requires a great deal of training and expertise to do things “right”.

Any practitioner can remember times when they changed something in the mouth just a tiny bit and discovered that even a tiny change can cause unexpected challenges. Proper contours and emergence angles are intrinsic to success and I’ve often found it incredible when changing something like that brings about a result that I just hadn’t foreseen.

We’ve all had those cases where changing the contours of a tooth or teeth in the aesthetic zone suddenly results in food getting caught in the interproximal “triangles” at the gingival simply because those contours are slightly different.

Things like that are incredibly common and they are even 

 common with direct restorations. The really interesting thing about that?The determining factor of these contours is not not usually the operator, the material, or the patient. No, the determining factor (or at least the biggest part of the determining factor equation) is 

Here’s the deal. When we are trained initially to perform indirect restorative procedures, we are generally trained on the easiest aspects first. Once any student is trained and can easily accomplish “the basics” more intricate parts can be introduced into the procedural process.

For dentistry, that means that almost everyone is trained to place amalgam first. As I’ve said many times in the past, procedurally, amalgam is a very forgiving material. Therefore, clinical neophytes are introduced to it first. Once the basics of a one surface indirect restoration are digested and understood, two surface restorations and then brought into the mix.

In order to recreate a missing wall of tooth structure, a form is needed, and in restorative dentistry, this form is a matrix band. As far as I can tell from my research, matrix bands have been around since at least 1945, but perhaps longer.

These early band designs, especially the most popular Tofflemire, are placed circumferentially around the tooth and then tightened around the tooth with a “retainer”. When tightened properly, the band resembles an inverted cone. While this helps recreate the missing wall, it does little in regards to recreating the natural shape of the tooth.

Because it is a very dense material, amalgam can be “packed” into the preparation and forced against the matrix band. The matrix band is made of a material that is a softer metal and can be distorted in shape by applied pressure. The act of condensing and packing the dense amalgam material against the band causes the band to change shape. The condensation process results in a band that has been distorted to resemble the natural shape of the missing tooth structure and helps recreate the all-important proper anatomical form of the natural tooth. This form makes the restorative material into a shape that has the interproximal contact in the correct place. When the band is removed, the restored tooth closely resembles its original shape and form. The restorative material and the matrix band “grew up together” and naturally evolved hand in glove.

In the early part of this millennium, composite materials had been subjected to a lot of use as well as a lot of research. Doctors saw the advantages of bonded materials while patients saw the cosmetic benefits. Because of these things, more and more doctors began to place more and more composites.

As we’ve already established, anatomical contours are really important. What hasn't been addressed yet is that human beings are very much creatures of habit. We have a serious tendency to do things the same way over and over simply because “that’s the way we’ve always done them.”In evolution, that can be a good thing. Trails exist because human beings follow the pathway of those that came before them and survived. If staggering through the jungle gets you eaten by the tiger, stay on the trail!

The disadvantage is in things like restorative dentistry. The original matrix band developed along with the restorative material and they worked together well. However, composite is a material with very different physical properties from amalgam. When composite is pushed into a prep, it doesn’t distort the matrix band simply because it lacks dentistry. Instead, the matrix band distorts the composite. The matrix band that has a contact even with the adjacent tooth’s marginal ridge will create a composite restoration with its contact even with the adjacent tooth’s marginal ridge.

We used the same matrix system “because we’ve always done it that way”, but in reality, the matrix system did not help create the end result we needed.

As doctors began to see two surface restorations on bitewing radiographs at recare, they realized that something needed to change. There were many efforts to improve existing systems, but they were more or less concepts of “don’t raise the bridge, lower the river”. By that, I mean folks tried tweaking the existing way to get it to work better. In reality that didn’t work out very well. Fortunately, there were others who decided that rather than trying to hack amalgam systems to work better with composite, it was just easier to create a system that was designed for composite at inception. This gave birth to the “sectional matrix” solution or what I refer to as “C-Bands”. These are “C” shaped bands that are placed in the interproximal space and held in place with “rings” that also slightly push the teeth apart to give a tighter contact. The bands are formed with the proper contour not only buccal to lingual, but also occlusal to cervical. They are created in a way that lets the composite form in a way to correctly recreate the interproximal surface and place the contact at the proper height and the proper contour. The result is a perfectly formed interproximal surface.

There are several of these “ground-up systems” on the market. I’m going to discuss my two personal favorites.

Triodent utilizes bands that are formed to the proper contour (also with the appropriate height of contour) right out of the package. The bands also have very critically placed small holes on each side, corresponding the buccal and lingual, as well as a hole in a small tab at the top 

. The system also comes with a remarkably well-made set of “pin tweezers”. These tweezers have a small pin at the tip to engage the small holes on the band to make holding the band and removing it simple. Once the pin is in this small hole, you cannot drop the band. It makes placing the band very easy and removing the band extraordinarily simple.

The big innovation for this system was the invention of the “V Ring”. As we all know, placing a wedge at the cervical of the matrix band keeps the band against the tooth. Placing a ring with small tines into the interproximal embrasure area was always a challenge because the wedge would get in the way. To eliminate this problem the tines of the Triodent rings split to form a “V” shape which allows them to straddle the wedge.

The wedge is also a forward-thinking product, made of flexible rubber that adapts well against the cervical margin and fits easily between the tines of the “V-Ring”.

Garrison Composi-Tight® 3D Fusion™ Sectional Matrix System

Garrison is a company that works incredibly hard at outside-the-box solutions. One of the things I love about these folks is that they are always innovating which means you can always expect constant improvements in their products.

Their bands are 3-dimensionally contoured, ultra-thin, and dead soft. The dead soft aspect of the bands allows for the user to burnish them after placement to adapt to the adjacent contact no matter how unusual that contact area might be. They do not have holes to engage with, but they do have a little tab at the top that Garrison calls a “Grab Tab”.

The rings in a sectional matrix system are designed to both hold the matrix band 

to apply pressure. The ring is expanded by use of a forcep, placed in the interproximal against the band, and then released. As the tines attempt to move back together, they place pressure on the teeth they are engaged against. This pressure drives the teeth apart microscopically which means, when the ring is removed, the teeth rebound back to their original position creating a remarkably snug contact.

Garrison Composi-Tight 3D Fusion Sectional Matrix System

The rings in this system have been created to deal with different clinical situations. There are two different heights of rings for both short & tall teeth. There is also a ring for preps that are wider than normal which makes dealing with those clinical situations that have a proximal box wider than the adjacent tooth, easier and less stressful.

These rings also have rubberized “grippers' ' on the arms of the tines 

. These retention extensions grab the matrix band as well as the surfaces of both teeth and keep the rings from moving or slipping up and/or off the tooth. One of the challenges of any sectional matrix system is how well it will engage and stay on teeth that are anatomically shorter than average. This also allows the rings to apply plenty of separating force while still staying securely in place.

The Garrison wedges are also incredibly functional. The wedges appear similar to feathers with the vanes of the feather extending to engage tooth structure. When I first used them I was amazed at how well these wedges adapted to the cervical margin and how strongly they worked to hold the band against that cervical margin. They are color-coded according to their size and work incredibly well.

The smart minds at Garrison Dental Solutions have even created a sectional matrix system for Class III preparations in the anterior. It is called the Fusion Anterior Matrix System and it can greatly simplify the placement of anterior composites.

The system does not use any separating rings, but uses incredibly thin metal bands that are much thinner than mylar strips. They slide between the teeth easily and can, if need be, slip into the interdental sulcus for deeper preparations without causing gingival hemorrhage.

They are paired with a unique wedge which is curved and is used to hold the band snugly while its curvature is used to enhance engagement on the labial and lingual surfaces. Rather than the wedges going straight through the interproximal space, they are placed in a “C”type orientation. The highly curved wedges are placed with the inside of the curve in contact with the tooth being restored which greatly enhances stabilization of the band and creates restorations with life-like anatomic contours which greatly decreases finishing and polishing times.

Legend has it that when Michelangelo was asked how he created the statue of David his reply was, “I just chipped off everything that didn’t look like David.”Whether that is true or not, I don’t know. However, I *do* know that there have been times that I’ve performed a composite restoration that, when the matrix was removed, looked nothing like the tooth I just restored. So I then spent a great deal of time “chipping off everything that didn’t look like a tooth”. That might have worked really well for Michelangelo, but it doesn’t work well in dentistry.

The secret is to find hardware that allows you to place restorations that look natural and perform in the manner that millions of years of evolution have proven to be the best. Those systems exist. It is our job to find them and use them to the best of our abilities to help those who trust us with their care.

The right hardware can be your secret weapon when placing natural-looking restorations. 

This Is the Shape of Things to Come

Bioactivity Really Does Matter in Dental Materials. Photo courtesy of 123dartist/stock.adobe.com. 

As Technology Evangelist, my job is 2-fold. One part is to scour our industry for the most promising new things that potentially can change the way we practice. The other part is to do adequate research to ensure these amazing new additions to our armamentarium perform as expected. One of the most disappointing things in our field is when we get really excited about a new product or procedure only to see it not perform as expected or, even worse, fail prematurely.

When I was originally trained to place composites in dental school, if there was 1 speck of acid etch on dentin, the procedure received a grade of “fail.” Prevailing thoughts at the time were that acid etch on dentin would lead to pulpal necrosis.

Then in 1989, John Kanca III, DMD, began to advocate etching of dentin. I give Dr Kanca a lot of credit because the dental villagers grabbed torches and pitchforks and stormed his castle. He took a lot of flak but stood firm in his beliefs. Time has proven him right.

Shortly after this, maybe within a year or 2, Dr Kanca was again promoting a radical new idea. This time it was leaving dentin moist to increase bond strengths. Once again, the villagers gathered at the drawbridge. After all, everyone knew that any kind of moisture in a prep doomed it to failure. Of course, time has once again proven that Dr Kanca was right.

After wet bonding became mainstream, he followed that up with the invention of the fourth-generation bonding technique.

I have a rule in life: “One time is luck, 2 times is a data point, 3 times is a pattern.” As I watched, studied, learned, and implemented his science and teachings, I came to appreciate what Dr Kanca knew. The guy is smart.

Over the years, we’ve become friends. It’s only fair that you know our relationship. Could that affect the way I view his ideas? I hope not, but it’s possible. We’ve also had our—ahem—disagreements. It also provides a bit of a backstory to this article.

I asked Dr Kanca if he ever thought about when he would start to slow down, and that’s when he dropped a bomb on me. He told me that he was as excited about what he was doing as at any other time in his career. He had been working on a new bonding agent, a material that was truly bioactive, or having an effect on living matter, and he could hardly wait to get it into the hands of the profession.

Bioactivity has been a big marketing buzzword in the profession for at least 10 years, encompassing several aspects of our profession.

What Dr Kanca came up with was different. His Re-Gen material employed Bioglass 45S5 as an active ingredient. The amazing thing about Bioglass 45S5 is that, when done correctly, it creates a bond with bone so strong that it cannot be removed without breaking the bone. By coating the surface of the bioactive glass with hydroxyapatite, the bond strengths that result are nothing short of amazing.

Bioglass 45S5 was first synthesized in 1969 and approved by the United States Food and Drug Administration for bone and dental repair in maxillofacial surgeries in 1999. It has been around for more than 50 years and has been used in our industry for more than 20 years.

Bioglass 45S5 has a track record in our profession. Knowing that this molecule has a history of success behind it goes a long way.

Re-Gen was created with the concept of bioactivity at the ground floor. It came off the drawing board with Bioglass 45S5 as its heart. The concept is simple to articulate, but building the material was anything but. The project was driven to create a material that was easy to use, had all the advantages of current materials, but went 1 step further into the realm of bioactivity.

Re-Gen not only releases ions to improve the result but attracts ions from the oral environment as well.

The product is available in 3 forms: as a bonding agent (both universal and self-etching), a flowable composite, and a pit-and-fissure sealant. By using the Re-Gen bonding agent and placing an initial thin layer of Re-Gen flowable composite over the bonding agent, you have created a tremendous environment to let the Bioglass 45S5 do its stuff.

Covering the dentin and enamel cut by the preparation processes gives the tooth structure the benefit of the bioactive aspect of Re-Gen. You can then place your preferred composite material over these initial layers knowing that the preparation has the Bioglass 45S5 underneath.

The bond strength for Re-Gen Universal is 35 MPa on dentin and 33 MPa on enamel. The bond strength of Re-Gen Self-Etch Adhesive is 55 MPa on dentin and 52 MPa on enamel. For those of you who have not memorized the bond strengths of leading materials, those numbers are right in line with other top-of-the-line materials. The important takeaway is Re-Gen works just as well as or maybe better than the material you are currently using, while providing the phenomenal benefits that come with its bioactivity.

We routinely see improvements that look like, “Well, they can’t do any better than that,” only to suddenly find out 2 years later that the latest and greatest we had just seen was but a steppingstone to something remarkably better.

Sensitivity is battled with a self-etch version as well as the activity of the bioactives. You have a material that can help create structures at the tooth material interface. You get bond strengths that are comparable to other bonding agents. However, with other materials bond strength is all you get. With Re-Gen, the bonding agent is not a barrier to the dentin. Instead it creates remineralization of the dentin-resin interface, which helps reduce sensitivity as the material works.

The tooth-composite interface will always be one of the weakest links in the restorative process. Bacteria at this interface will create an acidic environment, and hydroxyapatite is easily broken down by acid.

Current research shows the life of a 2-surface composite restoration to be approximately 5 years before recurrent caries forces a replacement. Re-Gen helps in this environment in a few ways. It has been shown that bioactive glass inhibits the growth of some pathogens while killing others. The second way is the bioactive glass helps to create an alkaline environment that buffers plaque acids. By returning the solution in this microscopic zoo back to a neutral pH, the Bioglass negates the bacteria’s acidic effects.

Re-Gen was launched in fall 2019, so it has been on the market for 2½ years. Techniques, materials, the oral biome, and patient home care are but a few of the things that contribute to the success or failure of what we do.

I’m excited to see the fantastic improvements of our materials. Dr Kanca is right. This is a remarkably exciting time to be a restorative dentist. Let’s all enjoy the ride.

Bioglass and Re-Gen help keep the oral biome healthy and maintain restorative integrity.

Bioactivity Really Does Matter in Dental Materials

Back in my days as an undergraduate at the University of Missouri-Kansas City, I became fascinated by human behavior. I made my mind up to be a dentist at an early age, and I started my undergrad career as a chemistry major, but that soon changed to psychology.

Little did I realize that my bachelor of arts in psychology would be put to frequent use in a dental practice as well as in my role keeping up with the numerous rapid advancements in dental technology.

Making changes can have an incredible effect, and I’d like to discuss the changes that can be made by using the Bien-Air Nova electric handpiece.

As a dentist, I grew up with air turbine handpieces. I practiced for about 10 years with air turbines without considering a change. Then I was given the opportunity to have a 2-week demo with an electric system. I was stunned…and excited by what I experienced. I ordered an electric handpiece the day the demo system was returned. If you have the option to make the change to electric handpieces, do so. You will not regret it.

Electrics offer many advantages over air turbines and some of those advantages are things you have to “feel.” Because I practiced the first half of my career with air turbines and the second half with electrics, I feel I’m qualified to offer some judgments on the subject. So let me tell you why I’m such a big fan of Bien-Air and their new Nova electric handpiece system.

Incredible Power, Control and Performance

First of all, electric handpieces are powerful. Air turbines depend on a tiny stream of pressurized air to spin the turbine in the handpiece head. They initially spin up to around 400k rpm, but when the bur engages with tooth structure, turbine handpieces immediately drop down to between 200k to 160k rpm. You can actually hear the pitch change as you engage tooth structure. Use too much pressure and you can stall the handpiece.

Electrics spin up to 200k rpm and maintain that speed. They are powered by motors that use gears to spin the bur, so the power they deliver is constant and predictable, alllowing for more consistent preparations.

Another benefit of electrics comes in the ability to maintain consistent speed even at low rpm. Creating perfect margins for fixed prosthetics becomes exponentially easier when there is no fluctuation in speed.

Because diamond burs cut in the same manner no matter which way they rotate, electric motors also offer the advantage of being able to reverse rotation. This is useful when interproximal reductions are performed as the bur pulls itself through on the mesial and the distal.

To perform well, the operator must see the field as clearly as possible. This is why most dentists now work under high magnification with auxiliary lighting mounted on their loupes. However, some electric handpieces require larger heads to allow room for the moving parts, making it harder to see while working.

Bien-Air has solved that problem. The Nova handpiece has a small head and a narrow neck for enhanced visibility. The benefits are augmented with a 4-port spray that immediately washes away dust and residue to provide pristine visual acuity. Additionally, the 4-port spray provides copious irrigation to prevent overheating of the pulp and keep the bur cleansed so debris does not build up and decrease cutting efficiency.

To provide smooth, vibration-free cutting, Bien-Air upgraded the moving parts in the Nova to employ Cylcro gears, a high-end solution noted for their precision and durability. This translates to a degree of performance that is unequaled in the world of dental handpieces. The performance of the Nova is smooth, powerful, and incredibly precise.

To ensure the Nova system holds up under the rigors of clinical use and constant sterilization, Bien-Air is the first company in the dental space to use a technology called PVD (physical vapor deposition) that can decrease temperature fatigue on metals.

Another safety feature is designed to protect the buccal mucosa (or any other tissues) from being damaged by an overheated handpiece head. Bien-Air uses CoolTouch+ technology. The chuck, protected by a ceramic insulated push button, will not heat above human body temperature during operation.

An important part of the high-speed handpiece that many doctors are not even aware of is the antiretraction valve. When the operator steps off the rheostat, the air and water pressure in the lines decreases rapidly, and this can result in bacteria and viral particles being sucked into the lines, and potentially transferred from one patient to another.

To eliminate this problem, engineers developed an antiretraction valve. The Nova handpiece has the first and only sterilizable antiretraction valve in the industry. It’s one more way to protect our patients.

I’ve been fortunate to be able to work with the Nova system for a few months now and I have nothing but good things to say about it. The Nova has made an appreciable difference in visualizing the field.

I’m impressed with the Nova, and I’m confident you’ll be impressed too. Give the Nova system a test drive and I think you will also become a fan.

John Flucke, DDS shares his experience taking Bien-Air's Nova electric handpiece for a Test Drive.

Advertorial: A New Standard of Excellence for Electric Handpieces

Greene Vardiman Black would be having a heyday right now. As all dentists know, Dr Black developed the first classification system for dental caries as well as the initial idea behind preparation designs.

Although dentistry is a huge amount of science with a dab of art thrown in for good measure, it needs to have standards. Well-known and universally taught standards are what helps differentiate a healthcare profession. Standards also help us provide the best possible care and give us a method to hold each other accountable.

The reason I think Dr Black would be thrilled with practicing today is because we are now in a phase where a lot of the procedures and prep designs that he created need to be updated. It’s interesting to review textbooks of operative dentistry and see how procedures and preparation designs were actually dictated by a combination of anatomy, but also the limitations of the materials of the day. When composites evolved to allow placement in posterior teeth, preparations were routinely performed using the preparation forms that doctors had learned in their training.

However, those preparation forms had been created and designed years earlier by considering the limitations of the restorative materials available. Amalgam, being the only restorative material available (other than gold) forced doctors to remove significant amounts of tooth structure to compensate for its physical properties.

There was another recommended rule from the early days of dentistry, which was that of “extension for prevention.” At the time, the prevailing thought was to prep into and remove remaining pits and fissures. The idea was that, by incorporating them into the preparation and hence the restoration, the doctor removed areas that could be sources of breakdown in the future. Since amalgam did not decay, the thought went, it was best to place it into areas that were susceptible to future decay.

The fallacy in that reasoning became apparent with the introduction of local anesthetic and fluoridation. Before anesthesia, dentistry was such a traumatic experience that doctors learned extension for prevention because the chance of getting someone to return for more treatment on the same tooth was practically nil. If a doctor got a chance to restore a tooth, it became critical to do everything possible to prevent breakdown in the future. The breakdown was also much more common before community fluoridation measures were put into effect. Stronger enamel meant less need for extension for prevention.

Novocaine was first synthesized in 1905, (Lidocaine was not discovered until 1948) and it is important to remember that local anesthesia did not gain widespread acceptance right away. Dr Black turned 70 the year novocaine was created and he published his book on operative dentistry in 1908, which means most, if not all, of his preparation rules, were created before patients were routinely receiving anesthesia. Dr Black passed away in 1915.

When the true bonded composite restoration was discovered, restorative dentistry changed dramatically. Suddenly materials could be “stuck” to enamel and dentin. As composite technology evolved and improved, preparation design evolved and improved along with it.

Once the evolution progressed to composites that could be placed reliably and long-term in posterior teeth, many began to change their preparation designs to match the changing materials. A material that chemically adhered to teeth did not absolutely require mechanical retention.

Since composites didn’t require mechanical retention, preparations could be smaller. Amalgam often required healthy tooth structure to be sacrificed because of its need for mechanical retention. It also required a certain thickness to resist fracture.

Fluoride and composite worked together to make the concepts of turn-of-the-century dentistry fairly antiquated. Suddenly there was no need for extension for prevention. Instead, our philosophy became a John Lennon-ish “give teeth a chance”.

Class II restorations began to be done as “slot preps”, where the bur went straight through the marginal ridge to create a small slot instead of dovetailing into the occlusal surface. Since teeth were not experiencing decay in a similar manner as in the past, doctors began removing only the carious area. Healthy and caries-free structures were left untouched. Adhesive dentistry began to truly save teeth.

I began to refer to this new philosophy as Zen dentistry because I thought, “When the tooth is ready to be treated, the tooth will show me where to treat it.” Why destroy the entire occlusal surface of a lower molar with a cloverleaf amalgam prep when I could simply and easily remove the caries from an occlusal pit and leave the remaining tooth structure untouched? Composites allowed us to completely rewrite large portions of our textbooks on operative dentistry.

There are often unforeseen consequences to our actions, and sometimes only the lens of time allows us to see those consequences clearly. With composite restorations, what dentistry found is that composites are finicky materials.

Where amalgam materials had all the problems I mentioned previously, it wasn’t really technique sensitive in placement. As long as the prep was long enough, deep enough, and was undercut, you could pack amalgam in there and it would most likely work. Composite—not so much.

We quickly discovered that composite is technique sensitive. There was more Zen to composites than we thought. Wet, but not too wet. Dry, but not too dry. Then there was control of the field that had to be mastered. No saliva, no blood, and no crevicular fluid.

I used to love to say to the reps that came into my office, “How much saliva can I get in the prep?” Of course, they would sputter, “None!” And I would reply, “Have you seen where I work?”

All jokes aside, the technique side of dentistry came back to bite us (no pun intended). Amalgams were ugly and sacrificed tooth structure, but they corroded and sealed. Their longevity was pretty darn good. Studies now show that the average 2-surface composite lasts approximately 5 years.

The problem with composites is recurrent decay. Composite doesn’t corrode like amalgam to seal its margins. That means that any breakdown in the bonding process, such as contamination, poor placement, or a bad curing light, can result in poor marginal integrity. That can then progress to marginal breakdown, and then the bacteria move into those tiny gaps and create acid, which causes caries. If we could just stop the bacteria, we could greatly extend the life span of a composite. The problem, of course, is stopping the bacteria.

Now, at long last, dentistry has a material that can do just that. Imagine a composite that can kill the bacteria that cause caries. You read that correctly. By the time you read this article, you will be able to purchase Infinix composite from Nobio.

For a very long time, dentistry has had materials that promised to limit decay, but now we have a material that has actually been scientifically proven to kill the bacteria that are the enemy of our restorations. Nobio has created a molecule that is embedded into the Infinix composite that kills bacteria. It is a quaternary-ammonium silica (QASi) that is mixed into the composite material. It doesn’t wear out or become depleted over time, and it doesn’t need to be replenished or recharged. The QASi molecule is part of the composite material, and it stays there for the life of the restoration.

Bacteria that come into contact with QASi are killed, which keeps bacteria from forming on the composite and along the tooth/restorative interface. Infinix has been cleared by the US Food and Drug Administration for reduction of demineralization, which is the beginning of the caries process. By reducing demineralization and killing the bacteria that cause caries, Infinix has the potential to greatly extend the life of composite restorations. Infinix is a complete restorative system that includes a dentin primer, bonding agent, and the Infinix composite, which is available in traditional and flowable viscosities.

The great thing about Infinix is that it is used in the same manner dentists are used to for traditional fourth-generation bonding procedures. Placement consists of acid etch with standard 37% phosphoric acid, rinse, lightly dry, apply primer, apply bonding agent, cure, place Infinix in an incremental placement technique, and cure. If you have placed a composite, you can place Infinix. It is a simple and efficient system that is easy to handle, matches well, and has laboratory studies that show it holds up well over time.

I was fortunate enough to be approached by Nobio about 2 years ago and have watched the product develop over that time. I began placing Infinix restorations in the fall of 2021, and I am starting to see those restorations in recare exams. They look as good today as the day I placed them.

Imagine a future where composites last for a decade or more. Imagine restoring your high caries rate patients with a material that actually kills the bacteria that causes that decay. The best part is that you no longer have to imagine those scenarios. They exist right now.

Infinix composites from Nobio are available now. Let the revolution begin! Dr Black would be proud.

Historically, dental preparations have evolved based on what materials were available—and Nobio’s Infinix composite brings us into a new age.

Turning the Tables on Recurrent Caries

Technology can be an interesting critter sometimes. I say that because sometimes it can follow slow and predictable patterns while at other times it can take off in unexpected directions. Take Moore’s Law, for example, named after Gordon Moore, the co-founder of Fairchild Semiconductor and Intel Corporation. In 1965 Moore predicted that the number of components on an integrated circuit would double every 18 to 24 months. He was only using his gut and not some complicated mathematical formula, but that statement has held true for so long it is now known as a “law.”

So what does Moore’s Law have to do with dentistry? Probably more than you might think, but my topic for this month focuses more on the evolution of our profession than anything else.

In my first 2 years of dental school, we did not wear gloves. I know that seems horribly antiquated and a tad nauseating to many of you, and that’s probably because both of those terms apply. But, we didn’t know any better.

Near the midpoint of my second year, there was a mandatory lecture for each class that spelled out the school’s new infection control protocol and procedures. At the time there were some concerns about losing tactile sensation due to wearing gloves and some other potential problems. I’m pretty sure the disease that drove the change didn’t even have a name at that point in time, but the profession stepped up and did the right things to ensure everyone’s safety. HIV is a tragic part of history, but it did drive dental infection control to where it needed to be.

Autoclaves were suddenly needed in every office, and we began running everything through them. Before the mid-1980s, dentistry did not steam sterilize handpieces and they were not designed to go through the abuse. Turbines failed almost as fast as they could be repaired. However, handpiece manufacturers rapidly designed and implemented changes to air turbines that allowed them to withstand the rigors of the autoclave.

And autoclaves themselves were flying out of warehouses as offices rushed to meet the new infection control protocols. When I graduated and began looking for my professional home, one of the first questions I had was, “Do you have an autoclave?” Sometimes the answer was “no,” and I would politely move on to another office.

I have been in the trenches since pre–“bloodborne pathogens standards,” and I have seen a lot of changes and improvements in our infection control devices.

I’ve seen latex gloves go powder-free and then latex gloves be overtaken by nitrile ones, which, at least for me, provide a much better tactile response and no allergies. I’ve seen handpieces go to ceramic bearings that withstand high-pressure steam and high temperatures, barriers that can inhibit cross-contamination, and custom-created optics that allow us to perform procedures under high magnification.

In the over 30 years since dentistry embraced wearing gloves and masks to help protect everyone from the transmission of diseases, our profession has seen incredible advances and changes in myriad products.

Yet it wasn’t until the sudden and unexpected arrival of SARS-CoV-2 and the resultant COVID-19 that dentistry turned to the concept of protecting our patients, our teams, and ourselves by utilizing snug, form-fitting, high-filtration respirators.

Up to that point, the prevailing wisdom appeared to be “any mask will do.” We paid little heed to the gaps at the sides of our masks or the fact that many particles were capable of passing straight through the limited filtration material they were composed of. The concepts of a Level 1, 2, or 3, or an N-95, were foreign to most of us, and we proceeded in blissful ignorance until the tidal wave of a novel coronavirus washed over us.

In our current environment, perfect fit is important, especially when it comes to masking. Not only does a mask need to provide adequate filtration, but it also needs to fit in a manner that all inspired air passes through the filtration medium and not through gaps due to poor fit. Yet comfort needs to be factored in as well. Most of us understand all too well the trauma inflicted on our ears by masks whose ear loops pull tight to ensure a proper seal along the borders.

I challenge the manufacturing sector of our profession to come up with something that can solve this problem. The dental industry is uniquely prepared to help overcome these limitations.

What I envision is a high-quality reusable facial respirator that is custom-fitted to the face of the user. We can scan teeth with incredibly high accuracy—enough to meet the tough standards of the profession—so let’s scan a face in the same manner. If we can scan a tooth with 50-µm accuracy, imagine what a respirator milled or printed to match your facial contours would be like. We would have a perfect fit that would not permit any kind of leakage around its perimeter.

The frame could then use a high-filtration medium in detachable filters that could be removed and replaced as often as the user required. While we’re brainstorming, let’s add in some antiviral LEDs. Studies show that light emitted at the 264-nm range is very effective at killing germs, bacteria, and most importantly, viruses. Whatever pathogens (if any) managed to squeeze through the filters would be immediately exposed to the energy emitted by the LEDs, which would add another degree of safety.

Many of us working in N-95s every day battle the problem of our glasses fogging. The custom-fit would probably decrease that, but to help with that and for comfort, a couple of small cooling fans could be added to help more air inside the device. The exhaust fans from the device would also pass air through filtration to protect the user from potentially passing anything back out into the room air.

If the seal and filtration are well created, it might make our voices harder to hear. Perhaps a small speaker could amplify the voice under the respirator. That would be pretty simple to add-in.

The LEDs, speaker, and built-in cooling fans could be powered by a lithium-polymer battery that would last all day on a single charge. We would recharge the respirator every night just like we recharge our LED headlights.

These are the features that came to me as I was daydreaming about this project, and I’m sure this isn’t pie in the sky. I’ve seen some masks that sort of follow this idea that are already available, although none have been sold as “medical grade.” For a peek at one such device, take a look at the RAZER ZEPHYR PRO (razer.com).

This may seem like overkill but think back to 2020 when we all thought a Level 2 surgical mask was just fine. Since returning to my office in the late spring of 2020, I have continued to work in an N-95 mask because I simply feel it is safer for me and my patients.

Is a custom respirator like this going to be expensive? Well, there is no doubt it would be more expensive than current solutions, but we spend lots of money on things such as magnification and other items. I think the comfort and safety of something like this would be well worth the initial expenditure.

We’ve upgraded and improved many of our other infection control systems. It’s now time for dental manufacturers to improve the comfort, safety, and ease of use of personal air filtration. This is definitely an idea whose time has come. If you are thinking of developing such a product, contact me right now. I’ve got even more ideas.

As with many infection control measures over the years, the need for personal air filtration manufacturing has arrived. 

Can PPE Be Improved?

Well over 80% of endodontic therapy in the United States is performed by general dentists. That is significant because US endodontists are quite busy. If general practitioners were not able to bear the load, patients would be lined up and in pain for months. Fortunately, that is not the case. Endo remains an important, predictable part of our clinical decision-making process.

The concept behind endodontics is simple, embracing one of the most common tenets of health care. If the body has infected tissue it cannot remove on its own, a doctor should remove that tissue and any related infection to allow the body to properly heal. It is no different than any other surgical excision process. Following that line of thought, the difficulty of endodontics is that we do not have 

 to the affected area. That means we are forced to work in tiny spaces, removing the nexus of infection while basically “going by feel.”

One of the greatest revolutions in the field was the introduction of rotary instrumentation. Suddenly endo therapy was 

. What had taken hours now took minutes. Rotary instrumentation is probably the greatest reason that many general dentists are now comfortable doing endo.

The most important part of endo is removing all necrotic tissue and bacteria from the canal system. When viewed microscopically, the canals are full of curves, nooks, crannies, and anastomoses that make effective cleaning extremely difficult. Most canals also do not have a perfectly round shape. That means we are attempting to use highly machined instruments that are perfectly round in a field that is anything but round. All those areas are “outside the circle” and not touched by round files…unless you make those round files with a larger diameter.

That concept has been used for almost as long as rotary instrumentation for endodontics has existed. Logically, if you take a drill and make a quarter-inch hole in a two-by-four and then ream that hole with a half-inch–diameter drill bit, all the sides of that existing quarter-inch hole will be removed. That is essentially what large taper rotary files do inside the canal.

Although that logic sounds good in theory, in practice large taper files remove a great deal of tooth structure, especially in the coronal third of the canal. Each individual tooth is a phenomenal example of engineering, and teeth are built the way they are through millions of years of evolution. Teeth exist in the form they do because that is the best engineering nature has come up with. One of the biggest challenges practitioners face is trying to rebuild teeth to be as strong or stronger than they were before they were affected by disease.

The idea of enlarging the canals to achieve access and to remove all the pathogens is noble. However, when you think of taking a canal that has trouble accepting a #6 .02 taper file all the way to the apex and then instrumenting the canal to a much larger diameter, that is a lot of root structure to remove. My grandfather used to say, “Son, never sacrifice the future upon the altar of the immediate,” and he was right. By greatly enlarging canals, we do make it easier to access and to clean. However, if that tooth suffers a catastrophic fracture and requires extraction 2 years later, was all the instrumentation in the patient’s best interest? The roots have a finite diameter and if we decrease the wall thickness by increasing the instrumentation diameter, we weaken things considerably.

For the past few years, I have been following the progress of endo instrumentation. Several years ago, dentistry began to focus (and rightfully so) on the concept of “minimally invasive” procedures. Why remove more tooth structure than necessary? Why not “bank” more tooth structure for later? Yet why have we moved more toward minimally invasive procedures while doing just the opposite in endodontics?

That is one reason I am excited about the new line of rotary files from SS White. The system is called ExactTaperHDC. I have been test-driving the system for a while now and am impressed.

There are several advantages to this system, the first of which is that you do not have to learn a new technique. There is nothing like trying to utilize new instruments while also trying to learn a new technique. That stress does not exist with ExactTaperHDC.

Another advantage is the one I am most excited about. SS White designed this system to effectively instrument canals while performing the task in a minimally invasive manner. The maximum file diameter is .08 taper and some canals do not even require that. This means that valuable tooth structure is preserved and strength retained. This is intrinsic to helping ensure the long-term viability of the tooth.

I have also been very impressed with the flexibility of these files. Nickel titanium really shows its abilities when instrumenting curved canals, but some files perform better than others. These files have exceptional flexibility, which makes navigating with them easy. There is also the matter of how well they clean a canal. The ExactTaperHDC files are not only incredibly flexible, but they also possess the ability to thoroughly instrument the canal system. They are efficient but not too aggressive, and this goes with the concept of being minimally invasive as well.

SS White has also made resistance to instrument fracture a priority. This is a tremendous benefit because having an instrument separate in a canal is one of the worst possible endodontic outcomes. A file system that features flexibility, efficiency in cleansing, and strength is a tremendous benefit to the doctor.

Obturation has also been greatly simplified. The gutta percha points are designed to precisely fit the files. This means that when a finishing file goes to length easily you can proceed knowing that the gutta percha point will as well. The precision of this system means that everything matches perfectly, giving the operator a “hand in glove” experience during obturation.

The company also created a bioceramic sealer to go with the system. Gone are the days of a sealer irritating periapical tissues. This sealer is based on Mineral trioxide aggregate (MTA), so it is incredibly kind to the body. It maintains a pH optimal to providing an antibacterial effect while encouraging new tissue formation and diseased tissue recovery. It is highly radiopaque and has a consistency that makes it easy to dispense and use.

The ExactTaperHDC system from SS White is an endo system with much to offer. If you are looking for a system that is easy to use, minimally invasive, and offers numerous other advantages, I advise you to take a close look. I am confident that you will be as impressed with it as I am.

John Flucke, DDS shares his experience taking SS White's ExactTaperH DC files for a test drive in his practice.

Advertorial: Test Drive With an Easy-to-Use, Minimally Invasive Endo System 

Knowledge is Power When Managing Presriptions. Photo courtesy of Steve Cukrow/stock.adobe.com. 

The doctor-patient relationship is the most important factor when considering prescription management.