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

When I was young, my grandfather’s office had a sign with a quote from English philosopher John Ruskin: “It’s unwise to pay too much, but it’s worse to pay too little. When you pay too much, you lose a little money—that is all. When you pay too little, you sometimes lose everything, because the thing you bought was incapable of doing the thing it was bought to do.”

That quote has stuck with me for my entire life. My grandfather, like John Ruskin, was a bit of a philosopher as well as a small business owner. He knew how to run a successful business. He taught me a lot, and I am frequently amazed at how much of his advice I apply to my own small business daily. Dentistry is a profession that requires precise and durable equipment, but as we all know, that equipment comes with a price tag. This even applies to your hygiene department.

When viewed from the perspective of the patient, the hygiene department is the practice’s gateway to clinical dentistry. For most patients, they spend more time with members of the hygiene team than they do with the doctor. You simply cannot understate the importance of the patient experience with the hygiene team. If a new patient with minimal restorative needs comes to a practice, their patient experience is principally linked to what they experience at their semiannual cleanings. They develop a relationship with their hygienist and that relationship leads to trust.

The trust factor is huge when it comes to clinical restorative diagnoses. When a patient builds a relationship with the hygienist, they are much more likely to follow treatment recommendations. That’s why codiagnosis between the doctor, the hygienist, and the patient is so important. Trust is not only built from the time the patient and hygienist spend together, but also from what the patient experiences during that time.

A patient approaches their hygiene visit with certain expectations, which may include getting questions answered, having concerns or fears allayed, and having a comfortable experience. However, for many patients, their No. 1 concern is leaving that visit with the wonderful feeling of their teeth and mouth being clean and fresh.

A large part of that hygiene experience comes from the ultrasonic scaler. As anyone who practices clinical dentistry can attest, the profession takes its toll on the human body. The art and science of performing quality prophylaxis is responsible for repetitive stress injuries to the hands, wrists, and fingers, which is why a quality ultrasonic scaler is one of the best purchases a doctor can make for the hygiene department. The hygienist benefits because they put less stress on their upper extremities, and the patient benefits because the ultrasonic scaler is more efficient, induces less sensitivity, and the energy helps lyse the cell wall of pathogens.

Ultrasonic scalers are valuable pieces of the hygiene armamentarium; however, they come with a price. That’s when John Ruskin comes to the rescue. It is unwise to pay too much, so how about paying less and getting all the quality you want and need? That is what my team has experienced as we have worked with the TurboSensor®+ Ultrasonic Scaler from Parkell.

I’ll gladly admit I have a penchant for top-of-the-line hardware, which transfers over to my purchases for the hygiene team. We’ve used the most expensive ultrasonic scalers on the market, and the team has been happy with them. However, they also understand me pretty well, and they know that if I get a chance to try something out, we are going to do that. So, we brought in the TurboSensor+ Ultrasonic Scaler and put it through its paces.

I have 6 hygienists on staff, and they have tons of experience. Many of them have been practicing for over 20 years, whereas my least experienced team member graduated in 2016. My point is that these women have seen and done it all. They also understand that when I am testing products, I need honest and critical answers.

One of the nice things about the TurboSensor+ is its small size. This unit will not require you to sacrifice a lot of your counter space. Its small size also means it is easy to move. For a doctor on a budget, that means transferring the unit from one room to another is simple, so you can buy 1, then purchase more as the need arises. For my team, it meant we could easily move it to give every hygienist ample time to use and experiment with it—and use it they did!

The unit is impressive. Designed for use with 30 KHz tips, it is compatible with inserts from all major manufacturers. The device features a new IntelliSense™ processor that delivers consistent performance with any 30 KHz tip.

The detachable handpieces are autoclavable, which eliminates the need for sleeves and allows the entire handpiece to be sterilized. The handpieces have held up well throughout cycle upon cycle in our autoclaves, and the quick-lock connector makes it simple to attach and detach them from the unit. Their texture allows for a good grip and tactile feedback, which has also remained throughout our testing range.

The TurboSensor+ also makes purging of the unit simple and efficient with safeguards that help prioritize infection control best practices. The unit will not start purging unless the handpiece is disconnected in order to make sure a sterilized handpiece isn’t contaminated during the purge. The entire process can be started and controlled with the foot pedal as well.

One of the handiest features is the quick, easy jump to turbo mode. It is not uncommon during treatment for the operator to come across an area with particularly tenacious calculus. For those instances, rather than stopping and performing manual adjustment of the power settings, the device allows the operator to do a hard press of the rheostat, which ramps up the power to turbo mode. This not only makes treatment easier but also makes the operator more efficient. The hard press feature allows the hygienist to keep their eyes on the target, which is better for everyone. Looking away, making the necessary power adjustment, getting repositioned to the treatment site, removing the tenacious calculus, then repeating the process in reverse is inefficient and time-consuming. No one wants a dental appointment to last longer than necessary.

During standard procedures, the unit allows for full customization of the power to the tip, as well as the water delivery. This allows the hygienist to get things dialed in to their favorite and desired parameters while providing the patient with a comfortable appointment.

The other highly desirable feature is, of course, the price. As a company, Parkell has existed since 1948—and a business doesn’t survive that long unless it does things the right way. Dentistry is a close-knit community in both the clinical and business sides of the industry. The profession demands quality goods for the benefit of our patients. Parkell has developed a reputation of not only quality goods but also of delivering that quality at a very reasonable price. The TurboSensor+ Ultrasonic Scaler is just another example of that. The company initially brought their line of ultrasonic scalers to the market in 2003. This line of products has a long history of innovation and dependability. In my office, we expect a lot from an ultrasonic scaler, and the TurboSensor+ unit has delivered. My team loves it, and I’m confident yours will, as well.

Articles

[SPONSORED] In this Test Drive, John Flucke, DDS, shares the experience he and his team had using the latest ultrasonic scaler from Parkell.

Test Drive: This Affordable Ultrasonic Unit Offers High-End Performance, Features 

As a technology lover and former psychology major, I have always been fascinated by what technology can do for us but also why we accept or reject things with the potential to change our world. History is full of examples of individuals who rejected new ideas and discoveries. One of my favorites is a quote from Alfred Loomis, MD, an accomplished clinician and luminary in medical education who served as president of the New York Academy of Medicine and the Association of American Physicians in the late 1800s.

The story goes that in 1882, Dr Loomis was told about Robert Koch’s discovery of tubercle bacillus as the cause of tuberculosis. A few days later, Dr Loomis was giving a lecture when he stated, to the delight and laughter of the students present, “People say there are bacteria in the air, but I cannot see them.”

Dr Loomis’ belief system was too strong to allow him to see the truth. This happens often in business, too. In the early days of computing, Ken Olsen, the CEO of Digital Equipment Corporation (DEC), told colleagues, “There is no reason anyone would want a computer in their home.” DEC made mainframe computers that were, at their smallest, the size of a refrigerator. A couple decades later, his company was bought by home computer manufacturer Compaq. Olsen was so entrenched in his world of giant computers that he was blind to the concept of smaller ones.

My point is even experts make mistakes regarding the future. If that mistake is made by a business, it can be the end of the business. This is especially true for a company comfortably entrenched in an industry, which brings me to the point of this column.

Whip Mix Corporation began back in 1919. The name comes from a machine they licensed from a dentist that easily and consistently mixed water and gypsum investment powder into the perfect consistency to pour around a wax pattern. That means Whip Mix has been involved in making cutting-edge products to make the creation of fixed dental prosthetics easier since 1919. That is an amazing and admirable mission!

Back when Whip Mix was founded, the lost-wax technique was the common fabrication method for gold prosthetics. The technique still works and is used today, but the profession has evolved. The use of nonesthetic materials such as gold has decreased significantly, and the need to mix investment material decreased with it.

I mentioned resistance to change because it is a common occurrence. A company develops something amazing and new, and the once tiny company has amazing success. However, instead of scanning the horizon for new and better things, the now large company, spends huge amounts of energy and capital to maintain the status quo.

Whip Mix did not do that. They embraced the future and kept on the cutting edge. As Technology Evangelist, I salute them! The company saw the market and profession changing and changed right along with it.

In the past 10 years, dentistry has made an evolutionary jump into the world of 3D. We are now seeing the incorporation of 3D impression/acquisition units (which some call scanners) and the pairing of those devices with 3D printers. This allows offices to print models, surgical guides, occlusal guards, dentures, orthodontic aligners, and even permanent crowns. This market is exploding with potential.

Doctors in today’s high-tech practices are working on ways to develop the best digital workflows. The snag is they only have a deep understanding of half the process. They know dental impressions, and this familiarity helps in choosing the 3D impression system that best fits an office. However, 3D printing is unknown to many doctors. Left to find their own answers, doctors must often work with new and unfamiliar companies because many 3D printer manufacturers are newer brands in the dental industry.

The other piece of expanding an office’s hardware footprint is the concept of compatibility. As a diehard technology lover, I am passionate about the concept of open architecture software and the interoperability that comes with it. Basically, it means every scanner will output to a file type that can be used by every 3D printer. It’s a great concept for mixing and matching hardware, but it also means a doctor has to be absolutely sure of their purchasing decisions.

There are many snags that can pop up that you don’t think about until you use a piece of hardware. As my grandfather used to say, “Son, experience is what you get 5 minutes after you needed it in the first place.”

Enter Whip Mix with their VeriONE line of digital workflow products. Combined they present a turnkey 3D concept I truly love. The company offers the full range of 3Shape TRIOS intraoral scanners, VeriEKO 3D printer, VeriLUX 3D model-curing station, and the VeriWHIRL 3D model-washing/processing station, which can all be purchased together.

3D in dentistry is moving past the early adopter phase. Doctors do not want to spend valuable time figuring out technology. They want to buy it and use it. That is what Whip Mix delivers.

The company allows the doctor to purchase with confidence. Whip Mix has looked at its product line from every angle. Not only does the doctor get state-of-the-art hardware but also state-of-the-art software as well. As an authorized dealer for 3Shape, Whip Mix gives the doctor access to this incredible design platform. But it goes 1 step further than that. If the office sees the benefits of 3D printing but doesn’t want to do their own design?, 3Shape offers their own offsite design services that create necessary files and email them to be printed with office hardware. Problem solved!

The mind trust at Whip Mix analyzed the industry, saw the changes coming, and looked at the solutions for how offices could integrate these amazing technologies. They then took it 1 step further and said, “Where are the potential problems?” They identified those problems and built solutions into their turnkey system.

An established company could have easily pointed out the risks of change and encouraged doctors to stay with the status quo. That is what many companies do. Instead, Whip Mix saw the future, saw the benefits, and embraced them. They went the extra step to make their customers’ experience less stressful.

I am impressed with Whip Mix and the system they designed for predictable digital dentistry. Doctors can now buy digital solutions from a company with more than 100 years of experience. Whip Mix began as a company of 4 brothers who worked together and saw the future. Today the company still maintains a culture of seeing and embracing the future.

If you want to reap the benefits of digital workflows, bring Whip Mix into your practice. They have done the hard work for you, and this means you can enjoy digital workflows while knowing you have a partner who has done everything to ensure your success. My time and experience working with their products has made me a strong believer in Whip Mix. I am confident you can benefit from their efforts as much as I have.

[SPONSORED] John Flucke, DDS, shares his impression of the new turnkey chairside 3D printing solution from Whip Mix.

Test Drive: Embracing a Changing Industry, Whip Mix’s VeriONE Turnkey Digital Solution Makes 3D Printing Accessible to Any Dental Practice

I’ve been doing this technology thing for quite a while now. I consider myself lucky to have been practicing when computers got a toehold into the industry. I managed to catch the wave just as it started to swell, and I have been riding that wave ever since. One of the better things my history in technology has given me is perspective. When I started with tech, older colleagues teased me about how I’d survive “when the computer quits working.” I would just smile and say, “There are ways around that,” and leave it at that.

The early days of the tech influx saw new, amazing high-tech devices come to dentistry, even before the computer became commonplace. The original intraoral cameras were on carts that were wheeled in when needed and connected to big electronic boxes that converted the camera signal into something readable, then that box was connected to a big monitor to display the image.

There was no way to save the images. You just showed the picture to the patient, then went on about treatment. You could print them if you desired, but that required expensive photo paper, and you had to then put the photos into a paper chart. It wasn’t worth the hassle.

Early digital radiography was a tad more sophisticated. It still required a cart, but at least it used a laptop. You could store the images in a digital patient file for later retrieval, but the process and the sensors were bulky. Plus, when you wanted to see the radiographs, you had to get the laptop and then open the files.

Suddenly the computer became the hub of the tech wheel, whereas the intraoral camera and the digital x-ray sensor became the spokes. The operatory computer was where everything connected. Suddenly and efficiency surged when we didn’t have all these separate pieces that we brought in to use.

A History Lesson: Cloudy With a Chance of Electrons

In 1982, a young and bright 28-year-old, Scott McNealy, helped found a company called Sun Microsystems. His statement in 1982 was: “The Network is the Computer.” We are now seeing this statement proven out time and time again.

The reason I bring this up is because, when translated to today’s environment, what he really meant was: “The Cloud is the Computer.” As a profession, we are already turning a large amount of our practice data over to the cloud, and that is only going to increase. Thanks to a near ubiquitous penetration of broadband internet, we are moving data around the planet like Marilyn Monroe’s skirt over a subway grate.

The computer in the operatory is not going away anytime soon, but it will function more and more as a gateway for the operatory to access information that all our connected devices will store.

The next big jump we will see is cloud storage of imaging, including our cone beam computed tomography data. Companies are putting the finishing touches on a single access point for extraoral photos, intraoral photos, intraoral radiographs, and cone beam.

Now let’s think about the Internet of Things (IoT) for a bit. Think of things like Ring doorbells, Nest thermostats, garage door openers, and, of course, the Amazon Echo that brings Alexa into your life. All the types of things that are connected and make your life easier without being connected to your computer. In most instances, the first time you plug them in, they ask you for your Wi-Fi username and password, and that’s it. They will automatically connect to your network, then they sit there in the background.

The biggest reason we haven’t seen tons of IoT in our offices yet is that we don’t often have to change our equipment. Sure, you might have an IoT thermostat currently, but that is a low-dollar item. I am talking about chairs, dental units, autoclaves, and the expensive things we use every day. We don’t often replace them, but as we do, you’ll see many devices that want to connect.

One of the first devices I saw with this ability is my SciCan STATIM 2000 G4 cassette autoclave. I purchased the device a couple years ago and was able to connect it to my network. It sends emails to me about every cycle it runs and warns me and my equipment support team at Goetze Dental if there is a problem.

Then there is Planmeca’s Romexis system. This software connects every piece of Planmeca equipment in the office and does cloud image storage that I mentioned above—all in 1 system.

Imagine devices that notify service when they break down or, better yet, 

they break down. It costs a lot of money to equip a service van from your equipment repair team. I’ve been told each van can cost a company well over $100,000 because they are full of the most needed parts, but they don’t carry every part. Often, a tech comes to the office, diagnoses the problem, then needs to go pick up the necessary part (or, heaven forbid, needs to order it). Until the repair is completed, an office is not functioning at peak efficiency. IoT technology will allow a device to contact service and say, “I need part XYZ or I will not work in X number of hours” or “I need part XYZ, and I am broken and not functioning.” Either scenario allows your service team to bring the necessary part on the first trip and minimize your downtime. Doesn’t that sound amazing? It is!

Being so dependent on things outside our control is scary for a lot of us. Dentists are almost all strictly type A personalities, and we love control. Some of the things we are going to deal with are going to be difficult for some of us, whereas some of these have things that need to be worked out.

Ransomware is a huge problem, and I don’t have the solution. The criminals that run those groups are well aware of what targets can be hit to maximize the chances that a target will pay. I often wonder what would happen if one of these groups knocked a digital impression system offline. Sure, we could all start using impression material, but that would create major problems for the industry. What if someone took a cloud imaging platform down? What if there were no radiographs for a certain percentage of dental offices? That would be a disaster for the industry.

In the past year or two, we have seen a lot of healthcare systems get hit with this problem. The crooks know hospitals need to run, which puts a tremendous amount of pressure on hospitals to pay to get access to their data. We’ve also seen a few dental systems get hit with this. One of the largest was when ransomware compromised a dental information technology company, then used that company’s access to their clients to freeze the clients.

Dental companies that are providing things like practice management and image storage need to put security at a premium. Every company I’ve spoken with has assured me they are locking things as tightly as they can, but there is always room for improvement. There are HIPAA requirements, but it’s also just the right thing to do both ethically and for the good of our businesses. Ransomware had been around for a very long time, and it’s not going away anytime soon.

There is also the problem of the connection itself. If your business is going to rely on offsite services, will you be able to go offsite? We recently lost our internet connection for 2 hours and our VoIP phones went down.

My office is still running a server, so our data were accessible, and our VoIP provider was able to quickly route our phone lines over to our cell phones, so the problem was minimized. I was lucky. If I was running cloud-based practice management or image management, we’d have been in a much deeper hole. Even with digital impressions, our scanners just queued up the scans, then sent them out when the connection came back, but it could have been a lot worse. Even though the internet in my office is not mission-critical to every operation, it soon will be, which means we must have connections and vendors we can rely on.

We are all becoming so dependent on our digital tools that in the very near future, losing 1 (or the connection to them all) will mean everything will come to a screeching halt. This also means these services and the internet connection that powers them must be as reliable as our other utilities like electricity. Things are incredibly more stable and reliable than in the past, but they need to be even more so.

As anyone who knows me will tell you, I’m bullish on technology. The problems I’ve discussed here aren’t problems we all deal with every day, but that doesn’t mean we can ignore them. In the past year or two, we have seen what can happen when a

Cloud-based software is the way of the future for dental practices, but what implications does that have on the evolution of technology in the industry?

The Cloud, IoT, and Me...Who’s Watching the Store?

Abstract

Historically, dental materials have been designed to be passive. They are considered successful if they do not interact with or harm the surrounding tissue. Thus, these materials are deemed biocompatible. Given the recent development of bioactive materials with impressive capabilities, this has started to change.

“A shift in thinking and a desire to do better for our patients have given rise to the era of bioactive dental materials. Bioactive materials are, by design, interactive with a patient’s tooth structure and help to stimulate and mimic the remineralization process that takes place in nature,” says Brittany Bergeron, DDS, owner of Town Center Cosmetic Dentistry near Baltimore, Maryland. During this process, bioactive materials participate in an ion exchange with surrounding tooth structure to help create minerals such as calcium, phosphate, and fluoride, all of which are vital for healthy teeth.

It has been well documented that fluoride possesses anticariogenic properties, Dr Bergeron adds. Numerous materials on the market contain and release fluoride, including but not limited to cements and composites that dentists use daily.

Despite the initial fluoride release of many of these products, their efficacy can decrease rapidly, preventing lasting effects. They often release the maximum amount of fluoride in the first 24 hours and taper off.

 What makes bioactive materials different is their ability for fluoride “recharge” when they come into contact with fluoride-containing products such as mouthwash or toothpaste.

 The recharge and release help maintain a higher level of fluoride ion exchange between a restoration and a tooth compared with traditional glass ionomer materials.

In addition to fluoride, bioactive materials also exchange phosphate and calcium with the surrounding tooth structure. This ion exchange is the reason bioactive materials have been deemed “smart materials”—they are able to react to changes in the pH of the oral cavity, triggering release and absorption of ions between tooth, saliva, and restorative material.

Each material’s mechanism for doing this is slightly different. For example, ACTIVA BioACTIVE-RESTORATIVE from Pulpdent Corporation is a bioactive material designed with an ionic resin matrix. The matrix lets the material significantly release and recharge with fluoride, calcium, and phosphate while exhibiting the properties expected of a direct restorative material.

There is always new research being conducted on bioactive materials and ways in which they might benefit our profession. Their nature-mimicking properties make them a great option for restoring teeth in patients of all ages, with lasting fillings that help improve the health of teeth and the oral cavity.

There is an interesting debate about using the term bioactivity to describe some newer dental restorative materials. This is a word used by the profession and industry, often erroneously, says Avijit Banerjee, BDS, a professor of cariology and operative dentistry at King’s College London, England.

“A truly bioactive material is one that elicits a positive cellular biological response when in direct contact with biological tissues. Most dental materials do not do this—indeed, they irritate tissues, creating an adjunctive cellular response at best,” says Dr Banerjee, a pioneer in the development of minimally invasive caries management systems and caries prevention. “Ion transfer between materials and biological tissues is not, strictly speaking, a sign of bioactivity. Therefore, I have suggested [in a paper published in the 

 in October 2020] perhaps a better term for these types of materials is biointeractive.

 One might consider this semantics but, as a clinical scientist, I do believe making the distinction is relevant.”

In this paper, titled, “Contemporary Restorative Ion-Releasing Materials: Current Status, Interfacial Properties and Operative Approaches,” Dr Banerjee and 7 coauthors explore the process that allows mineral deposition at the interface between such biointeractive materials and dentine, and describe how conventional bioactive restorative materials may be beneficial for treatments in MI dentistry.

 The authors add that contemporary therapeutic biointeractive materials should now be used for hard tissue replacement, because they may reduce susceptibility of tooth mineral to dissolution and/or to recover its mechanical properties via support of remineralization.

These MI concepts require practitioners not only provide a scientifically supported rationale for carious tissue removal/excavation and defect-oriented, biological cavity preparation, but also a deep understanding of how to ensure a biomechanically stable, durable restoration in different clinical situations by applying different restorative options.

 These biointeractive materials play an increasingly relevant role; they not only replace diseased or lost tissue but also optimize hard tissue mineral recovery (among other properties) when used in restorative and preventive dentistry.

This is of particular interest in MI dentistry, especially for cases in which gap formation jeopardizes integrity of margins along resin composite restorations, allowing penetration of bacteria and eventually promoting formation of secondary caries.

 Clinicians and scientists have growing interest in whether ion-releasing materials may reduce such biofilm penetration into margin gaps, reducing risk of development and propagation of secondary caries. This interest corresponds with increased awareness of these materials’ capabilities and the need for clinicians to be aware of their uses and impact in patient care.

Additionally, it should be noted that dentin is the most abundant mineralized tissue in the human tooth. Because of this, its mechanical performance is of major significance to the overall function of teeth.8 The goal for remineralization of carious dentin is reestablishing the functionality of affected tissue. From a biological perspective, the dentin matrix can be described as a semipermeable barrier between enamel and pulp, or between pulp and the outer surface of a cavitated lesion with exposed carious dentin. From a microstructural perspective, the collagen fibrils in dentin serve as a scaffold for mineral crystallites that reinforce the matrix, supporting the surrounding enamel.

From a biomechanical perspective, the mineralized dentin matrix preserves tooth function by helping prevent propagation of cracks from the brittle enamel through the dentin-enamel junction into dentin, preventing fracturing of the enamel crown.

Traditional cavity liners have included calcium hydroxide and resin-modified glass ionomer cements, explains Robert A. Lowe, DDS, associate professor, Department of Oral Rehabilitation, James B. Edwards College of Dental Medicine, Medical University of South Carolina. Use of liners containing eugenol is contraindicated under composite resins because it interferes with the polymerization of monomers. It should also be noted that resin-based cavity liners have been shown to be cytotoxic to odontoblast-like cells.

Many of today’s light-cured glass ionomer liners are resin reinforced; depending on resin content, this can limit any benefit from the release of fluoride. But Dr Lowe says bioactive liners that can help replenish the calcium and phosphate ions lost due to acid attack (decay) drastically change the way clinicians treat dental caries. There are 2 types of damaged dentin: infected (demineralized and full of bacteria) and affected (demineralized but bacteria-free).

It is well documented in the literature by Salvatore Sauro, PhD, and others that affected dentin can be remineralized and made healthy.

 Affected dentin may be sticky to the touch, but should it be removed? Round, polymer burs fabricated at the specific Knoop hardness of healthy dentin (90 kgf·mm−2) can be used to ensure only infected dentin is removed during excavation, according to Dr Lowe. Placement of a bioactive liner can then help remineralize and rebuild the remaining affected dentin and make it healthy.

Some materials available today have been developed for use during vital pulp therapy such as a pulpotomy, expanding on the ability to use a calcium silicate product for direct pulp capping. These dual-cured materials release calcium and fluoride and can be used when vital pulpotomies are performed on teeth with carious exposures.

Because these newer bioactive materials help promote tooth remineralization, they are ideal for challenging cases that might have required a “heroic” effort to save a tooth from endodontic therapy or extraction. Although some of these “heroic” cases may still require endodontic therapy, many others will respond favorably, avoiding an additional procedure and preserving vitality of the tooth.

The advantages of biointeractive restorative materials are clear after looking at bioactivity and the effects of rebuilding damaged tooth structure. Having restorative materials that can protect, repair, and seal the marginal gap around all dental restorations can help preserve the natural tooth and extend the life of the restoration, Dr Lowe says.

The judicious use of biointeractive restorative materials—with their ion exchange and remineralization support—negates the need for cavity liners and bases and in contemporary minimally invasive dentistry, Dr Banerjee adds. The need for a separate traditional liner is indeed contraindicated in many cases. This simplifies the restorative steps and protocols which therefore gives more standardized outcomes for restorations and the ultimate longevity of the tooth-restoration complex.

Bioactive materials are particularly useful for patients with high caries indices; getting control of the problem can be difficult in such cases. Adjunctive primary and secondary preventive measures are paramount in the ultimate long-term success of any restoration that is placed. Acidic oral environments can create extensive damage to teeth, particularly if a patient does not have the best toothbrushing routines. Pediatric patients and primary teeth have their own issues, adds Dr Lowe. Finishing a dental procedure quickly in a less than moisture-free environment makes using traditional composites and adhesives very difficult with pediatric patients.

ACTIVA BioACTIVE-RESTORATIVE can produce bioactive properties due to the structure of its ionic matrix. However, many methods of producing bioactive outcomes are being employed in modern dental materials.

Shofu Dental produces bioactive restoratives featuring glass fillers called Giomers. The glass is coated with a glass ionomer phase and has a protective coat over the top of that phase, which allows slow release of ions. Although Giomers do not release calcium and phosphate ions, they do release many other basic ions that can help “buffer” the effects of the acid environment in the oral cavity, helping inhibit plaque accumulation on restorations and at the margins.

RE-GEN materials from Vista Apex feature a matrix that includes Bioglass 45S5, a material that attracts and exchanges bioactive ions within the oral environment. The Thera family of products from BISCO offers calcium and fluoride ion release with a material designed to reduce acidity of the oral cavity.

Finally, MTA (mineral trioxide aggregate) is a long-standing option for pulp exposures and perforations of the root system. This material exhibits hydraulic properties, making it ideal for endodontic procedures. However, it can be clinically difficult to handle with long setting times.

Additionally, Biodentine from Septodont is a dual-cured material that releases calcium and fluoride and can be used to restore teeth with an overlaid resin composite layer and for vital pulpotomies on teeth with carious exposures. The material is a tricalcium silicate, which can be used as a bioactive buildup material where large areas of tooth structure are missing, and where a pulp exposure or root perforation may exist. There is no need for additional layers of linings or pulp protection when using this bioactive material.

As manufacturers develop dental materials, the future is bright for bioactive materials and improved patient care. New innovations help reinforce existing technologies and set new paradigms for treating dental disease and restoring broken dentitions. Dental restorations and adjunctive materials will no longer just occupy space between themselves and surrounding teeth but will help repair and sustain healthy tooth structure, giving patients a better chance of enjoying lifelong healthy dentition.

Jack L. Ferracane, PhD, from the Department of Restorative Dentistry, Oregon Health & Science University, Portland, expects new dental materials to feature bioactive benefits and features.

“In the future, the desire for a biomaterial to be inert and nonharmful to the patient, although still relevant and necessary, will no longer be considered sufficient,” Dr Ferracane says. “New materials currently being introduced, under development, or simply envisioned are expected to be bioactive in that they will be intended to interact in some positive way with the oral environment. These materials will provide a wide range of diverse functions, including the routine inhibition of bacterial biofilm formation, remineralization of lost dentin and enamel, and the regeneration of diseased pulp, bone, and soft tissues.”

Dr Ferracane’s summation aligns with what Dr Bergeron said about the nature-mimicking properties of bioactive materials and why this makes them a great option for restoring teeth in patients of all ages for lasting fillings that help improve health of teeth and the oral cavity.

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Özcan M, da Fonseca Roberti Garcia L, Volpato CAM. Bioactive materials for direct and indirect restorations: concepts and applications. 

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Earn 1 free continuing education credit provided by Catapult Education by reading this article and following the link to complete the test on the Catapult website.

Bioactive Restorative Dental Materials Hold Great Promise in Terms of Function, Use

The Physical and the Virtual: How Our Practices Are Changing. Photo courtesy of poplasen/stock.adobe.com. 


I am a huge believer in going back to go forward. I know that to many of you, that probably seems like a weird dichotomy—and it is. However, give me a chance to explain myself.

For this month’s column, we need to get in “The Wayback Machine.” Now we have even more confusion here because for many of you who have grown up in the digital age, that phrase means the digital internet archive of the World Wide Web. But for some of us who are just a tad older, it conjures images of the cartoon series 

. Sherman and Peabody would use The Wayback Machine to travel back in time to teach viewers about history. I won’t bore you with tales of how awesome Sherman and Peabody were (and trust me, they were awesome). Just go to YouTube, search for them, and you can see just what I mean.

For this month’s column, The Wayback Machine will deposit us in the decade of the 1950s. The reason? In the mid-1990s, a friend of mine decided to strike out on his own and purchased the practice of a retiring doctor in a suburb of the greater Kansas City area. He was really excited about it and invited me over to see the office.

What I found when I got there was a house on the edge of a sleepy suburban neighborhood. All the houses in the neighborhood had been built in the post–World War II housing boom and were small ranch floor plans surrounded by small green yards and gigantic leafy oak trees towering over them. Other than the unobtrusive sign in the front yard with the practice name, it was impossible to tell the building wasn’t just another home.

Opening the front door, you entered a reception room that would have been the living room in the residence. There was a small front office/business area with a sliding-glass partition and a door that opened into the rest of the space. The clinical portion consisted of 3 tiny operatories and another small room that was the doctor’s private office.

The hallway to the operatories and the office was so narrow that no one could pass each other without turning, pressing their back against the wall, and shuffling sideways until they were again in the clear. The place looked like the office of Doctor Ward Cleaver. I kept expecting Barbara Billingsley to round the corner with a plate of cookies the entire time I was there.

My friend knew he couldn’t stay there. He knew what a successful office looked like—and it wasn’t this.

Design and the Continuous Process of Evolution

I started in a suburban strip mall in an office that was a long, deep rectangle. It was 1400 square feet, and the only windows were in the reception room. It felt like working in a coal mine. It was laid out in a way to accommodate 4 operatories, but I only ever set up 3 because I had no idea where I would have stored my supplies. I moved out of that space after 18 years. I purchased land and began construction on a freestanding building.

It’s funny. I moved from 1400 square feet into a building with 4300 square feet. I couldn’t believe how big that office was as I walked through it the first few days seeing patients. Now I wish I would have built it bigger.

The truly amazing thing to me is that the first office was state of the art when it was built. We keep learning and changing and growing as time passes, and we keep making improvements to make things better.

My office is built on what I call a “pod” design. There is a reception/business pod, a clinical pod, and a staff pod. Each pod seals with doors, which provides for separate ambience and for containing the sounds of that pod. Although I think the open, airy, and interconnected concept of architectural design has some merits, every plus has a minus. There are times in any business when you need some isolation or simply some privacy. We attempted to create 3 open and airy concepts while isolating them from each other to create the best of both worlds, and I like to think we succeeded. One additional and unintended benefit was when we returned from the COVID-19 shutdown in May 2020, our clinical pod was already separated from the other parts of the office, helping decrease patient concerns about viral spread.

In the reception/business pod, it is quiet and peaceful. There is no sound of handpieces or the occasional crying child to be heard by waiting patients or the caller on the phone. The music is relaxing, there is a digital check-in area, and the flat-screen TVs in the seating area provide information on dentistry and the practice. Large windows let in lots of natural light, and because the office sits on a lot that is 1¼ acres, we don’t have other buildings obstructing the views. Even though we are in suburbia, it doesn’t appear crowded.

We also intentionally made the reception pod big with high ceilings that complement the windows and the feel. There is enough room that even on occasions when patients might be sitting, they have room and aren’t forced to sit close to one another. This keeps the stress level down in folks, and as we all know, many people feel stressful enough about dentistry.

Also, 2 doors lead into the clinical pod, so there is never a traffic jam and patients aren’t in each other’s way.

The clinical pod focuses on clinical care. There are no ringing phones, and each operatory can provide video or music to suit the patient’s needs. There are a lot of windows, which open to allow fresh air to circulate through the pod. Sunshine abounds. The windows look out on to a wooded area, where we can see deer, foxes, and the occasional groundhog. Under the concrete slab floor, 2-in conduit is in place that allows for any type of cabling to be run from one end of the pod to the other. My principle operatory also features a video line that runs to the conference room to allow me to directly broadcast clinical procedures there for anyone who wants to watch.

The clinical pod also has a lab room, but we kept it small. At the time of construction, I knew 

dentistry was headed to digital and virtual prosthetic fabrication, so I didn’t want to invest square footage and expense in creating a large room for laboratory work when I knew most of it would soon be done on a screen. We pour an occasional model there, but almost anything requiring lab work is done virtually these days.

The third pod is the staff pod. In my original 1400-square-foot office, my personal office was directly next to one of the treatment areas and I never felt I could ever get away from the pressure. Even when I closed my door, I could still hear everything that was going on.

When I designed the new office, I wanted an oasis for me and my team. The staff pod has doors that are always closed. The lighting is more subdued. There is a kitchen, a staff restroom, staff lockers, laundry, doctors’ offices, and the conference room. The staff pod has no sounds of handpieces or dentistry of any kind.

When the door closes behind you, the environment is totally different. You can breathe and relax, if only for a few minutes.

Our conference room has become a bit of the “digital lab” portion of the office. In addition to all the standard conference room amenities one would expect, we also have our design computers, mills, 3D printers, wash stations for printed models, and more.

The interesting thing about our digital lab is that the team feels that designing and creating in more of an office environment and in less of a dental lab environment are much more conducive to creativity and concentration and aid greatly in our digital workflow.

When we designed the space, we had to try to envision what things would look like in the future. The best part of all this is the ease that comes with the digital workflow. One of the buzz phrases that the staff and I use with each other is, “it’s just electrons,” and by that we mean that because our clinical data are digitized, we can move them and/or work with them anywhere we desire.

Our intraoral scanners send their information to the cloud, where we can then download it for use in-house or send it securely to anyone who needs it, be it specialist or lab. We can use the scans to design and mill restorations in-house for efficiency and cost savings. We can 3D print models. We can design and print or mill surgical guides, occlusal guards, or whitening trays.

The way we now handle patient workflows in our offices has changed dramatically in the past 50 to 60 years, and patient expectations regarding office design have changed too. In the early days of technology in health care, patients were more accepting of cords running all over and less-than-ideal office esthetics as we attempted to shoehorn our computers and other hardware into the clinical workspace.

Now our offices have become technology hubs where we create massive amounts of digital data every day in workspaces that are designed for that purpose. I don’t think dentistry has ever been more fun, and I love the fact that the quality just keeps getting better. The only thing we know for sure is that change is constant. However, make sure you enjoy the ride. Tomorrow will be even more fun, I’m confident of that. 

Setting the right design plan for your dental office boosts digital workflows in ways that can make the patient and practitioner happy.

The Physical and the Virtual: How Our Practices Are Changing

A combination of direct and indirect restorations make up a large part of a dentist’s workload. Although both approaches are designed to restore damaged dentition, they each require a specialized workflow and armamentarium that must be customized to meet the needs of the case and deliver the best results for the patient.

This is why I’m always on the lookout for new approaches, technologies, and materials that help me provide the best outcomes for my patients, so I’m excited to share the results of my recent test drive with a pair of Vista Apex materials that make restorative dentistry easier for me and my team while providing patients with enhanced outcomes.

Those products are Seamfree Composite Wetting Resin, which helps make direct restorations more consistent, and ZR-C™ Universal Cleanser, a solution that prevents contamination of crowns and bridges following try in.

Here’s what I discovered during these test drives.

If you are a typical practitioner, you probably find yourself reaching for a variety of composites, depending on the clinical situation and, on occasion, even the clinical demands of the patient. If a patient is a bruxer, you may find yourself reaching for a composite that is less subject to wear. Another patient may have high salivary flow, which might require you to work quickly to avoid contamination of the field. In that instance, a bulk fill might be a better choice.

We can’t always work with the same materials every time, and because each composite is a little bit different, you can’t always predict exactly how a material will handle before you place it. Material properties can even change depending on the environment. Even though I work in a controlled environment with heat and air conditioning, I still find noticeable changes in material handling depending on the humidity and temperature. This can make the material stiffer or stickier.

Wouldn’t it be nice if there were a way that you could magically make all composites handle in a similar manner? Well, the answer is here, and it doesn’t even require magic. You can leave that rabbit in the hat and simply use Seamfree Composite Wetting Resin from Vista Apex. This is one of those products that once you use it, you’ll wonder how you practiced without it. Seamfree greatly enhances the handling of any composite and reduces tackiness or stickiness.

Now I know a lot of you are saying, “I use bonding agent for that.” Let me explain why Seamfree is a much better option.

Often a non-bulk fill material is placed in 2- to 3-mm increments. Composite naturally bonds to itself, so the next layer easily bonds to the previous. This creates a monobloc of composite. However, using a light-cured bonding agent creates layers of bonding agent between the layers of composite, resulting in discrepancies and weaknesses in the restoration that can lead to fracturing or chipping. Also, in darker composites or thicker layers, there is a risk of the bonding agent not being adequately cured, which can lead to more potential layering problems.

Seamfree is unfilled, meaning there is no potential for film thickness, plus it is absorbed into the composite after it is placed. It is not light cured and does not require any drying or thinning. It also does not cause any physical change in the properties of the composite. It creates better handling characteristics for every composite material, and after use, it basically disappears.

Seamfree is one of those “better mousetrap” products that you will find yourself reaching for to make procedures easier and more predictable. Simply apply it to the composite or to your instrument and let it work its magic. No rabbit or hat required!

Bonding is the common way of placing fixed prosthetics in today’s dental practice. Before resin cements, sometimes cements could be soluble in oral fluids and begin to break down and dissolve. This led to a much greater chance of recurrent caries.

Today’s resin cements are insoluble in oral fluids and have eliminated the problems of “wash out,” giving clinicians more confidence in their margins holding up. However, as cements have changed, restorative materials have also changed—and that leads us from one potential problem to another.

Although current materials are remarkably esthetic, they also require greater thickness to resist fracture. Preparations can be made more retentive with attention paid to parallelism and adding retention grooves, but the incredible retention of long bevels has gone the way of the dinosaur. Due to that and other factors, today’s restorations are more dependent on chemical bonding than on mechanical retention.

Bonding is dependent on chemistry and control of the field. Restorations returned from the lab are chemically treated on the internal surface to increase retention, but the enemy of adhesive dentistry is saliva, blood, and crevicular fluid.

Careful control of the field is next to impossible during the try in and occlusal evaluation stage, and although restorations start out clean and uncontaminated, the internal surface is quickly contaminated by oral fluids. This can greatly reduce bond strength, leading to recurrent caries or debonded restorations.

How does the clinician solve this problem? Fortunately, there are products like ZR-C Universal Cleanser from Vista Apex. After the restoration has been tried in and is deemed ready for cementation, simply rinse the restoration thoroughly to remove any fluids and then dry the inside of the restoration with oil-free air. Next apply ZR-C Universal Cleanser and scrub it lightly onto the internal surface. Allow the material to set for 20 seconds, rinse with water, and apply oil-free air to thoroughly dry.

At this point, the restoration is ready to bond in the mouth. I love that ZR-C Universal Cleanser is truly universal and can be used with any prosthetic material. Also, it is orange, so it is easy to see and easy for the assistant to tell when it is completely removed. It also does not require shaking prior to use. And fewer things to remember means fewer mistakes.

Today, every indirect restoration in my office is cleaned with ZR-C Universal Cleanser prior to cementation, and every time I reach for composite, I also reach for Seamfree Composite Wetting Resin. These materials work. I think if you give them a try, you’ll feel the same way I do.

[Sponsored] In this test drive, John Flucke, DDS, explores the benefits of this pair of restorative materials from Vista Apex.

Test Drive: Using ZR-C Universal Cleanser and Seamfree Resin for Enhanced Restorative Outcomes

We all have friends who, despite their age, never quite outgrow their insecurities. You know what I mean, the folks who think that if I’ve done something once, they’ve done it twice and better both times. As someone with a degree in psychology, these individuals fascinate me. Allow me to illustrate.

Bob and Jim have known each other for years, but their relationship is strained because anytime Bob tells a story, Jim immediately claims he has had a similar—but superior—experience. Bob tolerates Jim’s behavior but wishes it would stop.

As they walk along the street one afternoon, Bob hears the distinctive whine of a high-performance V-12 engine. He points to a car in the distance and exclaims, “Wow, look at that Lamborghini!” Jim replies, “Yes, I saw it about 10 seconds before you did.”

They walk a bit further, Bob points to a bird circling overhead and says, “Look at that bald eagle.” Jim answers, “Yes, I noticed it long before you did.” They walk a bit further and Bob says, “Hey, watch that…” But Jim cuts him off with “Yes, I saw it before you did.” To which Bob retorts: “Then why did you step in it?”

It’s a dumb joke, I admit. But it does show that simply claiming something is true doesn’t make it true. We live in a world in which discoveries are being continually made and where information is developed and distributed constantly. As I’ve said here before, our medical knowledge is doubling every 18 months, according to the statistics I’ve seen. That is a lot to keep up with.

Although that timeframe covers total health care information, dentistry, as we know, is changing almost exponentially. Trying not to fall behind is a bit like drinking from the proverbial fire hose. The rapid development of workflows that combine digital scanning, designing, and fabrication is steering the profession in ways we could only have dreamed of a decade ago.

However, for every yin there is a yang and for every pro there is a con. Our knowledge is expanding more and more rapidly, but we must continuously keep aware of it, which is a daunting task, especially for a doctor whose main focus is the patient. Many of us spend countless hours outside of patient care trying to learn about the latest techniques and processes. Then along comes something like 3D printing, and suddenly we need to have a working knowledge of the hardware that creates the item, the software that designs it, and the companies that provide both. Oftentimes it seems as if we’re swimming upstream in a fast-flowing river of data.

Dentistry is a multibillion-dollar industry, and fortunes can be made quickly if you have the right ideas, the right marketing, and products that deliver what the advertising promises.

What follows is, admittedly, an oversimplification, but my goal is to broadly describe a scenario that can occur in any industry. It is not meant to be inclusive or an indictment of any company or process. I present it as food for thought for my peers in clinical practice, who may not ponder these questions as I do.

In any industry there is a fairly predictable product curve and invention and innovation come first in any business. A bright mind somewhere develops something that disrupts the status quo. In health care, a device or concept takes concrete shape: it becomes software or a prototype that is tested to make sure it works correctly. Then it goes to the United States Food and Drug Administration (FDA), which ensures that it is safe and efficacious. Afterward, and with great fanfare, the product is introduced to the market. The entire process requires a huge amount of money. Investors must be found, capital raised, and an organization built from the ground up.

Knowing what technologies are approved and suitable for dental patients is a matter of navigating the sometimes-tricky waters of the dental marketplace.