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

As someone who loves the practice of dentistry, I have a confession to make: I flat-out love endodontics. Now, don’t get me wrong; I love composites, I love fixed prosthetics, I love treating sleep apnea, and I love improving patients’ smiles. The great thing about being a general dentist is that I get to do all those things, but my favorite procedure is endo.

I’m willing to bet that a lot of you just groaned at that last sentence, but bear with me on this. Quite a few years back, I injured my right elbow—not severely, but enough that the process of performing extractions became painful. So I chose to stop doing them. I began to look for another procedure that I could be as passionate about that would save my patients from a referral.

I always had interest in endodontics, but after I was forced to give up on performing extractions, I decided to devote some time to learn. I consider myself fortunate because I became friends with an endodontist who loved tech as much as I do and who also happened to be a great teacher. 

We would get together frequently and with practice blocks and extracted teeth, he taught me the art and science of endodontics. I basically got a miniature residency from all the work we did together, and I became confident in my endo skills. I owe my friend Jerry a debt of gratitude.

That confidence allowed me to do more cases, and also allowed me to better evaluate products and techniques. As new, superior products and methods were introduced, I extrapolated what I had learned to help me incorporate those products into my cases.

Also, some of my time is spent evaluating products in different phases of development, so I often get a chance to see things well before they hit the market. That sometimes gives me months of experience with a product before it is even released.

Efficiency in endodontics is important. I look upon making the procedure faster while achieving better outcomes as critical. Patients do not want endo to take longer. In all my years of practice, no patient has ever asked me to leave the rubber dam on for 15 or 30 more minutes because they enjoy it so much. The procedure should take as little time as possible while providing the best outcomes we can deliver. These are products currently on the market that can make your endo life easier and less stressful.

Septodont Paroject Intraligamental Syringe

Although not strictly an endo product, this beauty can make a tremendous difference when an infected tooth won’t get numb. Sometimes teeth simply don’t cooperate, and a periodontal ligament injection is a great way to get anesthetic right where you need it.

The device is simple, sleek, and effective. We also routinely use it for restoring a single lower molar instead of delivering a block. You can check it out at 

https://www.septodontusa.com/products/paroject

One of the most important parts of endo is creating the “glide path.” This is the initial part of shaping that prepares the canal for rotary files. Often this is done with hand files, which can be a slow and difficult process. Some current instrumentation techniques allow for reciprocation and rotation with the same type of file. Other systems require the creation of a glide path with the time-tested process of using hand files. Of course, filing by hand is frequently a slow and arduous process.

But what if you could take that hand filing and convert it to engine driven? That is the beauty of the M4 Safety Handpiece. This device is a contra angle that fits on a standard E speed motor attachment (usually the one on your endo motor). The head has a push button chuck that will accept the handle of almost any type of hand file. Once the file has been gripped by the M4, it moves in a 60º “watch-winding” oscillation when you step on the rheostat, turning 30º in each direction. This makes the hand files efficient, allowing the operator to finish with a file in less than 30 seconds.

The M4 has become a vital part of my endo setups. My glide path steps are efficient and predictable. It truly is one of those devices I do not want to work without. Find it by going to 

https://www.kerrdental.com/kerr-endodontics/m4-safety-handpiece-endodontic-contra-angle-shape

If you follow the endodontic literature, you understand that mechanical debridement, even with the very best instruments in the hands of the very best operator, will not completely clean the canal system. There are too many oddities in its shape for a file to reach and adequately clean them. We need to use our irrigation chemistry to reach those areas for us.

Of course, the standard and most popular way of removing pulpal remnants and bacteria is to use sodium hypochlorite. Yet with all those little nooks and crannies in the canal system, how can we ensure that the irrigant is adequately reaching those areas and working its magic? The best way to do this is to agitate the irrigants with ultrasonic energy.

This can be done by using a piezo unit, but those devices are a bit pricey and also occupy a pretty large footprint. Instead, how about a small, light, and cordless unit designed specifically for endo? That is what you get with the EndoUltra from the folks at Vista Apex. The EndoUltra is the only cordless activator unit capable of generating the tip frequency (40,000 Hz) required to create sufficient acoustical streaming and the cavitation necessary to effectively clean, penetrate, and remove vapor lock. It uses titanium tips that can be bent to accommodate easy access to any tooth. It also has a white LED that helps illuminate the field during use.

One other thing that makes it so great is that, in addition to all its benefits, it is also affordable. Check it out by going to 

https://vistaapex.com/product/endoultra-cordless-ultrasonic-activator/

Medidenta Advanced Cordless Endo (ACE) Motor

I owe a great deal to my friend Dr Carlos S. Ramos. He is an endodontist as well as a tremendous endodontic researcher, teacher, and inventor. He has taught me and explained countless endodontic secrets of success. His outside-the-box thinking is inspiring, and one of his latest inventions deserves mention.

Two of the most important changes in endo in the past couple of decades involve the development of the electronic apex locator (EAL) and the electric torque-controlled endo motor. Achieving clinical success without an EAL is difficult, and knowing the location of the apex is critical. Knowing its exact length and then moving your instrument to it exactly is more difficult than it sounds. One must first determine the canal length, then translate the determined distance to a file in a handpiece. After that, getting it to precisely the right spot is challenging.

The solution is to have the EAL built into the electric torque-controlled motor so that the 2 devices work simultaneously. Being able to know the location of the file in the canal at any moment as you are working is powerful and helps ensure clinical success in instrumentation.

One of the more recent improvements in instrumentation is the concept of using a file system that allows for the files to be used in reciprocation as well as rotation. The ACE motor is one of a few motors on the market that will do just that. Dr Ramos has also invented the Endo-Eze™Genius® file system, which uses both reciprocation and rotation in instrumentation. To enable that, he has designed the ACE motor to perform those critical functions well.

However, it’s not simply that this motor (which he designed) works great with the Genius files (which he also designed). The other truly great aspect of this device is that it is designed with fully open architecture. By that I mean the motor is totally programmable by the end user. In a nutshell, that means the doctor can tell the motor precisely how to perform.

The ACE is far and away the most comprehensive and all-encompassing endo motor I have ever seen. The device is so impressive, I could easily have devoted this entire article to it. However, you can learn everything about it by watching an 11-minute video. Head over to YouTube and prepare to be amazed.

https://www.youtube.com/watch?app=desktop&v=Wd-4-8Fo7aQ

Almost every endodontist has a surgical microscope these days. However, although more than 80% of general dentists work with surgical telescopes, only a very small percentage actually work with microscopes. The main reason they have not embraced the concept of microscopes is the cost. Although microscopes aid in endo, most doctors feel that working in 3.0× to 5.0× is perfectly acceptable for quality restorative work.

The expense of a surgical microscope is hard to justify when endo is not the only procedure on your daily schedule. Enter Labomed, with their line of affordable surgical microscopes. The company currently offers 3 models, and they are more affordable than those from other companies in the dental space.

The products offer features such as the ability to connect a DSL camera for taking photos, connections for monitors, and even a splitter that allows the assistant to see what the doctor sees. I have had one of their microscopes in my office for the past few years and have been very happy with its performance. Give them a look at 

https://www.laboamerica.com/category/dental-microscopes/

If you noticed that I failed to mention a file system, I have a good explanation. File systems are a bit like cars. Each system has advantages and disadvantages. It really comes down to what works best in your hands. The products mentioned here will improve your clinical outcomes no matter which file system you use.

The important thing to remember is that endodontics is a constantly changing landscape. Like walking up the down escalator, if you are not pushing to move forward you will be moving backward. This constant push to be our best is one of the things I love most about what I do. I hope you feel the same way. I sincerely hope that this column has given you some nuggets to improve your patient outcomes.

Articles

A variety of endodontic products can help make procedures more cost-effective and efficient.

Getting to the Root of the Problem

For the last thirty years, dentistry has had a good track record when it comes to infection control. Once the concept of masks and gloves became ubiquitous in the early to mid 1980s, the profession gained a stellar reputation of protecting patients from potentially infective agents.

This battle against microbes is ongoing and, when you think about it, fighting microbes is almost the entire reason for the profession. Whether it is routine recare and prophylaxis or performing a Class II cavity preparation, most of what the profession does is about removing and restoring the aftermath of microbial invasion or decreasing microbial counts to give the body a chance to heal itself.

And, of course, the moment the prophylaxis appointment is over, the microbes begin to regrow. Like Superman who fights “The never-ending battle for Truth, Justice, and the American Way,” the profession of dentistry fights a never-ending battle against the microbes that are attempting to overtake the oral ecosystem.

Those tiny bugs are the bane of the dental profession and fighting them is a challenge. Even when a large number of those microbes are removed, the few that remain begin to immediately grow and repopulate.

To fight periodontal disease, we have chlorhexidine rinses and systemic antibiotics, but to prevent recurrent caries from affecting our restorations, we really haven’t had many choices. Most of us in the profession are familiar with quaternary ammonium compounds. Usually, we find them in different types of surface disinfectants, and they work well. However, what if we could work that agent into our restorative regimen?

Current estimates say that the life span of a Class II composite restoration is around 5 years. The main reason for a Class II composite failure is recurrent caries around the margin. Controlling the field when performing composite restorations is probably the most difficult part of the procedure. Contamination of the preparation surface at the margins can lead to low marginal bond strengths, which creates marginal failure and recurrent caries.

How can we deal with this situation? The smart minds at FiteBac Dental created an FDA-cleared cavity cleanser that contains quaternary ammonium silane. This cleanser is scrubbed onto the preparation surface before the bonding agent is applied. The cleanser leaves the quaternary ammonium silane on the dentin, and then the bonding agent is placed over. The cleanser kills microbes due to the quaternary ammonium and does not affect bond strength because of the silane.

This leaves the antimicrobial agent under the composite and at the margins. If there is ever any marginal breakdown, plaque and bacteria will quickly develop in that marginal discrepancy. However, because the FiteBac Antimicrobial Cavity Cleanser is on the surface under the restorative material, the microbes come in contact with the quaternary ammonium and are quickly killed. The molecule is not degraded over time, so it does not lose its effect. The concept is to develop materials so that when microbes come into contact with the cleanser molecule embedded in those materials, the microbes are killed, but no change occurs to the cleanser molecule itself. That means theoretically that the antimicrobial effect of the cleanser should last as long as the restoration. The molecule does not leach out over time, so the effect should be long-lasting…perhaps permanent.

The company has also created a similarly antimicrobial product that can be incorporated into the resin and used to make removable prosthetics such as Hawley retainers and removable partial dentures. Work is also under way to incorporate FiteBac’s antimicrobial chemistry into adhesives and cements, sealants, composites, glass ionomers, implants, and even restorations and appliances such as crowns, mouth guards, retainers, and dentures.

The concept is to create materials and appliances that are completely resistant to the microbes that cause infections underneath and around them. Like the cavity cleanser, the antimicrobial capabilities of these materials and appliances will not leach out over time or need to be replenished. The idea is that the antimicrobial properties will last as long as the appliance or restoration itself.

Although FiteBac is on the cutting edge of antimicrobial dental materials development, they are not the only company working in this area of research. In fact, the International Organization for Standardization (ISO) recognized this and is developing a set of testing standards to determine the antimicrobial effectiveness of dental materials. ISO/CD 3990 is currently under development as the ISO wants to be ready with standardized benchmarks for testing this new wave of materials with antimicrobial properties.

I’m excited to see a future that incorporates products such as these into our everyday clinical practice. It will be interesting to see situations where, instead of working to excavate and remove colonies of microbes, we kill them on contact with our dental materials before those microbes even get a toehold into the human body. With all the antimicrobial developments under way in dentistry, the future is bright!

The growth of antimicrobial dental materials is ushering in new possibilities in long-term dental care.

Advertorial: Innovative Materials Showing Promise in Fight Against Harmful Oral Microbes

interesting subject.In some ways, curing has changed a lot during its history…and in some ways it has changed very little. Let me give you an example of what I mean.

In the early days of light curing, we used actual light bulbs to produce the proper wavelength of light needed for polymerization. These were replaced by “high-speed curing lights” that used powerful halogen bulbs to create stronger beams with greater curing potential. However, even though they were more powerful, halogen bulbs still required long curing times. Back then 40 to 60 seconds per increment was not unheard of. That’s because those light bulbs put out all kinds of different wavelengths of light, and it took time for enough of them to cause photopolymerization. It was akin to throwing spaghetti against the wall and hoping enough would stick.

The industry’s holy grail became the sub–30-second cure. Companies tried tips that better focused the energy (called Turbo Tips), and there was even a type of light known as a plasma arc curing (PAC) light that could give a fast cure, but they were expensive and bulky.

Then around 2000 or 2001, the LED curing light took the market by storm. Suddenly dental curing lights were powerful and small. Within 5 years, curing lights using bulbs were practically off the market, replaced by smaller and more reliable LED systems that provided amazing results in adhesive dentistry.

Here’s a little bit of dental trivia you probably don’t know: Every time you use an LED curing light, you should thank its inventor, Densen Cao, PhD. He’s the man who invented this amazing device. Now, why would I mention Dr Cao in a discussion of a new curing light? It’s because he is also the inventor of the handheld curing laser.

And who better to stand the world of curing lights on its collective head than the man who has already done it once? Welcome to another game-changing piece of hardware from the fertile mind of Densen Cao.

Over the past 20 years, we have seen tremendous strides made in our curing lights. Intensity has increased and power needs have decreased. Today’s lights can cure an increment in 5 seconds and are cordless, going days without needing a charge. So where do we go from here?

The next generational jump in curing is the Monet curing laser. There has never before been a curing laser that fits in the palm of your hand. The Monet takes over with properties only a laser can bring, the most important being collimation.

With any light other than a laser, photons spread out in all directions as they leave the source. However, with a laser they all move in a tight beam that forms a column of photons (hence the term 

). This means that every photon produced strikes the target. Why is this important? It gives the laser more power and greater depth of cure. Simply put, there is very little waste of curing energy from a laser.

There is also a terrific advantage to laser-cured restorations. With “normal” curing lights it is imperative to be as close to the restoration as possible. If an LED light moves even 2 or 3 mm away from the restoration, the amount of curing power that the light delivers decreases exponentially. Lasers, due to their collimation, can properly cure a composite even if it is several millimeters from the target. This means you get a properly cured restoration every time.

I’ve spent a lot of time in dental offices in my career, and there is one mistake I’ve noticed time and again. An assistant puts the curing light close to the target and then looks away, in an effort to protect their eyes. However, the simple act of looking away often means the light moves away from the target and the LED beam intensity drops. The material cures on the surface but doesn’t receive sufficient depth of cure. The result is what I call “candy composites,” which are “crunchy on the outside and chewy on the inside.” This creates all kinds of problems later, as we all know. That same situation would never happen with the Monet, as the beam intensity is sufficient for a properly cured composite even if the device isn’t next to the target.

The collimation also means better depth of cure. When using a laser, every photon that is produced hits the target. This creates an incredibly strong restoration because the strength of the beam penetrates deep into the material. AMD Lasers’ in-house measurements have found a depth of cure of up to 8 mm. Think about that for a moment. Now, for argument’s sake, let’s say that number is actually 6 mm. Given that over 80% of Class II restorations are 5 mm or less, that means the Monet has just changed 80% of your restorations to bulk fill even if the material is not designed to be bulk fill. And that means your efficiency just took a really big boost.

It has always been popular for a curing device to have a variety of settings for intensity and time. The Monet completely changes that concept. It has 1 button that produces one 3-second curing cycle. That’s all there is because that’s all you need.

The curing head can rotate 360º so the user can position it with ease. It also comes with 2 interchangeable batteries to ensure the Monet is always ready. The device kit includes laser protective eyeglasses that should always be worn when using the device. Lasers have a strong beam, and eye protection is a must when using any type of laser.

The Monet provides intensity that makes composites stronger, increases efficiency, and is competitively priced.

If you are in the market for a curing light, you owe it to your patients to check out the Monet. It will take your curing to a whole new level!

Chief Technology Editor John Flucke, DDS, shares his experience taking the Monet Curing Light from AMD Lasers for a test drive.

Advertorial: A Laser Focus on Exceptional Curing

HIPAA: Those 5 little letters can cause sweaty palms for almost anyone in the health care sector. That probably stems from the fact that, although we all know about the Health Insurance Portability and Accountability Act, most of us do not understand it.

As many of you know, I am a big fan of DDS Rescue. The company has an amazing solution for backup and recovery as well as providing a full HIPAA compliance program including proper risk assessment and staff training. They also act as the office’s IT advocate. As part of the effort to help client offices better understand HIPAA, DDS Rescue has retained an expert. Kezia Josenberger, JD, was working for the federal government when the law was created and was part of the team that wrote the law. This gives her an incredible amount of insight that can help offices make informed decisions on ensuring compliance. I had a chance to speak with Ms Josenberger recently and get her thoughts on some of the current questions the profession has. Here’s what she had to say:

Q: Many doctors do not understand just how financially serious a HIPAA violation can be. Can you explain the structure of the law regarding fines?

In addition to financial penalties, covered entities are required to adopt a corrective action plan to bring policies and procedures up to the standards demanded by HIPAA. The US Department of Health & Human Services (HHS) may assess civil penalties when it discovers a HIPAA violation. Each year, HHS increases the penalty due to inflation. Here are the civil monetary penalty amounts for 2020. The penalty amount enforced by the Office for Civil Rights (OCR) depends on the facts involved. The 4 categories for the penalty structure are:

 A violation that the covered entity was unaware of and could not realistically have avoided, had a reasonable amount of care been taken to abide by HIPAA rules—the penalty amount is between $119 and $59,522 for each violation;

 A violation that the covered entity should have been aware of but could not have avoided even with a reasonable amount of care (but falling short of willful neglect of HIPAA rules)—the penalty amount is between $11,912 and $59,522 for each violation;

 A violation suffered as a direct result of willful neglect of HIPAA rules, for example, sharing protected health information (PHI) through office gossip, in cases where an attempt has been made to correct the violation—the penalty amount is between $11,904 and $59,522 for each violation; and

A violation of HIPAA rules constituting willful neglect, for example, an unauthorized release of information, where no attempt has been made to correct the violation—the amount is $59,522 per violation, with an annual cap of $1,785,651 for all violations of an identical requirement.

Q: Should we expect the number of dental offices audited this year to increase?

When looking at recent enforcement trends by HHS and OCR, smaller practices and solo practitioners are coming under enforcement scrutiny by OCR.

One potential reason is that OCR focused on larger organizations that suffered breaches, because larger fines could be imposed. This would prompt attention by other organizations to prioritize HIPAA compliance as an enterprise risk, meaning that was a financial and reputational risk for the organizations. However, applying hefty fines to larger organizations has not had the punitive effect that OCR thought it would have to encourage all entities, including smaller organizations, to prioritize HIPAA compliance.

HIPAA has been around for over 20 years, and the health care industry is still perplexed on what it takes to achieve compliance. This may be the result of not uniformly enforcing HIPAA across organizations. However, recent enforcement action by OCR shows that OCR is enforcing HIPAA requirements across all covered entity types, and not just focusing on larger organizations. This could be to trigger enforcement awareness across all types of organizations to protect the security of patients’ data. Dental practices are covered entities, and considering recent OCR enforcement action against smaller organizations, they should be vigilant about complying with HIPAA.

Q: Has there been a lessening of HIPAA rules because of COVID-19?

No. At the onset of the pandemic, OCR issued notifications of enforcement discretion, because the United States declared the pandemic a public health emergency. The notifications of enforcement discretion should be narrowly applied, because their issuances are to enable covered entities and their business associates to continue their treatment and health care operation efforts during this public health emergency.

Q: What are the top items that dental offices are not addressing as far as HIPAA regulations?

The top issues that dental offices are not addressing under HIPAA are:

Not implementing a security management process, including performing a comprehensive and/or enterprise-wide HIPAA risk analysis and having a risk management plan;

Not having access or identity management access controls to ensure that only those employees who need access to PHI for their responsibilities have access, especially for their electronic health or medical records systems;

Not having processes for ongoing monitoring and auditing of these electronic health records/electronic medical record systems;

Not having technical controls for their desktops, laptops, and mobile devices, including encryption and password management processes;

Not having policies and processes for individuals to exercise their rights to their data, and especially the right of access; and

Vendor management (ie, not ensuring that they have subcontractor business associate agreements [BAAs] with their vendors or ensuring that vendors are reporting their privacy and security incidents).

Q: Do you believe a dental office can do a risk assessment on their own (without a third party with tech experience) that will meet the standards of HHS?

A dental office could perform a risk analysis/risk assessment on its own, but I would advise against it for several reasons:

OCR requests evidence of a thorough, comprehensive, and enterprise-wide risk analysis/assessment that inventories all e-PHI created, received, maintained, or transmitted by the organization as a measure to assess compliance with HIPAA and specifically, the security rule. This can be a time-consuming task for most organizations that are operating under lean resources. Because the HIPAA risk analysis/assessment is a foundational requirement for complying with HIPAA, it is important that organizations try to retain assistance from third parties that have the resources to help with at least the initial risk analysis or assessment.

The risk analysis/assessment requires entities to evaluate risks and vulnerabilities in their environments and to implement appropriate security measures to protect against reasonably anticipated threats to the security or integrity of e-PHI. Retaining a resource that has industry and organization-based experience—for example, a third party with tech experience in the dental industry—assures the organization that it is complying with the security rule requirements and that application of these requirements are specific to its environment. When OCR reviews an organization’s HIPAA risk analysis/assessment, it is looking to see that the risk analysis /assessment is not general but specifically evaluates vulnerabilities in the organization’s environment.

The HIPAA risk analysis/assessment helps the organization determine what controls, including policies and procedures, are necessary to meet all requirements of the security rule. The risk analysis /assessment evaluates whether an addressable implementation specification is reasonable. Retaining resources to ensure that the organization is applying the appropriate controls to address the requirements of the HIPAA security rule and documenting it are also important, especially if OCR initiates a complaint, compliance review, or an audit against the organization.

Q: What advice would you give for a dental office to be compliant with HIPAA?

HIPAA compliance is an ongoing activity that takes money, time, and resources, but the benefits of complying with HIPAA outweigh the risks. The initial steps in achieving HIPAA compliance are performing the risk analysis/risk assessment; conducting an inventory of third parties contracted to perform health care operations and the data and e-PHI they receive, create, maintain, or transmit; making sure that the dental office has BAAs with their vendors or third parties, as well as reviewing their third parties’ subcontractor agreements with subcontractor BAAs; and ensuring that the dental practice develops and implements appropriate policies and procedures relating to minimum necessary requests, uses, disclosures, and transfers of PHI, verification, permitted uses and disclosures, and individual rights.

Learning the importance of understanding what HIPAA is and why practices should be knowledgeable about compliance.