Dentaltown 2015october

The Benefits of Mini Dental Implants by Dr.
Eric Hanson page 70
October 2015
The Benefits of Mini Dental Implants

by Dr. Eric Hanson, p. 70
Surgical Crown Lengthening

by Dr. Cirimpei Vasile, p. 100
October 2015
CE: Treatment Planning for

Severe Anterior Tooth Wear
by Dr. Brent Engelberg, p. 120
real dentistry for real dentists www.dentaltown.com
An Office Visit
with Michigan Endodontist

Dr. Mickey Zuroff
P. 50
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contents
october 2015
In This
Issue
08
On Dentaltown.com
16
Continuing
Education Update
18
Industry News
36
Practice Solutions:
Clear-Aligner
Therapy
90 | RADIOLOGY
CAD/CAM as a
Marketing Tool
You know its great for
improved diagnoses. Your
patients think its cool. Dr.
Michael Kelly on why CAD/
CAM keeps them coming back.
100 | GENERAL
PRACTICE
108 | HYGIENE
Surgical Crown Lengthening

Check out this integrated
approach in an esthetic
treatment of altered passive
eruption. Dr. Cirimpei Vasile
shares the details.
And Sealants for All

Emilee Berger, RDH, shows
hygienists how they can
increase their value to
the practice, serve their
patients, and help the
practices bottom line.
68
10 | HOWARD SPEAKS
You Should Know:

Healthy Grid
Dr. Howard Farran, publisher of Dentaltown Magazine, talks about how sharing technology and
knowledge not only saves us money, but also makes us all smarter.
94
14 | PROFESSIONAL COURTESY
New Products
95
Practice Solutions:
Voco
98
Poll
107
Product Prole:
Umbie
112
Ad Index
128
Dentally Incorrect
Dont Go it Alone
Great Patient Relationships? F.U.!

Dr. Thomas Giaccobbi, Dentaltown editorial director, gives tips on how to build better relationships.
28 | SPECIAL FEATURE
A Direct Hit to the Jaw: Bisphosphonates and Osteonecrosis of the Jaw
in Osteoporosis and Cancer Patients
No, youre not time traveling: phossy jaw is back. Dr. Betty Fleming tells you what you
need to know.
32 | PRACTICE MANAGEMENT
Five Components to Team Synergy
ea dra a is in the top e o all dentistry stressors
becoming a statistic.
en utler gi es you tools so you an a oid
BRING THE INSIDE FRONT COVER

TO LIFE. DOWNLOAD THE LAY AR
APP FOR AN AMAZING
INTERACTIVE EXPERIENCE.
Continued on p. 4
OCTOBER 2015 // dentaltown.com
contents
october 2015
Continued from p. 2
38 | ENDODONTICS
70 | PROSTHODONTICS
In Focus: Microphotography using the

Dental Operative Microscope
The Benets of Mini Dental Implants
How to Track True

Treatment Acceptance
Frustrated with trying to get great photos

of a tiny subject? Dr. Jorge Zapata shows
you how to get great shots in small spaces.
43 | GENERAL PRACTICE
Anesthesia Safety
Dr. Betty Fleming gives you the info you
need to accurately and effectively numb
that gum.
Dr. Eric Hanson shows you how to use

mini implants to rescue the dental cripple.
76 | PROSTHODONTICS
Kirk Sweigard helps dentists nd out why

treatment plans sometimes stall in their
tracksand how to get them moving again.
Denture Stabilization with SmallDiameter Implants
113 | GENERAL PRACTICE
Increase the comfort of your edentulous

patients by utilizing these tiny implants.
Dr. Ara Nazarian gives you the scoop.
78 | CORPORATE PROFILE
50 | OFFICE VISIT
The Practice that Perseverance Built
Independence Day
Dentaltown Magazine talks with Dr.

Michael Zuroff about his endodontics
practice and how hes kept it all in
the family.
Jay Geier chats with Dentaltown

Magazine about the expanding presence
of corporate dentistry and what it means
for the future of the industryand
independent dentists everywhere.
82 | ORTHODONTICS
Are You Providing Five-Star Service?
Post-Treatment Management of
Orthodontic Patients
Jay Geier gives you the details on providing service excellenceand tells you why
its critical to the growth of your practice.
MESSAGE
BOARDS
What happens after the braces come off?

Dr. Gerald Nelson has the answers.
22
ORAL SURGERY
All on Fourd Out
Townies take a look at
a well-documented
case involving
multiple implants.
Human Herpesvirus Infections and

What They Mean for Dentists
Dr. Ronald Keeney explains why this
virusoften fodder for late-night
comediansis no laughing matter.
120 | CE
Quick, Conservative and Highly
Esthetic Treatment Planning for
Severe Anterior Tooth Wear
Using occlusal equilibration, very thin
lithium disilicate veneers, and composite
resin, this case presentation from Dr.
Brent Engelberg demonstrates a logical
treatment plan that works well to ensure
proper function, occlusion, and restoration of the patients esthetics.
56
PRACTICE
MANAGEMENT
What Kind of Payment
Plans to Offer?
What payment options
if anydo you have
in place for patients?
Townies weigh in.
Dentaltown (ISSN 1555-404X) is published monthly on a controlled/complimentary basis by Farran Media, LLC,
9633 S. 48th St., Ste. 200, Phoenix, AZ 85044. Tel. (480) 598-0001. Fax (480) 598-3450. USPS# 023-324 Periodical Postage Paid in Phoenix, Arizona and additional mailing offices. POSTMASTER: Send address changes to:
Dentaltown.com, LLC, 9633 S. 48th St., Ste. 200, Phoenix, AZ 85044
2015 Dentaltown.com, LLC, a division of Farran Media, LLC. All rights reserved. Printed in the USA.
62
RADIOLOGY
Am I Being
Too Conservative?
A Townie asks for
advice before beginning
ortho treatment on a
patient needing multiple
restorations.
dentaltown
staff
EDI TORIAL ADVISORY BOARD

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Thomas Giacobbi, DDS, FAGD tom@farranmedia.com
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Lee Ann Brady, DMD

Glendale, Arizona
Cari Callaway-Nelson, DDS

Las Vegas, Nevada
Doug Carlsen, DDS

Denver, Colorado
Howard M. Chasolen, DMD

Sarasota, Florida
Linda Douglas, RDH

Toronto, Canada
Joshua Halderman, DDS

Columbus, Ohio
Glenn Hanf, DMD, FAGD, PC

Plantation, Florida
William Kisker, DMD, FAGD, MaCCS

Vernon Hills, Illinois
John Nosti, DMD, FAGD, FACE

Mays Landing, New Jersey
Jay Reznick, DMD, MD

Tarzana, California
Elizabeth Fleming, DDS

Phoenix, Arizona
Donald Roman, DMD, AFAAID

Paramus, New Jersey
Seth Gibree, DMD, FAGD

Cumming, Georgia
Timothy Tishler, DDS

Sister Bay, Wisconsin
Stephen Glass, DDS, FAGD

Spring, Texas
Brian Gurinsky, DDS, MS

Denver, Colorado
Eyad Haidar, DMD

Weston, Massachusetts
Glenn Van As, BSc, DMD

British Columbia, Canada
Fayette Williams, DDS

Weatherford, Texas
Josh Wren, DMD

Brandon, Mississippi
19992015 Dentaltown.com, LLC. All rights reserved. Printed in the USA.

Copyrights of individual articles appearing in Dentaltown reside with the individual authors. No article appearing
in Dentaltown may be reproduced in any manner or format without the express written permission of its author
and Dentaltown.com, LLC. Dentaltown.com message board content is owned solely by Dentaltown.com, LLC.
Dentaltown.com message boards may not be reproduced in any manner or format without the expressed written consent of Dentaltown.com, LLC.
Dentaltown makes every effort to report clinical information and manufacturers product news accurately, but cannot assume responsibility for the validity of product claims or typographical errors. Neither do the publishers assume responsibility for product names, claims, or
statements made by contributors, in message board posts, or by advertisers. Opinions or interpretations expressed by authors are their own and
do not necessarily reflect those of Dentaltown.com, LLC.
The Dentaltown.com Townie Poll is a voluntary survey and is not scientifically projectable to any other population. Surveys are presented
to give Dentaltown participants an opportunity to share their opinions on particular topics of interest.
Letters: Whether you want to contradict, compliment, confirm or complain about what you have read in our pages, we want to hear from
you. Please visit us online at www.dentaltown.com.
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The magazine is just a part of what we do at Dentaltown. Visit Dentaltown.com for an ongoing conversation about
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Message Boards
Brushing Your Toddlers Teeth: Please do not Comment Unless
You are a Parent
See what advice dentist parents give to this doc who is trying to get into a brushing routine with her uncooperative child.
Toddlers Teeth
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What Prompts a Visit from HIPAA?

Info from these docs can help you be ready for a HIPAA audit.
Visit HIPAA
Featured Case
Replacing an Overcountoured Crown
Five-year Follow-up: Life Lessons Learned
Crown Five
Find out what this doc learned five years after he placed this crown.
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Practice Leadership 101 by Travis Frederickson

The changing landscape of healthcare brings into sharp focus the necessity for
dentistry to understand its need to engage in the leadership process as well as
effective management. This course is intended to introduce the learner to what
practice leadership is all about and the many benefits that accompany
this approach.
howard speaks
column
Dont Go it Alone
How Sharing Technology and Knowledge Saves Money
and Makes Us All Smarter
Writing my book, Uncomplicate Business: All It

Takes Is People, Time and Money, got me thinking
even more than usual about how dental entrepreneurs
can make the best financial decisions. Some financial
wisdom Id like to share is this: buy what you can
afford when you can afford it, and only if you really
need it. This is especially true when it comes to big
technology purchases. As a practice owner, you want
to find that balance between having modern technology and having a stable financial situation.
Now some endodontists will say, I

dont want to teach you because then
who will you refer to me? But in my
case, I wasnt referring to this person
in the first place.
The latest and greatest can be cool, but I know
many dentists who spend way too much on technology they dont need. Those purchases seem fun
at first, but often come with a built-in migraine.
You have to research before you buy, you may need
to reconfigure your office, your operatory or your
wiring, and you have to train on
the machine/technology and teach
people how to use it. That doesnt
sound like a day at the beach.
When you hear that everyone
has a certain piece of technology,
its tempting to think that you
need it too. However, even though
a certain piece of technology is good for another

practice, it might not be right for you. Dont feel
pressured to buy it all, or all at once. Space out your
big purchases and talk to everyone and their brother
before you make your choice. The Dentaltown message boards are an amazing resource for this. Product reps often know a lot about a product, but you
definitely want to talk to dentists who have used that
product, and who own it. Ask many questions.
Do they use it as often as they thought they
would?
Is it saving them money?
How long did it take before they turned a profit
on that investment?
When it comes to technology, keep up with
your needs and what your accountant tells you,
instead of keeping up with the (Dr.) Joness.
Do you need it?

If youre established in your career and you
have a strong fi nancial situation, taking a chance
on a technology purchase wont destroy you. But
if youre young and you have $250,000 in student
loans, why do you need to spend a boatload of
money on technology when you dont have a dime
and only have debt?
If youre going to use other peoples money to buy
this technology you think you need, youll likely pay
interest, so factor that into the technology price. If I
said to all of you, How about you buy that technology in cash? it would be a whole different game.
Now, dont get me wrong. I love technology.
Technology has brought dentistry a long way. You
need access to CBCT, but maybe you dont need to
own it. Lets say you want CBCT but you dont want
to spend $150,000. Well, I never met a specialist who
Continued on p. 12
by Howard Farran, DDS, MBA, Publisher, Dentaltown Magazine
10
WANT MORE HOWARD?
go to: www.dentaltown.com/podcasts
howard speaks
column
Continued from p. 10
doesnt want to form a relationship with a general

dentist. Every oral surgeon and periodontist I know
has a CBCT, and you can just call one of them up
and say, Hey, if I have a patient who needs CBCT
can I send him over to you, and Ill pay you to use
your machine? Form a relationship! We can all learn
from each other in this profession.
Teach a man to fish

When I wanted to learn endo back in 1987, I just
called a nearby endodontist and said, Hey, I dont
have any patients on Friday until nooncan I come
and watch you? Every single time he says, Hell yes.
People like to share what they know and they like to
talk about things that excite them and that theyre
good at. Most people like to teach.
Now some endodontists will say, I dont want to
teach you because then who will you refer to me? But
in my case, I wasnt referring to this person in the first
place. I met him and became his friend, and since I
knew there would be all kinds of endo that I am not
going to want to do or will be too busy for, I told this
endodontist that Ill start referring to him. We went
Howard Live
Howard Farran, DDS, MBA, is an international speaker
who has written books and dozens of articles. To schedule Howard to speak at your next national, state or local
dental meeting, email rebecca@farranmedia.com.
2015
21
NOV
DEC
Calgary District Dental Society

Calgary, Canada
faridasaher@gmail.com
www.cdds.ca
Greater New York Dental Meeting

New York, NY
JAYME@GNYDM.COM
www.GNYDM.com
from a situation where he wasnt getting referrals from

me, and now he will be, all because he had the generosity to teach me something and I had the guts to ask.
See, we can share more than technology.
Smart specialists, smart orthodontists, smart
oral surgeons, want the relationship. In many cases
you can get the best hands-on lectures in the world
in your own county! Conferences can be great, but
dont fall into this validation deal where you think
that just to continue your education you have to pay
$5,000 for a course, or you think you have to fly
halfway across the country and stay in some five-star
resort and take fancy day trips. Sometimes you come
back, look at the bill and say, OK, the class was five
grand, the expenses were five grand, but what did I
actually learn?
Im a big fan of conferences, but they should be
balanced with other types of learning. I could learn
elements of dentistry for free on YouTube for the rest
of my life. Its amazing how dentists in the entire
poor world who barely have anything and cant go
to these courses or hire consultants can get a great
education online. If they want to know something,
they type it into YouTube. Now, we all know some
of the videos there are garbage, but there are excellent videos too. Some can be very practical. I was
reminded of this with my car the other day. I had a
flat. To get the spare out of the back you have to be
a mechanical engineer. This guy walks by and I say,
I cant figure out how to get this thing off. He cant
figure it out either. He takes out his cell phone, goes
on YouTube, types in, How to get the car jack out of
a Lexus 450 SLs, and boom. There was a video on it.
We watched the video and then I changed the tire. Be
street smartlearn from the guy across the street.
Theres a big difference between street-smart
dentistry and book-smart dentistry. Too many damn
dentists are book smart. I know youre book smart
you got As in calculus, physics, geometry. But book
smart has nothing to do with street smart. There are
a hell of a lot of street-smart people who never went
to college, dont have a degree, and they are millionaires, billionaires. They are just street smart and they
get rich by learning from other people, and by not
spending too much on stuff (ahem, technology) that
they may not even need.
Want to share some advice with our community? Visit dentaltown.com.
12
professional courtesy
column
Great Patient Relationships? F.U.!

Everyone finds some frustration in the patients
who are always chasing the best deals and not the
best care. I have had my share of current patients
ask if I will match some ridiculous whitening special
advertised in a coupon mailer and I can comfortably
say no. Why? Because Im building a relationship
of mutual respect, and when I tell the patient that I
simply cant provide that service at that pricethey
are free to make a choice. They may have me do it
for a bit more, or they may chase the deal and never
return. Its a win either way in my book.
Wait a minutedid I just say that they might
never return? Yes I did, and if I have developed a
strong relationship, I know the majority of the time
they will come back. In fact, they come back with an
even greater appreciation for what I have to offer and
an understanding of why I might charge more than
Groupons deal of the day. You know the old saying:
If you love something, set it free. If it comes back it
was meant to be.
Dont worry, we will get to the F.U.Im going
to drag that teaser for just one more paragraph. I
didnt want to go any further without describing
my practice, because I think that is very germane
to this discussion. I have a practice that is similar
to the majority in that I participate with a number
of PPO plansfour to be exact. I also practice in a
community where a large percentage of people in my
area are from someplace elseincluding me. So in a
world where the abundance of PPO providers allows
patients to move freely from one office to another,
distinguishing yourself is an important ingredient to
a lasting relationship and a strong practice.
How can you build strong
patient relationships? Lets get to
it. F.U. = follow up. There are so
many ways we can follow up with
our patients and each time we do
it, the act is often unexpected and
the patient is pleasantly surprised.
First, the personal phone call to your patient is one

of the most mentioned and least performed in dental circles. Modern technology has made it a breeze
because very few people answer their phones any
more. Simply place a call and leave a message. If the
patient answers his or her phone, even better, you
can have a brief conversation. The latest and greatest
appointment reminder systems also provide a mechanism for follow up in the form of a review. The vast
majority will be positive and you will always learn
something from the negative. Sometimes you learn
that you have a patient with unreasonable expectations or you have a weak spot in the quality of service
you are providing.
Another simple follow up occurs when a patient
comes in to have something checked or there is
something discovered in hygiene, but no treatment
is planned yet. Perhaps it is a soft-tissue lesion that
will likely heal or a sensitive tooth that may get
better. The first task is to have someone from your
staff call two weeks after the visit to see if everything
has resolved. We often give the patient the default
instruction: If this is still bothering you, give us a
call. Why not take the lead and make the patients
day by checking up on them?
Treatment plan follow up is a task that many
offices will do on a routine basis but can be overlooked. The obvious benefit is in your schedule and
practice productivity. This is also an opportunity to
gather feedback and discover unanswered questions
from the last office visit.
I hope you will fi nd these suggestions refreshing
reminders of the opportunities that wait in your
practice to develop better relationships with your
patients. Great relationships not only help retain
patients but also avoid lawsuits and increase that
magical goodwill that people factor into the value
of a practice.
If you like Twitter, follow me @ddsTom. I can be
reached via email: tom@dentaltown.com.
What do you do to maintain a good patient relationship?

Comment on this article at Dentaltown.com/magazine.aspx.
by Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine
14
continuing education
update
Whats New in Continuing Education?

There are great beers and brats being released
right now for Oktoberfest. There are also great CE
courses being released on Dentaltown. Watch a course
and celebrate the fall season! Sounds like a plan.
Townie Meeting 2015 Lecture Series

We cant bring you all the action from our annual
Townie Meeting in Las Vegas, but we can certainly
share some of the top-notch education that was
presented there. This month, we are releasing our
Townie Meeting 2015 series, containing courses from
Lee Ann Brady, Ara Nazarian, Mike Melkers, Bruce
Baird, Mark Hyman, Neal Patel, Dale Miles, and
many more. You now have access to more than 22
hours of excellent education in both clinical dentistry
and practice management.
As part of the registration fee for Townie Meeting, all 2015 attendees have access to these courses for
free. Miss the meeting? Dont worryits only $225
to view for anyone unable to attend. (But be sure to
sign up for Townie Meeting 2016!)
Repair and Protect Enamel with

Remineralizing Agents
by Deborah Levin-Goldstein, RDH, MS
Caries is a dynamic disease process involving
the cyclic demineralization and remineralization
of the tooth structure. A key preventive approach is
maintaining an oral environment favorable to remineralization. Fluorides ability to promote remineralization is limited by the availability of calcium and
phosphate in saliva. The four types of remineralizing
therapeutics that attract calcium and phosphate will
be discussed, as well as the caries
process and CAMBRA.
Orthodontics in the Multidisciplinary Treatment of

Complex Cases
by Dr. Miguel Hirschhaut
Orthodontics sets up the foundation for future prosthetics in
cases with periodontal, surgical and
restorative dentistry requirements.
Adult orthodontics simplifies complex clinical

situations, making it easier for restorative dentists
to achieve better esthetic and functional results.
Orthognathic surgery combined with orthodontics
corrects skeletal discrepancies in order to prepare the
patient for prosthodontic replacement of multiple
missing teeth. We will illustrate through combined
clinical cases the importance of orthodontics in
setting up a proper occlusion prior to the restorative
phase of treatment.
Patients to be restored with implants will be
shown, to illustrate our protocol for combined orthodontic/prosthetic cases to restore form and function.
This will further illustrate the importance of multidisciplinary dentistry to meet the goals of dentofacial
total esthetics and masticatory function. These cases
will show how orthodontics combines with distraction osteogenesis and conventional orthognathic
surgery to remedy severe dentofacial deformities.
Orthodontics combined with other dental specialties
produces an end result that guarantees long-term
periodontal health and produces a patients satisfaction with his or her dentofacial esthetics.
Success, Profitability & Destiny

Begin with You
by Tuan Pham, DDS
In this course, you will learn to see that through
the principle of reframing, each and every problem
and issue is an opportunity to find success. You will
see how vision is important and that each and every
decision we make will guide us towards our ultimate
goal, and how a lack of vision leads to missteps.
You will learn that our technical hand skills are
not actually our main job and that they are secondary
to our job of education and imparting of value, which
in turn leads to increased treatment-plan acceptance
and profits. You will further learn how likability and
the creation of likability are crucial to the success of
our businesses because of the shift in public perception. You will see how education and implementation
of nonclinical skills are crucial to your business
growth and long-term profitability.
by Howard M. Goldstein, DMD, Director of Continuing Education, Dentaltown Magazine
16
update
Realizing the Magic of Guided Surgery

by Dr. Sheldon Lerner
To some, guided surgery is a mixture of buzzwords, expensive tools, and tedious process flows. In
this course, Dr. Sheldon Lerner pulls back the curtain
and presents guided surgery as it is meant to be: tools
that work for you, software that assists the implant
planning process and surgical guides that improve the
safety and accuracy of the implant placement.
This course shows how to streamline the entire
guided surgical process by giving full control to the
user. Software can be a platform allowing users to
control the entire planning and guide fabrication process, or enabling users to collaborate and so benefit
from the help of labs or other dental professionals.
Dental Sleep Medicine: Sleep Principles

and Oral Appliances
by Dr. Barry Glassman
Dentistry could and should be the No. 1 portal
for patients into sleep medicine. What steps should

the general dentist take in order to help benefit
patients? As a general dentist, what factors will help
you decide exactly how involved you should be in
your patients treatment? In this two-hour presentation, we will discuss the principles of sleep medicine,
and the role of dentistry in treating snoring and other
obstructive sleep disorders. This honest look at sleep
medicine will concentrate on the challenges that dentists face when incorporating dental sleep medicine
into their practices.
Those viewing this presentation will begin to
have a thorough understanding of dental sleep medicine and will be in a position to appropriately screen
all their patients. As important, they will have the
needed information to decide if they want to incorporate oral-appliance therapy into their offices and if
so, what steps to take. The oral-appliance review will
help them select and insert appliances and monitor
appliance use.
View more CE offerings on Dentaltown.com/onlineCE
dentaltown.com \\ OCTOBER 2015
17
industry
news
Henry Schein Announces Call for Entries for Inaugural Henry Schein Cares Medal
Henry Schein has announced the creation of the Henry Schein Cares Medal, which will be awarded annually to organizations
that demonstrate excellence in expanding access to care for the underserved.
Through the Henry Schein Cares global corporate social responsibility program, the company uses its resources to support
health-care professionals around the world who provide care for those who would otherwise receive little or no medical attention.
The medal will honor organizations whose work has been especially effective in bringing care to those in need.
Nine finalists will be selected among applicants from the fields of oral health, animal health and medical health. From those
nine finalists, a medalist will be selected from each field, for a total of three medalists. Each of the nine finalists will receive $10,000
worth of product from Henry Schein for use in caring for the underserved, and each of the three medalists will receive an additional
$15,000 in cash from the Henry Schein Cares Foundation to support their charitable work. The finalists will be notified in January
2016, and the medalists will be announced at a gala event in New York City later in 2016.
For more information on the program, and to apply for the award, please visit www.Hscaresfoundation.org/apply.asp.
Industry News
The Industry News section helps keep you informed and up to date about whats
happening in the dental profession. If you would like to share information in
this section, please email your news releases to arselia@farranmedia.com.
All material is subject to editing and space availability.
www.dentaltown.com
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The American Dental Association (ADA) has announced an exclusive endorsement
with Darien Rowayton Bank (DRB). The endorsement allows ADA member dentists the
opportunity to refinance existing federal and private undergraduate and graduate school
loans at a lower rate to save tens of thousands of dollars, on average.
The DRB low-rate student-refinance loan, offered at both fi xed and variable rates,
is one of the many resources that the ADA provides to new dentists. The ADA endorsement not only gives ADA members access to one of the lowest student-loan-refinance
lenders in the country, but the ADA has also secured DRB preferential interest rates for
its members who qualify.
DRBs chairman of the board Gary Lieberman said dentists who refinance with
DRB can save an average of $38,000* with a fi xed-rate refinance loan. Only ADA
member dentists are eligible for this offer, and annual renewal of ADA membership is a
requirement to receive the lower rates per the terms of the agreement.
* Annual percentage rate. Savings of $38,000 over the life of the loan assumes loan
size of $247,000 with an average rate of 7.25 percent before refi nancing and 4.75 percent (with EFT discount and ADA member discount) after refi nancing on a 10-year
fi xed rate loan.
18
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industry
news
DENTSPLY and Sirona Enter Into Definitive Merger Agreement

On Sept. 15, DENTSPLY International and Sirona Dental
Systems announced that boards of directors of both companies
unanimously approved a definitive merger agreement.
The combination will create a combined company with the
largest sales and service infrastructure in dental with 15,000
employees globally.
This is an exciting day for both companies, for the dental
community and for patients around the globe. We are bringing together two world-class companies that share a culture of
innovation and will foster the development of differentiated,
integrated solutions for general practitioners and specialists,
particularly in the highest growth segments of the dental
industry, said Jeffrey T. Slovin, president and CEO of Sirona.
Combining Sironas proven digital solutions and equipment
with DENTSPLYs leading consumables platform creates the
most comprehensive dental solutions offering available to
meet customer demand in every key segment. I look forward
to leading the talented teams of both Sirona and DENTSPLY
as we drive the global digitization of dentistry, offer superior
solutions to customers and patients, and create The Dental
Solutions Company.
The combined company, supported by its leading platforms
in consumables, equipment and technology, will offer a powerful set of complementary offerings and end-to-end solutions to
enhance patient care. Dental professionals across the globe will be
supported by one of the largest sales-and-service infrastructure in
the industry, supported by leading distributors, to deliver an optimized product range that will meet the increasing global demand
for digital dentistry and integrated solutions.
We are excited about bringing together two industry leaders, said Bret W. Wise, chairman and CEO of DENTSPLY.
DENTSPLY SIRONA will offer a comprehensive line of
solutions to more effectively meet the needs of dental professionals all over the world and advance patient care. With a
strong financial profile, comprehensive product offerings and
integrated solutions, DENTSPLY SIRONA will be uniquely
positioned to deliver attractive returns to our shareholders and
make dentistry better, faster and safer around the world. I look
forward to working with Jeff and the combined management
team to deliver on this mission.
The combined company will be called DENTSPLY
SIRONA and trade on the NASDAQ under the symbol XRAY.
DENTSPLY SIRONAs global headquarters will be located in
York, Pennsylvania, the location of DENTSPLYs current headquarters, and the international headquarters will be located in
Salzburg, Austria.
20
Townies React to Merger News

Once the news of the DENTSPLY Sirona merger became
known to the public, Townies took to the message boards to discuss the situation. To find this conversation, search for, Dentsply
buying Sirona or visit Dentaltown.com/DentsplySirona.
[In] my mind big mergers seem to favor the company
over the customer. This is a premature criticism leveled
before any actual information has been provided, but
judging by other mergers (airlines, telecom) the news is
not guaranteed to be favorable for the consumer. There is
a reason why there are anti-monopoly laws, and its not to
protect CEOs. Has anyone tried booking travel lately? The
glory days of early 2000s cheap flights is absent at least for
the time being. Oh well, lets see what happens.
-dominickiii
The track record of large M&A is spotty at best.
The success rate is not very good. They tend to be good
for stockholders, not so great over the long term for the
companies themselves. Lots of hurdlesmanagement differences, culture of the companies, customers and how they
view the transactiontricky business on a small level, let
alone the multi-billion dollar level.
-TimmyG
Could get interesting. If the merger doesnt keep the
Sirona software/hardware engineers happy, they might
jump ship and join other projects to help others catch up,
perhaps with a more open approach to technology.
-drfredc
DENTSPLY will be majority owner. [It] would appear
that DENTSPLY holds the upper hand in this going forward. Will be interesting to see if Slovin is able to hold
onto the CEO position over the next couple of years.
-TimmyG
More reflections on how relationships might change:
Ivoclar had a patent dispute with Dentsply over CAD/CAM
blocks which was settled at the end of last year: Sirona has
always had a great relationship with Ivoclar. I think it is safe
to say that eMax blocks are the dominant item milled in
CEREC machines. This is how things look now ... its just
like the time when your friend [Ivoclar] got into a big fight
with a girl [Dentsply] and then you [Sirona] married that
girl less than a year later. You are probably not great friends
anymore, but you still say hello at the holiday parties.
-NY2AZ
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oral surgery
message board
All on Fourd Out

A look at a well-documented case involving multiple implants.
Dentaltown.com > Message Boards > Implantology > Implantology > All on Fourd Out
John Ha
Member Since: 12/11/10
Post: 1 of 44
Related Message Boards

All on Four Course
All on Four Course
All-on-4 Compensation
All on Four Compensation
22
Introduction:
I had shared the pre-op photos of this case during the work-up stages. I was able to get some
pictures during the procedure. Unfortunately, no one was available to grab some pics of the temp
bridge conversion.
Before the surgery, I had the patient in for a leaf gauge load test that yielded no pain,
tightness, or discomfort. I decided we didnt need to deprogram. Load test with leaf gauge was
performed again at one week post op. Again, no discomfort, so equilibration was done. Will
have patient back in another two weeks to equilibrate if necessary.
Five NobelActive implants were placed (one at mid-line). Four 4.3x13 and one 3.8x8.5. I
have some rads and a CBCT but dont have a DVD drive here at home to transfer things over. If
I remember to load them up at work, Ill post them later.
(Fig. 1) Pre-op smile
Fig. 2
Fig. 1
(Fig. 2) Pre-op retracted
(Fig. 3) Pre-op occlusal shot
(Fig. 4) Horizontal incision made,
papilla was not included. Removing
them makes for easier closing of
Fig. 4
Fig. 3
the flap afterwards. Full thickness
reflected back.
(Fig. 5) After the teeth were
extracted, alveolectomy was performed to flatten out crest. Quite a
Fig. 6
Fig. 5
bit of bone was removed due to the
patients extreme flare of her teeth.
(Fig. 6) Pilot drill at midline
placed and Nobels All-on-4 surgical
guide put in place.
Fig. 8
Fig. 7
(Fig. 7) The guide was used to
place the anterior vertical implants
and posterior angled implants.
(Fig. 8) Vertical parallel pins in
Fig. 10
Fig. 9
place.
(Fig. 9) All implants were torqued
to at least 45nM.
(Fig. 10) Needs graft.
(Fig. 11) Multi-unit abutments
Fig. 12
Fig. 11
and healing caps. Healing caps were
used to retract the tissue.
(Fig. 12) Graft was 50-50 mix of
Bio-Oss and Pur-Oss.
oral surgery
message board
(Fig. 13) Membrane placed

Fig. 13
and stitched everything up.
Unfortunately after this, there
arent any pics of the denture-temp
bridge conversion.
(Fig. 14) One week post-op smile
Fig. 15
(Fig. 15) One week post-op
retracted. Lower arch will be done
within 6-12 months.
(Fig. 16) One week post-op
occlusal shot.
Fig. 17
(Fig. 17) Before and after
smile shots.
(Fig. 18) Before and after
retracted shots.
(Fig. 19) Before and after full
face.
Conclusion:
Shes planning on doing the
mandible as well but needs to stage things out. For now shes got
a flipper that shell wear in the short term. A night guard was
given to her that shell use during osseointegration and will also
wear one once the final prosthesis is delivered. This was a fun
but also challengingcase. During the post-op appointment,
she said she couldnt stop smiling, even though she was slightly
swollen. Happy patient who cant wait for the next step!
Fig. 14
Fig. 16
Fig. 18
Fig. 19
MAY 3 2015
Interesting case; thanks for posting. I have a couple of questions. Did you really need angled
screw receiving abutments for the three anterior implants, or could you have gone with straight?
(Or 17s if these are 30s that you used.) If you could have brought the screw access holes closer
to the teeth, the final prosthesis could be made much more cleansable, especially with the labial
flange you have on the temp.
Also, why do you prefer the midline to one of the central incisor sites? Isnt the incisive
foramen in the way a lot of the time? This is an ugly high-palate case for full-arch restoration.
How is the patient making out with dental-alveolar phonetics (T and D sounds)? If she cant
accommodate, what is your plan?
If you discover that the patient cant clean around the temp (a real possibility here), what is
your fallback plan?
holden
Post: 3 of 44
MAY 3 2015
We would have loved to use straight multi-abutments but due to the patients teeth and
crestal bone being extremely flared and the subsequent amount of bone that was removed, we
ended up using the 17-degree for the anterior implants and 30-degree for the posterior implants.
If we used a straight abutment, her occlusion would be extremely off or there would have been a
larger labial flange that would have been even harder to clean.
The location of the midline was off toward the central due to the patients occlusion. After
John Ha
Post: 10 of 44
23
oral surgery
message board
alveolectomy, putting things together proved more difficult than we thought it would be. In
order to get her occlusion where we planned (bite verification jig was used to make sure upper
and lower arches fit as intended), we found that her midline did not line up where we thought it
would and had to improvise during the temp hybrid conversion.
I would have preferred to obliterate the incisive canal to remove more palatal tissue at the
midline, but the periodontist that I collaborated with advised not to. I didnt question his advice.
Ive heard that IC obliteration is pretty safe and is routinely done on these cases, correct?
Great question about the palate. This was a huge concern for me that I discussed in great
detail with the patient. I discussed with her hygiene practices and she is currently on CHX rinses
bid for the next six weeks to aid with healing and cleansability. I also told her that she is going
to have to work hard to get herself sounding right after the hybrid was delivered. I told her she
needed to get a book and read it out loud daily to really practice her d, t, sh-, ch-, and fricative
sounds or shell really struggle with speech. Luckily shes been a trouper and really put in the
hours to get her speaking back to normal. She said it hasnt been an issue and our one week
post-op check included a phonetics check where she sounded spot on.
After the lower arch is done, the upper and lower hybrids will be moved in an anterior-posterior
relation to prevent an excess in labial-lingual flange. By changing the relationship of the final
hybrid prosthetics, I think itll make for more hygienic restorations in the end, but when we
spoke about this change, she was concerned with how much lip support she would lose and that
she wouldnt look like herself. This will all be discussed further with her before the finals are
designed and delivered.
MAY 4 2015
billschaeffer
Post: 23 of 44
Thanks for posting this case. Youve certainly transformed this ladys smile. Great job.
I do wonder however, whether Holden might have a point about the position that the temporary cylinders emerge from the bridge. I can see that this was a challenging caseits certainly
not an easy one to do with that flared alveolusbut do you think that it might have been
possible to angle the anterior abutment so that the temporary cylinder emerges closer to the
incisor teeth?
That would have made the bridge thinner, less bulky and possibly easier to clean than this
slightly thicker bridge.
In addition, do you think that judicious adjustment of the abutments further back might
have got them all coming through the occlusal surfacesagain making the bridge thinner and
easier to clean?
What did you use to guide you as you positioned the abutments?
MAY 6 2015
vomer6
Post: 27 of 44
All good points, Bill, but I will say I saw a similar full arch case presented at the national
ADA meeting a few years ago with implants placed too palatal just like these, so I asked about
it. The answer was that even though it was staged, they didnt get a good result on the bone
grafting, so thats all he had. So even the guys presenting nationally on how to get great results
have some compromised cases.
MAY 6 2015
John Ha
Posts: 29 & 30 of 44
24
Thanks, Bill, for stopping by. Im honored to have a practitioner of your experience and skill
give me constructive criticism.
I think that the photo of the surgery when the multi-unit abutments are in place and the
heal caps being placed is throwing people off. During the conversion of the denture to hybrid,
oral surgery
message board
I ended up repositioning the multi-unit abutments to angle more toward the

labial and this is where it ended up. That may give you an idea of how much
alveolectomy was necessary and how flared the maxillary teeth and bone were.
The position of the temp abutments is definitely not ideal. In order to make
sure occlusion was functional and something we could work with, we had to
compromise on the location. There is a slight chance the VDO may be changed
depending on what things end up at once the lower arch is converted to a temp
hybrid and healed. There is a certainty that the labial-lingual orientation of
permanent hybrids will be changed. These things would enable us to make for a
much more hygienic hybrid design.
Currently, we are planning to use a zirconia bridge with e.max layered over
it for a compromise between strength and esthetics. I would love to use a monolithic material, but zirconia just doesnt look as good in my opinion. My lab
technician told me that they have been able to get zirconia looking as good as
e.max these days, and if that holds true, we may go with zirconia all the way.
As for design, I would love to change the anterior-posterior relationship of
both temp hybrids to create a more hygienic permanent restoration. A VDO
change may be in the cards as well, to aid in making cleansing the restoration
easier. By changing the VDO, it would help with the bulkiness of the labial
flange without sacrificing too much lip support.
My biggest concern would be tooth position. Right now, she shows a pretty
ideal amount of teeth in her smile and at repose in the temps. Changing VDO
could make the esthetic result less than ideal. Right now shes very happy with
her smile.
Uwe: What are your thoughts on the design of the permanent hybrids?
MAY 6 2015
When doing any immediate load full-arch case, billschaeffer

the bit that I take the longest time over is getting the Post: 33 of 44
abutment position correct. With a hybrid bridge, like
this one, it does not matter where the implants are placed (within reason). What
matters is the position of the abutments.
A case like this can be a disaster if the screw holes emerge through the facial
of the bridge, but it can also be a disaster if the screw holes emerge too far to the
palate. The huge number of abutment options and angulations mean that you
almost never need to have the screw-holes emerge in an unfavorable sitejust
twist the abutment slightly or change the angulation on it.
When planning up a case like this, you need to have not just the All-On-4
surgical guide that you show so nicely in this thread, but also a prosthetic guide
that has the labial/buccal aspects of the teeth on it, so that you can ensure you
are not through the labial but also not too far to the palatal.
If you dont have that guide to help you when youre choosing and attaching
the abutments, then you are simply guessing where they need to go.
MAY 8 2015
The patient comes in tomorrow and Im gonna

have a come to Jesus talk with her about the final
prosthesis type.
John Ha
Post: 36 of 44
25
oral surgery
message board
Ive never done a zirconia hybrid and I dont think this would be an easy case to start doing
them, so Im going to plan for acrylic with pretty Phonares teeth and splinted implants in the
prosthetic design. This is mainly for repairability and retrievability in the event of an unforeseeable
break or chip of the prosthesis.
Im going to try to convince her to go with a telescopic overdenture to help with home
care after its been delivered (credit to my buddy Kevin for this suggestion). Its going to be a
hard sell, but depending on how healing and hygiene is going, it may be necessary to ensure
long-term success.
Before the surgery, she voiced her concern about her lip support and looking like herself. I
may use that in our conversation to tell her that in order to have a full labial flange to give her
that lip support, a removable device may be our only option or we risk losing the natural shape
of her face by minimizing that flange. A large labial flange that doesnt lend itself to ease of
cleansability will hurt long term success.
What are everyones thoughts on that?
MAY 10 2015
Uwe Mohr MDT

Post: 38 of 44
Telescopes are the go-to option in Germany.
MAY 10 2015
holden
Post: 39 of 44
Fair enough, but the pictures above show eight units, not five, and some may be teeth, and
all are underneath the eventual prosthetic teeth, and all implants appear to be axially angulated.
Nothing wrong with telescopes, but these are two different situations in my opinion.
MAY 10 2015
John Ha
Post: 42 of 44
Got to follow up with her, refine occlusion and speak with her this week. That palatal tissue
looks better but still pretty mad. Its gonna be an issue restoratively from a hygienic point of view.
After explaining to her the importance of making those implants and her investment in
them last while keeping the lip support she gets from such a significant labial flange, she was
actually open to something that is removable, like a telescopic or Marius bridge.
Uwe: Beautiful work as always.
Bill: I did not use a guide but with the lab guy with me, we tried to position the temp abutments as far forward as possible with the parts that were available to us. We rummaged through
both of our stash of parts we had on us. I will check to see what exact abutments were used at
which angle but it would totally suck to have to have the lab guy come and set up shop in my
office, remove the hybrid, remove the existing temp abutments and attempt to get a less of the
flange that is difficult to clean around (may or may not be possible). I will also send out an email
to my Nobel rep to see if there are other parts exist to angle the temp abutments further labially.
In your eyes, do you think this is the only way to achieve success long term with a fi xed
prosthesis?
MAY 15 2015
Join the discussion online at: www.dentaltown.com

All on Fourd
26
special
feature
A Direc
Hit to
the Jaw
by Elizabeth Fleming, DDS
In 1858, workers in matchmaking factories started to complain of pain, swelling, debilitation and
painful exposed bone in the mouth. Labeled phossy jaw, the disorder reached epidemic proportions
and had a reported mortality rate of 20 percent.
The disorder was linked to yellow phosphorous, the key ingredient in strike-anywhere matches.
In the factories, workerscalled mixers, dippers, and boxerswere exposed to heated fumes
containing this compound. Many workers developed painful exposed bone in the mouth, whereas their
office-based counterparts did not. As proper safeguards were put into place, the phossy-jaw epidemic
tapered off in the early 20th century, with only a few cases appearing since.1
Until now.
Some troubling, albeit interesting,

cases have appeared more than a hundred years later. The exposed bone and
clinical course of todays disease are eerily
similar to what our historic counterparts
saw in match-factory workers. This time
the potential cause is not tied to factory
conditions, but instead to people receiving treatment for certain types of cancer.
Researchers believe its due to bisphosphonates used to treat metastatic cancer
deposits in bone or osteoporosis.
Although yellow phosphorus has
a simple chemistry of P4O10, when its
combined with H2O and CO2 from
28
respiration, and with common amino acids

such as lysine, the resulting chemical compound is similar to that found in the prescription medications Fosamax or Aredia.
In patients with phossy jaw, forensic
evidence directly points to conversion of
the yellow phosphorus to potent amino
bisphosphonates by natural chemical
reactions in the human body.
The cause of phossy jaw in the late
1800s was actually bisphosphonate-induced
osteonecrosis of the jaws, long before clever
modern pharmaceutical chemists synthesized bisphosphonates. Todays bisphosphonate-induced osteonecrosis represents the
second epidemic of phossy jaw.1

The three stages of osteonecrosis of
the jaw (ONJ):
1. Exposed bone, but no symptoms of
pain or infection. Treatment consists
of chlorhexidine rinses and monitoring the exposed bone by a dentist or
oral surgeon.
2. Exposed bone with symptoms of pain
and infection. Treatment consists
of oral antibiotic therapy and
chlorhexidine rinses with superficial
debridement of the infected areas
of bone.
3. Exposed bone with extensive pain
special
feature
and bone involvement. These

patients require the use of chlorhexidine, oral antibiotic therapy,
debridement and possible resection
to remove the areas of necrotic bone.
Bisphosphonates today
For more than a decade, recipients of
bisphosphonate drugs have sued pharmaceutical companies over these devastating
drug side effects. The plaintiffs allege
that the drug, intended as a part of cancer
treatment, led to osteonecrosis of the jaw.
Many of the lawsuits allege that the pharmaceutical companies either failed to warn
the patients of the potential risks, or downplayed the possibility of the associated risks.
Bisphosphonates are a type of drug
used to treat bone loss for those who
have osteoporosis, bone diseases or cancers that may metastasize to the bones.
There can be serious side effects when
taking bisphosphonates, especially the IV
form, including embolism, myocardial
infarction and osteonecrosis. The action
of the drug is on the osteoclasts, which
deal with the remodeling of bone. When
the osteoclasts are shut down, the cells
can become infected, leading to exposed
bone, infections, pain and numbness.
So far, most of the lawsuits have been
decided in favor of the pharmaceutical
companies, with courts citing that the
drug is fit for the purpose even though
there are health hazards to some patients.
Inside look
Prior to any modern-day bisphosphonate-related lawsuits, a Dr. Vishtasb
Broumand, who now practices in
Phoenix, Arizona, began seeing high
numbers of patients with necrosis of the
bone, as did his mentor at the University of Miami, Dr. Robert Marx, and
others across the country. At the time,
Broumand was in his advanced training
and fellowship in oral and maxillofacial
surgery. After completing his position as
associate professor of oral surgery at The
University of Miami School of Medicine,
Broumand relocated to Arizona. He
recently shared with me his experience

of being an expert witness in a landmark
trial involving bisphosphonates.
The patients hed seen had exposed
bone, pain and infection, but had no
exposure to radiation, a plausible cause of
osteoradionecrosis of the bone.
At the time, the necrosis was of
unknown origin. Was it due to an exposure
to chemotherapy in these cancer patients?
Not all the patients were undergoing chemotherapy. What was the common link?
Other clinicians began to refer similar
patients with osteonecrosis of the jaw to
Marx and Broumand in Miami. During
this time, they researched bisphosphonates heavily, and subsequently published
an article at about the same time as Dr.
Sal Ruggierro. Both articles established
links between bisphosphonate drugs and
osteonecrosis of the jaw, and were turning
points regarding bisphosphonates.
Patients who had taken IV bisphosphonates as part of their cancer treatments, and then later undergone dental
extractions, were more likely to have
necrosis of the jaw. This was due, in part,
to osteoclastic suppression.
After the publication of their article,
patients with ONJ flocked to be treated
by Broumand and Marx at University of
Miami. The two oral surgeons had no idea
that this would inevitably render them
authorities in dealing with osteonecrosis.
An eight-year trial
Because of his experience in dealing with ONJ, Broumand became an
expert witness for the plaintiffs during a
class-action lawsuit in which more than
600 patients sued Novartis Pharmaceuticals after suffering osteonecrosis from
taking bisphosphonates.
The trial took nearly eight years
(2008-2015). During this time, Broumand
stayed current with information regarding
bisphosphonates. As he was employed by
the University of Miami and continued to
see patients who were dealing with osteonecrosis, his practice was not adversely
affected by the long trial. Additionally,
he compiled more than 20 expert reports

from his studies on bisphosphonates that
were used in testifying during the trial
against the big pharmaceutical companies.
Novartiss earlier clinical trials had
revealed that bisphosphonates caused some
complications, but those results were never
released. Novartis hired paid consultants
for the trial, some of whom were oral surgeons (and Broumands friends/associates),
who suggested that the necrosis was due to
periodontal disease or smoking, and not
as a result of Zometa (IV bisphosphonate)
usage. On the record, he had to disagree
with them on their responses.
The trial was exciting but unnerving, Broumand said. The legal counsel
for the defense was pretty harsh when it
came to questioning the plaintiff expert
witnesses. During my depositions, which
had lasted as long as nine hours, I remember thinking to myself that the crossexamining attorney had to be as tired
as I was, but they kept going on and on
and on and they tried to get me and other
witnesses to break. Fortunately, at the end
of the case we prevailed and that meant
financial freedom and restitution for over
600 participants in the class-action lawsuit. For me it meant going back to being
a clinician, which is what I wanted in the
first place. I never thought Id find myself
testifying in such a large trial when they
first asked me to be an expert witness.
The defense recently settled with the
600 patients, as a result of the testimonies and expert witness reports shared by
Broumand and other experts in the field.
In practice
In the dental field, osteonecrosis of
the jaw can occur when a patient has
been treated using high levels of IV bisphosphonates prior to a dental surgery
involving bone. This happens in some 60
percent of the cases of osteonecrosis. The
mandible is twice as likely to be affected
by osteonecrosis as the maxilla. Current
recommendations for patients on oral
bisphosphonates are not as rigid as the
recommendations for those having been
29
special
feature
on intravenous bisphosphonates, and

generally treatment can proceed as long
as there is no active sign of osteonecrosis.
When a cancer patient must be treated
using bisphosphonates, dental clearance
should be done ahead of treatment, if possible. Any teeth with poor prognosis should
be removed, or treated with root canals.
If the patient has already begun
IV bisphosphonate therapy, surgeries
involving bone should be avoided. Root
canals, rather than extractions, should
be performed. Implants or any surgeries
involving the bone should be avoided.
Cleanings, RCTs and fillings are less risky
for these patients and should be done to
maintain the patients dental health.
A newer osteoclast inhibitor called
Xgeva was approved by the FDA in late
2010, which shut down the osteoclasts,
but by a different mechanism than the
bisphosphonates. The action to the bone
was reversible when the drug was discontinued, unlike the bisphosphonates, since
Xgeva did not bind to the bone. But this
drug could also create osteonecrosis of the
jaw due to disruption of the vascular supply to the jawbone; therefore it was found
to be the suppression of the osteoclasts
themselves that contributed to ONJ.2
For the general dentist, treatment recommendations for those who have taken
bisphosphonates differ regarding whether
the medication was orally or intravenously given.
Fig. 1
Most of these patients are cancer

patients. In general, no elective procedures
should be performed once a patient has
received a dose, unless medically necessary.
Before the initiation of IV

Bisphosphonate Therapy
Sloughing of lingual gingiva, Fosamax patient

Fig. 2
Osteonecrosis on denture patient taking Zometa
Less than 3 years of treatment,

most all dental procedures are safe,
including implants.
Less than 3 years of treatment, but
also took steroids or methotrexate,
consult with prescribing MD and
consider 3 month drug holiday before
surgery. (Implant placement would
increase risk of ONJ).
More than 3 years of treatment,
increased risk. Consult with prescribing MD and consider 3 month drug
holiday before surgery.
30
Remove unsalvageable teeth

Treat periodontitis and gingivitis
Treat caries
Defer the start of Bisphosphonates for
2 months
Recommendations during IV
Bisphosphonate Therapy
Fig. 3
Avoid invasive procedures

(extractions, periosurgery, implants)
Treat caries. If needed, RCT and
amputation of crown of tooth, to
avoid extraction
Supragingival scaling
Splint mobile teeth
If extractions are unavoidable, provide informed consent of increased
risk of ONJ
Drug holiday is not helpful
Recommendations for treatment of

ONJ with exposed bone
Osteonecrosis posterior maxilla, Fosamax patient

Fig. 4
Oral Bisphosphonates and Dentistry

Recommendations
IV Bisphosphonates and Dentistry

Recommendations
X-ray showing fracture of the mandible,

Zometa patient
Avoid debridements or elective

dentoalveolar surgery
Smooth sharp edges
Treat with Pen VK 500 mg QID for
3-4 weeks and Peridex TID for life
Use Levaquin, Zithromycin or
Doxycycline in patients allergic to
Penicillin
Add Flagyl 500 mg TID for 10 days
in refractory cases
If surgery is unavoidable, perform
alveolectomy or continuity resection
Fig. 5
References
1. Uncovering the cause of phossy jaw Circa 1858 to 1906: oral
and maxillofacial surgery closed case files-case closed. J Oral Maxillofac Surg. 2008 Nov;66(11):2356-63
2. http://myeloma.org/ArticlePage.action?articleId=3285
3. Bisphosphonates: Extractions, Implants, and Beyond. Fayette
Williams. Http://www.dentaltown.com/Dentaltown/OnlineCE.
aspx?action=DETAILS&cid=421
Non-healing extraction site, Fosamax patient
practice management
feature
Five
Components
to Team
Synergy
by Jen Butler, M.Ed.
Team drama is in the top five of all dentistry stressors. According to several studies, 56 percent of dentists
claim that team issues contribute most to their stress levels. That is a large number of dentists being
stressed out by the people they employ and depend on. So this is not a stressor to be avoided or put
on the back burner. But too often thats exactly what dentists do, and they start paying the mental,
emotional, and financial cost for it. Heres how to cope.
o have the kind of team youve

always wished you hadone that
doesnt complain, push buttons,
expect more while giving less,
and be a constant financial drain on the
businessrequires a committed effort to
build team synergy. Synergy is the creation of a whole that is greater than the
sum of its parts.
A dental team that works without
team synergy uses a huge amount of
effort to create very little in the way of
positive results. The only way to have
what you want from your team is to build
and maintain team synergy by using this
simple formula and its five components.
Component No. 1: Inspiration

Inspiration is the internal connection
a team member has to his job that propels
32
him to achieve, independently of his leaders and managers. When a team member
is inspired, she is eagerly engaged from
within her role, and exceeds expectations
with high morale. In addition, the team
member is also proactively looking for
ways to experience personal growth in
and outside of her designated position.
When you think of your team members,
how many can you say this describes?
Inspiration is created. It cannot be
bought, threatened, or dangled like a carrot.
Teams need to know they have a purpose
at work, and its not just to make profits.
Here are two ways to build inspiration.
INSIDE OUT
Since inspiration is an internal drive,
the only way to build it is from the inside
out. And the inside out of your business
Continued on p. 34
practice management
feature
is your VMPM, or vision, mission, purpose, mantra. Your VMPM is the inner
structure of your business that, when
leveraged, offers your team and patients a
deeper emotional connection to who you
are and what you do. In the absence of a
VMPM there are only bricks, mortar, task
lists, and moneynone of which inspire
people. If you want to create synergy with
your team, you must have an active and
manifested VMPM.
THREE RS, NOT TWO

Often, dental owners, managers, and
consultants talk about the importance of
having 2 Rs: roles and responsibilities.
dental teams get confused is in thinking

that the act of being transparent (around
patient education, costs, communication, etc.) is the same as building trust.
Researchers in behavioral and organizational psychology find this to be far from
the truth. There is a clear first step to
building trust, and that is with our common threads.
OUR COMMON THREADS

Research shows our level of trust
with someone is equal to the number of
threads we have in common. For example, when you meet a new patient you
both are going through a psychological
A dental team that works without team synergy

uses a huge amount of effort to create very little
in the way of positive results.
Whats missing is the third R: respect.

People are inspired when they know
that the role they play and the tasks they
complete make a difference in the lives of
people around them. You can convey this
by respecting their timelines, needs, value,
and place on the team. Its more than
recognition for a job well done and tasks
completed. Its truly respecting your team
member as a person and viewing him or
her as an equal partner within the business.
Component No. 2: Trust

Due to the dynamics, function, and
purpose of a dental team, trust is a key
component in creating team synergy.
The importance of trust is often talked
about within a dental office because of
the nature of the work performed. Where
34
and emotional process of categorizing

each other. Its the ultimate sizing up. As
you uncover more information about one
another, it either reinforces or inhibits the
trust sense. As the common threads pile up
(kids of similar age, you live in the same
neighborhood, attend the same organizations, have the same values, etc.), the trust
sense grows exponentially. To build trust
you have to spend time and conduct activities that encourage sharing. If you can
articulate the common threads you have
with each of your team members, youre on
your way to building team synergy.
Component No. 3: Communication

Effective communication plays a
significant role in building and maintaining team synergy because it serves as the
delivery tool for the other components. If
team members participate in high levels of
communicationsuch as understanding,
active listening, problem solving, conflict resolution, and asking empowering
questionssynergy rises and discord

falls. To increase effective communication
within the team, start by understanding
each team members communication style.
UNDERSTANDING COMMUNICATION STYLES

There are four communication
styles, each with its own characteristics,
advantages, disadvantages, and patterns.
When the team is educated and trained
on their own communication styles,
this knowledge expands their awareness
around their own communication needs.
When a member knows what she needs,
she can easily let others know what works
for her. Also, when the team understands
each communication style of each of their
members, they are able to increase their
versatility and modify the way in which
they approach a situation.
Component No. 4: Will

Will is the internal drive and energy
a person applies as he takes action. You
see a team members will by how quickly,
thoroughly, or efficiently he approaches
his work. Team synergy soars when two
parts of will are present.
EQUAL PARTS OF SELF-DETERMINATION

When each team member brings an
equal part of self-determination to the
practice, the heavy lifting of building,
running, and maintaining a successful
dental practice is shared. There is no single person doing more or covering up for
another. She can rely on her colleagues to
meet expectations while giving maximum
loyalty. He sees his job as an opportunity
for personal growth and not just a linear
checklist of responsibility.
LEVEL OF EFFORT
Ones will is expressed through his
level of effort. With three different levels
of effort, team synergy is only established when the highest level is achieved
unanimously. The lowest level of effort
is intended effort, one in which a person
tries or wishes an action to happen. A
practice management
feature
moderate level of effort is when one has

attempted effort. In this level, at least
some effort is extended, but little is given
to preparation and follow-through. Committed effort is the highest level, in which
team members are focused and give all
their energies to moving forward.
Component No. 5: Reason

Reason is the last component necessary to create team synergy. Skills,
knowledge, abilities, competencies, and
experiences are the elements that make up
a team members reason. For team synergy to develop, each member must have
similar levels of each element present so
professional services and patient care are
consistent within each department.
Next steps
Every office has the potential to build
team synergy. Follow these first few steps:
1. Ask each of your team members to

read this article. When they know
better, they do better.
2. Carve out time in your daily huddle
to focus on one of the components
every day. Even baby steps get you
there.
3. Identify a Team Synergy Captain
who will spearhead activities,
meetings, discussions, and events
that nurture everyones connection.
Or, instead of one person being the
captain, have each team member

choose a component to help develop
throughout the team.
Team synergy must be attended to,
nurtured, and cultivated on a daily basis.
It requires time, energy, patience, intention and focus from each member of the
team. But you will find that the payoff is
worth itand you can avoid being one of
the 56 percent.
How do you create a drama-free office environment?

Comment on this article at Dentaltown.com/magazine.aspx.
Author Bio
Jen Butler has been working in the area of stress management and resiliency coaching
for more than 25 years. She is founder of Jen Butler Inc., a SMART (Stress Management
and Resiliency Training) firm offering comprehensive programs to help doctors and
teams stress less. To reach Jen, email her at Jen@JenButlerInc.com or (623) 776-6715.
35
practice solutions
Practice Solutions explores how specific products and services can be of use clinically or in practice management.
Orthodontic Roadblocks:
How to Get Patients to Say
Yes to Treatment
by Peter Gardell, DDS

Dr. Peter Gardell graduated from
New York University College of
Dentistry with honors. He has
received numerous awards
for clinical excellence and has
attained faculty and clinical
mentor positions at some of the
most prestigious educational
institutions in the United States.
He has written articles and
lectured extensively on many of
the technologies he has implemented in his office. Dr. Gardell
is a member of the American
Academy of Cosmetic Dentistry.
36
Often when patients are approached with

options for orthodontic treatment, they seem
to hit a roadblock that prevents them from
accepting treatment.
These roadblocks can include:
Fear of pain
Fear of commitment/length of treatment
Fear of unsightly wires and brackets
Fear of another relapse (for patients who
have previously had braces)
Dislike of gagging and goopy impression
materials
Clear-aligner therapy removed manybut
not allof these roadblocks until now.
Modern advances have eliminated the
need to take physical impressions with goopy
impression material in order to correct malocclusions present in a patients dentition. For
instance, intraoral scans are now an accepted

part of the workflow for ClearCorrect, and the
company accepts scans from pretty much every
scanner on the market. If you have a CEREC
scanner, you can now send scans in place of traditional PVS impressions. This feature removes
the last roadblock to treatment for our patients
who have gag-reflex issues or who fear having
PVS material in their mouths.
In fact, digital impressions are so accurate that doctors can now do quality control
in-office, removing the potential for rejected
impressions and the dreaded message, Details
lacking in X area; please re-impress patient to
facilitate accurate production of trays.
When traditional impressions are rejected
due to poor quality or lack of detail, both
time and money are wasted. Patients are
inconvenienced and can easily become aggravated with

the situation. And we all know how quickly the cost of
PVS material can add up. Going digital will eliminate
rejected impressions from your practices workflow.
And going digital is easy. Converting to a digital
workflow will not require you to re-engineer your
records appointments. The same series of photographs and radiographs (radiographs optional) will
need to be taken: full upper and lower arch, lateral
buccal views with teeth occluding, straight on with
teeth occluding, full face (smiling and not smiling),
and a full face profile shot of your patient preop.
These pictures, in addition to the intraoral scan,
allow treatment planning to be done with the accuracy required for safe tooth movement. The only
difference with the digital workflow is that physical
impressions are no longer needed.
In fact, digital impressions are

so accurate that doctors can
now do quality control in-
practice solutions
number is assigned. This number is used to identify

the case from start to finish. The program will amass
all the information submitted (including the scans)
and will send a confirmation of receipt.
Youll then receive a proposed treatment plan
(called a treatment setup), often within 24 hours.
With traditional PVS impressions, this can take up
to a week or longer, depending on shipping and the
quality of your impressions.
We all know that with clear-aligner therapy the
patient can be the weakest link to his or her own
success. Compliance is key. However, most people
who come in for therapy have already thought long
and hard about the pros and cons of straightening
their teeth, and theyre financially committed to
the process. As a result, theyre usually engaged and
determined to make it work.
These are some of the same individuals who
previously hit roadblocks that prevented them from
moving forward with correcting their malocclusion.
Fortunately, modern advances help patients feel comfortable accepting treatment and moving forward to a
nicer smile.
office, removing the potential

for rejected impressions and
the dreaded message, Details
lacking in X area; please reimpress patient to facilitate
accurate production of trays.
As a CEREC dentist, I have quickly come to
realize the substantial cost savings of digital impressions over traditional impressions for use with
crowns, bridges, implants, etc. This is no different
with orthodontics. There are no shipping costs, no
impression trays are required, and theres no need
for costly PVS impression material. Every dollar
saved adds up quickly.
Scanning with the new CEREC Ortho software is
easy, and the workflow is guided. The software takes
you through the steps to capturing a beautiful digital
scan. Once the scan is completed, you access a doctors
portal in order to submit the corresponding case.
Basic patient information is entered, a checklist
is filled out on the desired treatment, and there is
even a section where radiographs and photos can be
easily uploaded. Once your case is submitted, a case
37
endodontics
feature
INMicrophotography
FOCUSusing the
dental operative microscope

by Jorge Zapata, DDS
Fig. 1
38
Microphotography, as
it relates to dentistry,
is the art of capturing
pictures through the dental
operative microscope
(DOM). One of the main
differences between
microphotography and
macrophotography is
that no lens is attached
to the camera in
microphotography. This
creates unique challenges
for the clinician in capturing
quality images.
endodontics
feature
These challenges include: controlling

the vibration of both the microscope and
the camera, working in conjunction with
live view monitors, and understanding
the par-focal adjustment of the microscope to assure clear focus of both the
camera and microscope.
Avoiding vibration
In microphotography, many different
sources of vibration can affect the sharpness of pictures, and each must be isolated and eliminated in order to capture
the highest-quality images.
In Fig. 1, (pg. 38) dots and thin,
short, horizontal lines can be noted.
These distortions create the sensation that
the picture is moving sideways. This perceived motion is the result of one or more
of the following factors:
Vibration in the body of the
microscope
Tremor of the clinicians hand while
holding the dental mirror
Shaking of the patients jaw
Vibration related to the movement
of the internal mirror of the camera
(SLRs) at moment of shutter release.
Some of the vibration can be
improved and controlled by the clinician.
However, some vibration will continue to
exist, despite the clinicians best efforts to
overcome it.
Vibration of the scopes body is nearly
impossible to eliminate. Other vibration
can be improved with the use of surgical
armrests, a mouth prop, a remote control
and a fast shutter speed of at least 1/125
and above.
Out of focus
The desire of every photographer is
that each picture captured will be clear,
and every detail in the given subject accurately reproduced; any tiny movement can
affect the final result of the image. The
photographer can correct for vibration,
but the camera may still capture images

that are not sharp because of focus issues.
So how can the photographer take
pictures that are sharp and full of the
desired detail? What specific techniques
do professional photographers use to capture acute images? Sometimes the photographer will find that when the focus is
set on the foreground of the subject, the
background goes out of focus, and vice
versa. The answer to this dilemma is to
use the depth of field (DOF) correctly.
Photographer Bryan Peterson defines this
in his book, Understanding Exposure, as
the area of sharpness (from near to far)
within a photograph.
The real key

to successful
microphotography
is to nd the precise
balance between
the camera and the
microscope.
It is important to understand DOF
in microphotography in order to control
image sharpness. In microphotography,
the DOF is very shallow, so missing the
focus point by even a millimeter causes
the pictures to be out of focus. The DOF
is impacted by the level of magnification. For example, lower magnification
produces more DOF, as demonstrated in
Fig. 2. Whereas Fig. 3 shows that higher
magnification has a narrower DOF.
Fig. 2
This picture was captured at 8x magnification and

therefore has greater DOF.
Fig. 3
When the magnification increases, the

DOF narrows.
Selecting the focus point

Because the DOF is so restricted
when shooting under the microscope, the
focus point has to be the sharpest spot in
your picture. Before capturing an image,
it is necessary to think like a photographer and ask yourself some questions:
1. Why do I want to capture this
picture?
2. What is the point of interest in this
image?
3. What do I want the viewers to see in
the image?
4. How is this image going to be
different from others?
5. Where do I want to focus?
This is my formula: Find the things
in the image that stand out as being most
important, and place the focus point
Continued on p. 41
39
3M and ESPE are trademarks of 3M or 3M Deutschland GmbH.

Used under license in Canada. 3M 2015. All rights reserved.
Lets make
happiness a
clinical outcome.
For patients, happiness means a beautiful smile that looks natural and
creates confidence. For you, it means a practice that runs smoothly and
efficiently and allows you to create restorations that are fast and easy.
Dentists tell us more than 50 percent of restorative procedures involve
direct restorations, so getting them right is critical.
At 3M, we create products and programs that help you simplify
outcomes and achieve happiness. For you and your patients.
Learn more at 3MESPE.com/directprocedure
endodontics
feature
there. For example, in Fig. 5, I wanted

to capture the gutta percha in the mesial
buccal canals. Therefore, I selected my
focus point as the tiny white spot in the
DB canal. The important parts of the
picture were in focus.
Fig. 5
Working with live view

Live-view mode is a useful tool in
successful microphotography. One of the
significant advantages to using live view
in DSLR cameras is that the cameras
internal mirror will be flipped up, allowing you to display on your LCD or monitors exactly what your camera is seeing.
Because the mirror is raised up when
working in live view, the camera does not
cause vibration of the scope, so the microscopes bounce is decreased and sharper
images are obtained. Mirrorless and
translucent cameras always display live
view. Live-view display gives significant
help in achieving sharply focused pictures, and the assistant can confirm that
the image is centered and focused prior to
capturing the final image.
Live view also allows the photographer
to easily readjust the settings because he or
she can quickly check focus, framing, etc.
The focus point is placed on the tiny bubbles

between teeth #8 and #9 at 8x magnification.
Its the one that

can do it all.
Procedures are more efficient when
you have go-to products you know
will produce the same excellent
results from one case to the next.
The natural beauty and proven
strength of Filtek Supreme Ultra
Universal Restorative make it trusted
and versatile.
Any placeanterior or posterior
Any classClass I, Class II,
Class III, Class IV, Class V
Fig. 6
Fig. 7
Any place.
Any Class.
Because the mirror

is raised up when
working in live view,
the camera does
not cause vibration
of the scope, so the
microscopes bounce
is decreased and
sharper images
are obtained.
No wonder its the

#1 nanocomposite.
Learn more at:
3m.com/FiltekSupremeUltra
Filtek Supreme Ultra

Ultra Universal
Restorative
3M, ESPE and Filtek are trademarks of 3M or

3M Deutschland GmbH. Used under license in Canada.
3M 2015. All rights reserved.
41
endodontics
feature
Fig. 8
For example, in Fig. 6 on p. 41, the

image is out of focus, the framing is off,
the picture is overexposed, the ISO, white
balance and the shutter speed are not
ideal. After readjusting the settings in live
view, the final result was greatly improved
(see Fig. 7 on p. 41).
Perfecting focus
Fig. 9
Fig. 10
The real key to successful microphotography is to find the precise

balance between the camera and the
microscope. In other words, the subject
that is observed through the eyepieces of
the DOM must be perfectly duplicated
by the camera, without any distortion.
Par-focal adjustment is crucial to success
in microphotography.
This desired outcome is accomplished
through correct par-focal adjustment of
the microscope. Par-focal adjustments
assure that the image is in focus under
the DOM and camera simultaneously,
and when magnification is changed from
higher to lower (or vice versa), the object
stays in focus.
However, if we follow the typical
guidelines to make the par-focal adjustments, the image as seen through the
microscope will be clear, but will reproduce as blurry in photographs. This
unwanted result occurs because the manufacturers par-focal procedures indicate
the use of a two-dimensional, flat target
as point of reference.
Translation of these adjustment
settings to the mouth of the patient
results in pictures that are out of focus
because the open mouth of the patient

is triangular in shape, as demonstrated
in Fig. 8, but par-focal adjustments were
made using the flat target. Therefore, it
is necessary to set the camera and DOM
using a three-dimensional target, which
recreates the position of the open mouth.
Successful setting of the DOM and camera can be accomplished by constructing
a three-dimensional focusing target that
mirrors the angles and dimensions of a
mouth-propped patient.
Finally, set the camera to center
metering mode (CMM), put the focus
point on a small dot on your custom PF
target and, working with monitors, center
the image in the middle of the screen.
Next, follow the traditional steps as outlined by your microscope company for
par-focal adjustment. Fig. 9 is an example
of a photograph where par-focal adjustment has been done incorrectly.
Fig. 10 is a picture taken with correct
par-focal adjustment.
Conclusion
Microphotography is an art, and
in order to capture the highest-quality
pictures it is necessary to understand the
obstacles that will be encountered and
how to overcome them. The photographer must achieve the perfect balance
between the microscope and camera in
order to get the desired results.
References
Peterson, Bryan (2010). Understanding Exposure. (3rd Edition, p.
42). New York: Crown Publishing Company
Do you have questions for the author? Ask them online at Dentaltown.com/magazine.aspx.
Author Bio
Dr. Jorge Zapata is a dentist in Ogden, Utah, who has been practicing microscope dentistry in his private dental practice since 2005. Dr. Zapata is treasurer of
the Academy of Microscope Enhanced Dentistry (AMED). He has been a member of the board of directors for AMED since 2011, and in 2014 he was a recipient
of AMEDs Outstanding Service Award. Zapata was a guest lecturer at Roseman Dental School in Salt Lake City in 2015 and was a guest speaker at the European Society of Microscope Dentistry in Berlin. He can be contacted at zapata_dental@yahoo.com.
42
general practice
feature
Safety
A.N.E.S.T.H.E.S.I.A
ocal anesthetics were first introduced in the 1880s by

William Halsted, MD, when he found injectable cocaine
to be useful for surgeries. Local anesthetics are now used
for dental treatment on a daily basis. Previously, patients
were given ester medications (remember Novocaine?). In todays
dental offices, amides such as lidocaine, mepivacaine, bupivacaine, articaine or prilocaine are likely used.
Adverse effects from dental injections can range from mild,
such as prolonged anesthesia, hematoma or soreness in the injection site, to moderate/severe effects such as an allergic response
(rare with amides) or overdosage, which could lead to respiratory
arrest and death.
With proper precautions, it is difficult to overdose an adult
patient. The toxic level of anesthetic is figured by a patients
weight. The smaller the patient, the less anesthetic is needed to
reach toxic levels. (See tables on page 48.)
To calculate the maximum amount of lidocaine 2 percent
with 1:100,000 epinephrine and the number of carpules that can
be safely administered to a 30-pound patient, the clinician would
perform the following calculations.
by Elizabeth J. Fleming, DDS
(MRD) Maximum
Recommended Dose (mg/lb.)*
x weight (lbs.) =
Maximum Total Dosage (mg)
3.2mg/lb x 30 lbs. =
96 mgs
Maximum Total Dosage (mg)

mg/cartridge* =
Maximum number of cartridges
96mg 36mg/cartridge =
2.67 cartridges
*See tables on page 48 for (MRD) maximum recommended dose/lb

(or kg) and mg/cartridge for anesthetic used.
The type of dental procedure may dictate the duration of
local anesthetic needed. Vasoconstrictors such as epinephrine are
added to anesthetics to increase duration by concentrating the
solution in the injection site.
Healthy patients undergoing dental treatment are less apt to
suffer from complications from the anesthetic. Contraindications
to the use of vasoconstrictors or dental anesthetics include:
Recent heart attack (<1 month) Uncontrolled hypertension
Uncontrolled diabetes mellitus
Uncontrolled hyperthyroidism
Documented allergy
Recent drug abuse
43
As with all local anesthetics, the dose varies, depending on the area to be anesthetized,
the vascularity of the tissues, individual tolerance, and the technique of anesthesia. The
lowest dose needed to provide effective anesthesia should be administered.
general practice
2
Doses indicated are the maximum suggested for normal healthy individuals (ASA 1);
feature
they should be decreased for debilitated or elderly patients.
3
Rounded to the nearest half-cartridge.
1
Before administering local anesthetics, it is recommended to

get a thorough medical history, including blood pressure readings. Frequently this screening will uncover high blood pressure
that will need to be monitored and treated by the patients physician. We will refer our patients to their PCP if their BP readings
are too high.
TABLE 1
Guidelines for Blood Pressure (Adult)

Blood Pressure,
mm Hg, or torr
ASA
Classification
Dental Therapy Consideration
<140 and <90
1. Routine dental management

2. Recheck in 6 mo, unless specific treatment dictates more frequent monitoring.
140-159 and/or 90-94
1. Recheck BP before dental treatment for three consecutive appointments; if all exceed
these guidelines, medical consultation is indicated.
2. Routine dental management
3. SRP as indicated
160-199 and/or 95-114
1. Recheck BP in 5 min.
2. If BP is still elevated, medical consultation before dental therapy is warranted.
3. Routine dental therapy
4. SRP
200+ and/or 115+
1. Recheck BP in 5 min.
2. Immediate medical consultation if still elevated.
3. No dental therapy, routine or emergency,1 until elevated BP is corrected
4. Refer to hospital if immediate dental therapy is indicated.
ASA, American Society of Anesthesiologists; BP, blood pressure; SRP, stress reduction protocol.
1
When the BP of the patient is slightly above the cutoff for category 4 and anxiety is present, inhalation sedation may be employed in an effort to diminish the BP (via the elimination
of stress).
Information source: American Dental Hygienists Association
44
Dentists regularly use local anesthetics, and most states also

allow hygienists to administer local anesthetics for their patients
prior to scaling and root planing visits. As of 2012, all states except
Texas, Alabama, North Carolina, Mississippi, Delaware and
Georgia have licensed hygienists to administer local anesthetics.
Continued on p. 46
Glowing Results
DENTAL
(articaine HCI and epinephrine) Injection
For more information, call 1.800.989.8826

or visit www.dentsply.com.
Your trusted partner in dental anesthetics
2015 DENTSPLY International

Articadent is a registered trademark of DENTSPLY International and/or its subsidiaries.
ART01-0115-1.0Rev.00
general practice
feature
A variety of injections are used for anesthetizing a patient for
dental treatment. The areas anesthetized for the most common
dental injections are shown:
Maxillary Arch
Posterior Superior Alveolar Block (PSA)
Greater Palatine Block
Middle Superior Alveolar Block (MSA)
Nasopalatine Block
Anterior Superior Alveolar Block (ASA)
46
Recent improvements in the administration of local anesthetics include buffering of the anesthetic solution with sodium
bicarbonate, which raises the pH, allowing a more comfortable injection and hastening the onset of profound anesthesia.
Because the buffered solution becomes unstable quickly, it
must be mixed minutes before administering the anesthetic to
the patient. The effectiveness of the buffered anesthetic allows
a decrease in the amount of carpules used, due to fewer missed
blocks (Onpharma, Anutra Medical).
An injectable solution of phentolamine mesylate can be given
to reverse the effects of local anesthesia (OraVerse). It is not recommended for children under the age of 6, or who weigh less
than 33 pounds. It may be most helpful in older children, geriatric patients and special-needs patients.
general practice
Mandibular Arch
feature
Inferior
Alveolar Block
Incisive Block,
also called Mental
Buccal
Block
Gow-Gates
Mandibular Nerve Block
47
general practice
feature
TABLE 2.2
TABLE 2.1
Lidocaine
2% With Epinephrine 1: 100,000
For the needle-phobes, intranasal local anesthetic
1, 2, 3
is
Concentration:
36 mg It
being tested
and may2%
be releasedCartridge
soon (St Contains:
Renatus, LLC).
7.0 mg/kg
MRD: 3.2
mg/lb
providesMRD:
anesthesia
bilaterally in the maxilla
from
first molar
toWeight,
first molar, with 100 percent success
occurring
from
bicusWeight,
3
3
pid kg
to bicuspid
On maxillary
molarsCartridges
there were
lb first mg
mg #4-#13.
Cartridges
mixed
10 results,
70so injections
2.0 on these20teeth may
72 be needed
2.0 for
profound anesthesia when using this technique.
20
140
4.0
40
144
4.0
Delivery systems such as The Wand or STA are computer30
210
6.0
60 systems
216 (C-CLAD),
6.0
controlled
local anesthetic
delivery
which
more predictable
single-80tooth anesthesia.
In tests
40 allow280
7.5
288
8.0
on children there was a measurable decrease in reactions to
50
350
9.5
100
360
10.0
C-CLAD anesthesia administration compared to the stand4
60
420
120 dentistry.
432
11.04
ard syringe,
making it 11.0
useful in pediatric
4
Whether490
you are a11.0
recent
graduate
experienced
70
140 or an500
11.04dentist, 80
periodically
500 reviewing
11.04 the dosages,
160 contraindications
500
11.04 and
new developments in local anesthetics will be helpful to you
90
500
11.04
180
500
11.04
and your patients. For more information, consult the Hand4 th
100of Local
500Anesthesia
11.0(6
200Dr. Stanley
500 Malamed.
11.04
book
Ed.) by
MRD, Maximum recommended dose.
References
1
As withSF.
all local
anesthetics,
dose varies,
onMissouri:
the areaElsevier
to be anesthetized,
Malamed,
Handbook
of Localthe
Anesthesia,
6th depending
Ed. St. Louis,
Mosby; 2013.
2
Doses indicated are
the maximum suggested for
normal healthy
Maximum
recommended
number
ofindividuals (ASA 1);
cartridges
for
commonly
used
anesthetics
3
4
200 g of epinephrine is the dose-limiting factor (1:100,000 contains 18 g/cartridge).
Mepivacaine 3% Without Vasoconstrictor 1, 2

Concentration: 3%
MRD: 6.6 mg/kg
Cartridge Contains: 54 mg
MRD: 3.0 mg/lb
Weight,
kg
mg
Cartridges3
Weight,
lb
mg
Cartridges3
10
66
1.0
20
60
1.0
20
132
2.5
40
120
2.0
30
198
3.5
60
180
3.0
40
264
4.5
80
240
4.5
50
330
6.0
100
300
5.5
60
396
7.0
120
360
6.5
70
400
7.5
140
400
7.5
80
400
7.5
160
400
7.5
90
400
7.5
180
400
7.5
100
400
7.5
200
400
7.5

1
2
3
Rounded down to the nearest half-cartridge.
TABLE 2.1
TABLE 2.3
2.2
Lidocaine 2% With Epinephrine 1: 100,000 1, 2, 3
Articaine
4% 3%
WithWithout
Epinephrine
1 : 100,0001, 2
Mepivacaine
Vasoconstrictor
1, 2
or 1 : 200,000
Concentration: 2%
MRD: 7.0 mg/kg
MRD: 3.2 mg/lb
Weight,
kg
mg
Cartridges3
Weight,
lb
mg
Cartridges3
10
70
2.0
20
72
2.0
20
140
4.0
40
144
4.0
30
210
6.0
60
216
6.0
40
280
7.5
80
288
8.0
50
350
9.5
100
360
10.0
60
420
11.04
120
432
11.04
70
490
11.04
140
500
11.04
80
500
11.04
160
500
11.04
90
500
11.04
180
500
11.04
100
500
11.04
200
500
11.04

1
2
3
4
200 g of epinephrine is the dose-limiting factor (1:100,000 contains 18 g/cartridge).
48
Concentration: 3%
Concentration:
4%
MRD: 6.6 mg/kg
MRD: 7.0 mg/kg
Weight,
Weight,
kg
mg Cartridges3
3
kg
mg
Cartridges
10
66
1.0
10
20
20
30
30
40
40
50
50
60
60
70
70
80
80
90
90
100
100
70
132
140
198
210
264
280
330
350
396
420
400
490
400
560
400
630
400
700
1.0
2.5
2.0
3.5
3.0
4.5
4.0
6.0
5.0
7.0
6.0
7.5
7.0
7.5
8.0
7.5
9.0
7.5
10.0
Cartridge
MRD:Contains:
3.0 mg/lb72 mg
MRD: 3.6 mg/lb
Weight,
Weight,
lb
mg Cartridges3
3
lb
mg
Cartridges
20
60
1.0
20
40
40
60
60
80
80
100
100
120
120
140
140
160
160
180
180
200
200
72
120
144
180
216
240
288
300
360
360
432
400
504
400
576
400
648
400
720
1.0
2.0
2.0
3.0
3.0
4.5
4.0
5.5
5.0
6.5
6.0
7.5
7.0
7.5
8.0
7.5
9.0
7.5
10.0

1
As with
all local recommended
anesthetics, thedose.
dose varies, depending on the area to be anesthetized,
MRD,
Maximum
1 the vascularity of the tissues, individual tolerance, and the technique of anesthesia. The
lowest
dose needed
provideindividual
effectivetolerance,
anesthesiaand
should
be administered.
the
vascularity
of thetotissues,
the technique
of anesthesia. The
2
Doses dose
indicated
aretothe
maximum
suggested
for normal
healthy
individuals (ASA 1);
lowest
needed
provide
effective
anesthesia
should be
administered.
2 they should be decreased for debilitated or elderly patients.
3
Rounded
down
to the nearest
half-cartridge.
they
should
be decreased
for debilitated
or elderly patients.
3
office visit
feature
The Practice that

Perseverance Built
Michigan Endodontist Pairs Clinical Excellence with Compassionate Care

by Arselia Gales, Assistant Editor, Dentaltown Magazine
As a dentist, you spend most of your time at your

practice. Its understandable that you might not get
many opportunities to see what its like in another
doctors office. Thats why we bring you an office
visit six times a year. Its a chance for you to meet
with your peers, see their practices and hear their
stories. This month we caught up with Dr. Michael
Zuroff, an endodontist in the Detroit metropolitan
area whose practice has years of family history.
Theres no mistaking that dentistry runs in his veins.
Heres his story.
OFFICE HIGHLIGHTS
Name: Michael Zuroff, DDS, diplomate, American
Association of Endodontists
Practice Name: : Endodontics, P.C.
Graduated From: University of Detroit,
New York University
Practice Location: Dearborn, Canton, Monroe and
Wyandotte, Michigan
Practice Size: 7 doctors
Staff: 37 staff members
Web site: www.endodonticspc.com
50
What was the path you took to becoming a dentist? What drove
you into dentistry?
Dr. Zuroff: I was fortunate to grow up around dentistry. My
father was an endodontist and started Endodontics P.C. in 1973.
The practice grew over the years, and partnerships evolved that
endured for more than 35 years. As a child I spent time around
the office and benefited from the positive influence of my father
and his partners. My father loved the practice of dentistry. He
enjoyed all aspects of it, from the patient and staff interaction
to the clinical endodontics. That positive energy was contagious
and led me to the obvious choice of dentistry as a profession.
Regarding your practice, how is it laid out? Whats the
workflow like?
Dr. Zuroff: Our practice has four locations, which are
served by seven endodontists. The support staff is composed of
37 dedicated people. Many staff members have been with our
practice for more than 25 years. Since we are an endodontic
office visit
feature
practice, there are emergency patients every day. Our

typical schedule involves both non-surgical and surgical endodontics. We also perform all phases of implant
surgery and offer IV sedation for all of our procedures.
While its true that we have a busy practice, there is an
emphasis on delivering an exceptional experience for
every patient.
I treat patients the way

I want to be treated:
quality care in a safe and
comfortable environment.
What is your practice philosophy?

Dr. Zuroff: We believe that providing clinical excellence through the use of highly technical equipment and
compassionate care will always put the patient first.
What do you do to help set the practice apart
from others?
Dr. Zuroff: Many endodontists limit their practice
to endodontic procedures. Like most, we are a microscope-based practice. Offering implant surgery and
IV sedation sets us apart. I believe that these aspects
of dentistry have made me a better endodontist. I can
approach diagnosis and treatment planning without a
bias for endodontics vs. implants. Its been amazing to
see this part of the practice grow. I now see referral slips
that ask me to determine if the patient is best served
with endodontics or implants.
It is very rewarding to be involved in the overall
treatment plan. Many patients are fearful of the dentist,
and specifically the prospect of endodontic therapy or
implant surgery. Offering IV sedation has benefited so
many patients. It is extremely rewarding to be able to
help our patients make it through a daunting experience
and to be a part in improving their health. I believe that
quality care is imperative, but that is only a portion of
creating an exceptional patient experience. Empathy
and compassion go a long way.
Tell me about your partners.
Dr. Zuroff: I am fortunate to have six wonderful
partners: Dr. Ronald Michaelson, Dr. Ronald Shoha,
Dr. Daron Yarjanian, Dr. Jeremy Michaelson, Dr.
Gianni Decarolis and Dr. Daniel Gilliland. The best
TOP PRODUCTS
Endo Files: ProTaper NEXT, Vortex Blue .04 Taper, both by DENTSPLY
Tulsa Dental Specialties. I use multiple systems depending on the
case. I especially like DENTSPLY. I am also impressed with the potential of their TruShape file.
Qmix 2in1 Irrigating Solution by DENTSPLY Tulsa. For smear layer

removal and added antibacterial effects.
Implants: ANKYLOS by DENTSPLY. Ive been using them since 2006

and Im continually impressed with the lack of crestal bone loss.
Patient Financing. We use CareCredit.
Global Dental Microscopes. This is a staple in our practice. We have

one in every room.
51
office visit
feature
compliment that I can give is that I would feel comfortable with any of them caring for my family or myself. We
have been practicing together for so long, we consider each
other family.
What are your favorite marketing techniques? How do
you get the word out about your practice?
Dr. Zuroff: We have a staff member dedicated to
practice relations. The best marketing is a positive patient
experience. Often patients return to the restorative dentist
and thank him or her for referring to our practice. We
have seminars with continuing education credit for our
referring doctors. Monthly raffles and office visits help our
practice stay relevant.
What do you think is the biggest problem dentists
face today?
Dr. Zuroff: I have had the opportunity to teach in the
local dental school and to interview many young dentists.
The cost of dental school is astronomical. This has created a burden for the new dentist. The need to produce in
order to cover overhead is stressful and, I believe, has had
a negative effect on the field.
What are your patient and technique philosophies?
Dr. Zuroff: I treat patients the way I want to be treated:
quality care in a safe and comfortable environment.
In terms of nonsurgical endodontics, I prefer to complete my cases in a single visit. Cases that are too infected
or involve complex treatment are an exception. I am a
proponent of conservative shapes and dentin preservation.
I lean toward retreatment before surgical endodontics, but
will certainly do a surgical procedure if retreatment is not
feasible. Immediate implants are a wonderful service in
the correct case.
Continued on p. 54
52
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office visit
feature
Since many of the cases I treat are infected and
involve bone loss, most cases involve a graft. I do
not believe in sacrificing the long-term success for
a short-term gain. In terms of sedation, I prefer to
include the patient in deciding the correct approach
and depth of sedation. In some cases that may be oral
sedation with nitrous oxide, while others may involve
deep IV sedation.
What is the greatest advancement of change you
have seen during your tenure as a dentist?
Dr. Zuroff: The ability to clean and shape canals
has improved dramatically. The introduction of the
micro-CT has allowed us to appreciate the complexity
of root-canal anatomy. Advancements in metallurgy
and file design, and improved irrigants have made a
major impact in the way we deliver our care.
Regenerative therapy is also an exciting advancement in the endodontic field. I believe the surface has
just been scratched in the regeneration arena. Perhaps
it wont be long until dental implants will be replaced
by the regeneration of teeth. Amazing!
Looking ahead, how would you like to see dentistry
operate as a profession in the next five to 10 years?
Dr. Zuroff: Our profession needs to educate the
public on the relationship of oral health to systemic
disease. While this relationship has been clearly
54
established, there is still research to be done. We

have the opportunity to be involved in the overall
well-being of our patients. We also need to educate
ourselves. Since we are a procedure-driven profession,
it will require a shift in our approach to patient care.
What is your favorite procedure?
Dr. Zuroff: I dont have a favorite procedure. All
of the procedures can be rewarding and all of them
can be extremely challenging. There are multiple
contributing factors on any given day. I am certain
that any experienced practitioner can relate. When it
goes well, they are all my favorite!
Describe the most successful or rewarding
experience in your professional life.
Dr. Zuroff: I have been fortunate to be able to
provide a large amount of free care for patients who
are financially challenged. In 2009, I started a free
dental clinic for qualified patients. We have close to
70 volunteer dentists, hygienists and staff members
who dedicate themselves to this project.
Becoming a diplomate of the American Board
of Endodontics has been rewarding. Having reached
the pinnacle of the profession is a testament to years
of hard work and study. It is also a humbling experience because it is a reminder that we are never done
growing and learning.
Where ANKYLOS
goes, hard and
soft tissue follow.
The ANKYLOS TissueCare Concept
The micro-rough implant shoulder and steep tapered

connection allow for subcrestal placement, while the
horizontal offset and concave abutment design
allow space for a chamber of soft tissue and

bone to form, supporting long-term stability.
Tissue response is especially important in the
anterior esthetic zone. Gain in interdental papilla
height that can be achieved with the use of the
ANKYLOS implant system, contributes to naturallooking outcomes and long-term esthetic results.
SoftTissue Chamber
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hard and soft tissue long term, the ANKYLOS
TissueCare Concept is the combination of unique
features of the ANKYLOS implant system.
practice management
message board
What Kind of Payment Plans to Offer?

Townies discuss what kinds of payment plan options they have in place for their patients.
Dentaltown.com > Message Boards > Finance > Patient Finance Plans > What Kind of Payment Plans to Offer?
tootdoc
Post: 1 of 35
What works best in terms of in-office payment plans? Three months, four months, etc.? Any
experience, good or bad with this idea?
MAR 31 2013
Brad Blair
Post: 2 of 35
We only offer these types of plans for long-term patients with great histories who we know
very well and like a lot. We might consider four payments only like this. Payment at time of
scheduling, another day of prep, next one at cementation. Special folks get to make the fourth.
But most are done after one or two payments, or CareCredit. I encourage you to look into
CareCredit or similar.
MAR 31 2013
tootdoc
Post: 3 of 35
mauty
Post: 5 of 35
So, is it uncommon to just outright finance in-office payments for new patients? Is it risky?
APR 6 2013
Heres my payment plan: patient pays 100 percent and I do treatment. Simple. If they cant
do this, I have plenty of other patients. Occasionally with long-time patients Ill let them break
up payments.
APR 6 2013
ponderosa
Post: 6 of 35
If the bank wont give people credit, why will you? New patients never get payment plans.
You will be burned badly. Those who do get plans are long timers I can trust, and even then, its
50 down to start and 25 percent at cement and 25 percent a month later. And that is very rare.
Dont do it.
APR 6 2013
lorinberland
Post: 7 of 35
I agree with all of you, but like Alex and Brad, I offer Care Credit and surprisingly, a lot of
wealthy people go with CareCredit because, for whatever reasons, they like the terms.
APR 6 2013
NY sent
Post: 16 of 35
You can also auto-debit checking accounts, not just credit cards. Yes, there are risks of
non-sufficient funds in the account.
APR 7 2013
Sandy Pardue
Post: 10 of 35
I know a lot of very productive practices with payment plans, doing a couple million a year
solo collecting over 100 percent consistently. Just like anything else, to win you have to have a
game plan and your staff have to know the rules and be able to apply it consistently.
Going into payment plans without a real system would be practice suicide! Without a doubt.
It just gives you flexibility with patients who are ethical, good paying patients. You
have to be able to tell the difference between good paying patients, credit criminals and
premeditated fraud.
APR 7 2013
Continued on p. 58
56
practice management
message board
Toddy
Post: 15 of 35
I have had a positive experience with payment plans. Defi nitely some work required with
it but it has defi nitely played a part in our growth and patients appreciate it in my opinion.
Our collections have been around 96 percent for the last two years. Not great but not bad
either to me.
My view on it was if I had open chair time it was worth the chance if sound financial
arrangements were made. I still believe that to be true after offering payment plan options for
more than three years in my startup. If I were 40 years old with an established practice Im sure
I could handle things differently.
APR 7 2013
Sandy Pardue
Post: 17 of 35
Make sure you are PCI compliant and you have those credit cards numbers in a place that
is password protected.
APR 7 2013
NY sent
Post: 18 of 35
Yes, I have been trying to do this. I followed the steps on the website my CC processor sent
me and the result was that I wasnt. I havent had a chance to dissect why and how to fi x it. The
numbers are stored in my practice management software, but you cant see the numbers. The
software blocks them once you set up the account. The numbers might be accessible from my
CC processors website but you need a login and password for that too.
It is overwhelming that these things I had no idea about keep on popping up while just
trying to do some dentistry.
APR 7 2013
imaginarydave
Post: 19 of 35

Simple Pay Patient Financing?
Pay Patient
Patient Refuses to Consider

Outside Financing
Outside Financing
We set up an account with Braintree and process everything through them. You can set up
auto charges, and if it doesnt go through, you can charge outside of the scheduled charges. So
if we get a charge that hits the max and the charge was supposed to be for $500, we go back and
manually charge $400 if that doesnt work $300 and so on.
Think about it this way. If you have an insurance patient with $1,500 worth of benefits, and a $3,000 treatment plan. Say you break up their $1,500 portion into four $375 charges
and the first one is due at the time of initiating treatment, or in order to start treatment. If you
do all the work you still get $1,875 of the $3,000. That is 62.5 percent of the fee, and is pretty
close to the typical overhead of the office.
If you have open chair that is producing zero dollars, it makes sense to take that gamble
because if the patient walks and you have zero dollars then you got nothing. The majority of
the time the patient pays, and in the case of the few who dont you can rationalize your decision
because of the benefit you got from the risk you took on.
Once patients are banging down your doors and you are bursting at the seams then
you can become more selective. If you are financing someone who is cash pay the risks are
higher. Still you have to look at what you are getting in return. Not all dollars coming into your
practice are equal in value.
APR 7 2013
john galt dds

Post: 23 of 35
Sandy, in those practices you describe, do they go longer than three months and, if they do,
how do they manage the increased risk factor of non-payment simply due to time? Increase the
setup fee? Request more down upfront? Other ways?
I completely agree that in-office plans are not the devil, unless it is mismanaged or not
managed at all.
JUN 24 2013
58
practice management
message board
The best system for this includes seeing their credit report. You are more likely to collect
from someone who has never not paid a bill. Knowing this in advance allows you and your team
to know who may be premeditated fraud, a credit criminal, etc., without becoming a victim.
Oh and you will sell a lot more dentistry. The advantage is knowing in advance who goes
through life not paying their bills. Also, these are usually the people who break appointments.
You really dont have to treat everyone like a credit criminal.
Sandy Pardue
Post: 24 of 35
JUN 24 2013
Greatly appreciated response, Sandy. My wife and I have differing mindsets on in-office
financing. It is tied to risk tolerance. Both of us like getting the money upfront. Who doesnt? Her
preference after the payment-before-treatment concept is to route everyone to CareCredit, get
the money now minus CareCredit fee, and have no risk, or to do three monthly payments with a
credit card on file and have a very low risk. My thoughts are to use CareCredit or Comprehensive
Dental Finance as a credit check, then to extend in-office financing perhaps as long as nine or
12 months with a credit card on file with an interest hedge or setup fee hedge. Much like CDF
touts the interest as a hedge against the non-payer, why not do more in-office financing with
an interest hedge, or a set-up fee hedge, to protect against the occasional delinquent account?
Perhaps more simply put, lowering monthly payments may allow more patients to get
the treatment we recommend and they need; however, it brings some added risk. The interest/
set up fee would minimize the risk. Pulling the credit history or rating for a patient is a great
idea. In essence, CDF or CareCredit is doing that for us, no?
john galt dds

Post: 26 of 35
JUN 24 2013

Payment Plans
59
practice management
feature
ARE
Y
In my life and career, Ive traveled throughout the United States
and to several countries around the
world. Whether Im traveling for work
or for pleasure, I know that I will always
book my stay at a Ritz-Carlton Hotel. If
there isnt a Ritz-Carlton around, I will
compare every hotel at which I stay to the
Ritz-Carlton. Do you want to know why?
Whats the big difference, say, between
the Ritz-Carlton and another 4- or 5-star
hotel chain? Both provide clean beds, cable
television, hot showers, room service, and
more. So why is the Ritz-Carlton worldrenowned and twice the price? Why are
so many people (including myself) willing
to pay so much more for the unmatchable
Ritz experience?
Its because the Ritz-Carlton is run
on a 100 percent, client-centric business
model.
Ritz-Carlton staffs are trained for
hundreds of hours per year to perfect the
art of customer service and satisfaction,
and they always, always, always put the
customer first. Their people are impeccably trained, they ensure the dcor is
immaculate, they consistently over-deliver, they customize their service to suit
your wants and needs, and they wait on
you hand and foot. You ask for somethingthey bring it. You expect somethingthey surpass it. They constantly
60
service?
NG
DI
PROVI
U
O
by Jay Geier
go above and beyond the call of duty.
They have actually created a hotel experience that is completely unique for each
guest and, because of that, they will have
my business for life.
Puttin on the Ritz

What does this have to do with you?
Well, the Ritz-Carlton has figured out the
secret to attracting and keeping lifelong
customers. This secret will allow you to
revolutionize the way that you run your
practice, and create a flood of patient
referrals. Do you want to achieve this
model and its awesome results? First you
may have to face some facts. If your practice hasnt experienced significant, booming growth over the past five years to 10
years, then I can tell you two things:
1. You arent living up to your
potential.
2. Your practice is not 100 percent
patient-centric.
If you can accept those two things,
and accept that theres room for improvement when it comes to your practices
patient experience, then its time to get to
work making some changes.

First, the issue: 99 percent of
all businessesincluding yours
are based around the comfort of the
person or people who run the business.
Plain and simple.
The only way you will become truly
patient-centric is if you intentionally shift
the focus from yourself and your team to
what is most convenient for the patient,
even when its inconvenient for you. And
I promise yousometimes it will be.
Like the Ritz-Carlton, you need to
go out of your way to over-deliver to your
patients. Give your patients more in service
value than what they give you in dollar
value. Its unrealistic to expect patients to
love you if youre just giving them exactly
what they paid for: a typical trip to the
dentist, basic services, minimal effort, a
mediocre experience, etc. Thats called
meeting expectations, and lets face it,
sometimes dentists dont even do that.
The existential dentist

And let me tell you, meeting expectations is definitely not going to get you
that boatload of referrals you dream
about. No, if you want to see serious
practice growth, you need to make a significant effort to stand out from the other
offices in your town. You need to become
the Ritz-Carlton of dental practices.
practice management
feature
Ive got a few pointers on how to

do just that. The first one is deceptively
simple. You and your staff need to give
the impression that you exist for the sole
purpose of making each patient as comfortable and happy as possible for the
entire time that she or he is in your office
building. It doesnt matter what mood
youre in, or if youd rather poke your eye
out than deal with people. Your whole
team had better act like that patient is the
most significant person in the world, and
make sure you serve that persons every
want and need.
Unfortunately, people have a natural
tendency to look for flaws, especially
when theyre paying top dollar. It doesnt
make them mean-spirited people. We
all do it. The fact is, when your patients
walk in to your office for the first time,
they are waiting for you or your team to
mess up and disappoint. They are sizing
you upfrom what youre wearing to
what you say, from how the carpet looks
to how the environment makes them feel.
So if your staff member is having a
bad day and makes a curt comment or his
or her expression is less than cheeryyou
can bet thats the last time youll see that
patient. The patientand the patients
moneywill go somewhere else.
Supercharge your service

That brings me to my second point.
You need to stop thinking about the
money you are spending and start focusing on the value you are providing to your
patients. You can start by supercharging
your patient experience.
Add new-patient gifts, remodel your
office, send out a cool new marketing
piece, create a monthly newsletter,

and hold patient appreciation events.
Remember, these are investments with
an enormous returnnot expenses!
These changes will help set you apart
from the crowd, and have your patients
coming back for more.
Another crucial investment that you
need to start making is in staff training.
I mentioned that the Ritz-Carlton trains
its staff for hundreds of hours each year
(more than 200 hours, to be exact)so
why arent you doing the same thing?
Think about it this way. Your staff is your
single largest overhead expense. But they
are also your largest existing resource
(and asset)! In order to maximize that
resource and give your patients an experi-
could be investing more and receiving

higher payback. If you are currently
committed to training your team and
growing your practice but youre not
seeing results, there are only two possibilities for whats occurring. Youre
making the wrong investment, or you
have the wrong team.
When you work with thousands of dentists, you learn a lot about their teams, their
habits (good and bad), and their strengths.
After 25 years in the practice-growth business, I now know that the highest-earning,
most successful doctors invest in training
their teams every single quarter, whether
its in scheduling efficiency, hygiene, the
new-patient experience, or team building.
So, assess your practice. Isnt it time you,
The only way you will become

truly patient-centric is if you
intentionally shift the focus from
yourself and your team to what is
most convenient for the patient,
even when its inconvenient for you.
ence theyll talk about to all their friends,
you must take the initiative to train your
staff. Set high expectations, help them set
personal goals in the office, and create a
culture of performance and continuous
improvement. You want your staff to be
proud of the work they do, and its your
job to give them the necessary tools.
If youre already investing in training your staff, I guarantee that you
your team, and your practice start achieving

maximum potential? After all, isnt that
what your patientsand youdeserve?
So let me encourage you to invest in
your practice. Invest in yourself. Becoming the Ritz-Carlton of dental practices
may not be easy, but it can give you the
kind of practice you always dreamed of
havingand your patients will think
theyve found a dream come true!
What do you do to make your patients feel exceptional? Comment on this article at Dentaltown.com/magazine.aspx.
Author Bio
Jay Geier, founder and president of the Scheduling Institute, is a well-known coach and speaker and has helped more than 11,000 dentists
nationwide grow their practices and change their lives. For more information on Geiers programs, call (877) 317-6514 or e-mail info@
schedulinginstitute.com or go to www.schedulinginstitute.com/dentaltown.
61
radiology
message board
Am I Being Too Conservative?

A Townie asks for advice before beginning ortho treatment on a patient needing multiple restorations.
Dentaltown.com > Message Boards > Pediatric Dentistry > Pediatric Dentistry > Am I Being Too Conservative?
Pedo911
Post: 1 of 93

Restoring Deep Cavity
Preparations
Deep Cavity Prep
Conservative Treatment vs.

Over-Treatment
Introduction
So this was a consult patient who wanted to start ortho, was told she needed a cavity clearance first, and was treatment planned for 13 IP restorations. I realize some of these lesions may
need treatment now and some in the future, but 13 seemed awfully aggressive to me. Just want
to see how others view these situations.
The patient is obviously high risk, and with ortho probably more so. Not sure if it is prudent
to restore everything now. There was a definite occlusal on #19, but for my own family member
I would not have a quarrel about fluoride varnish, rinses, etc. and checking again at a recall. Not
sure six months will make a huge difference anyway.
Conservative Treatment
Conclusion
I thought some new eyes
might help make a difference
in how I evaluate these cases.
Please chime in, GP and pedo
alike, and let me know your
thought processes.
JUN 29 2015
DrZ123
Post: 2 of 93
I see, I would definitely do at least #7-8. Especially if they are about to get braces and be
unable to floss effectively, so I would say take care of them!
JUN 29 2015
midwestboy
Post: 3 of 93
Those would be monitored in our offices as well! Id insist that patient have wire removed
for annual radiographs and treat as needed.
JUN 29 2015
tooth43
Post: 4 of 93
I would restore most of them. Caries lesions are bigger than on X-rays view, especially
digital X-rays.
JUN 29 2015
Natedogg
Post: 5 of 93
I could see restoring #3 and #14, assuming they are going to be banded. The others, Im okay
with Prevident and monitoring on recall.
JUN 29 2015
62
radiology
message board
I would restore #3, #14 and #19 for sure (as mentioned previously, they are about to be
banded and we wont get a look at these surfaces for a couple years).
I would also request that we take another set of BWX in six months (without ortho wire).
Make sure Mom knows they wont be covered by insurance, but could end up not allowing
these other lesions to get out of control. Dont think Id want to wait a full 12 months to see
them again.
jradds7
Post: 6 of 93
JUN 29 2015
I would restore all of them. Most of them are in dentin. Patients dont start flossing suddenly
(unless they get several needles).
JUN 29 2015
I really appreciate all of the various opinions. It goes without saying that I will be taking
BWs every six months without the ortho wire. If she takes my recommendation and goes to one
of the orthos I know this will be a team approach.
Natedogg, as far as treating the teeth being banded, I am wondering if anyone thinks the
fact that the IP surfaces of these teeth will be covered essentially in GI makes a difference in
possibly slowing these lesions down? What if the ortho uses brackets on these teeth and not
bands, as a few orthos band the molars from what Ive seen? Just throwing out some thoughts.
This is an interesting discussion and I appreciate the different approaches.
OpenAndSayAhhh
Post: 7 of 93
Pedo911
Post: 9 of 93
JUN 29 2015
I would restore 6-7 of these, especially since the patient is going to be in braces. I would also
counsel the patient on diet. Its been my experience that eight out of 10 younger patients with
this type of decay drink too much soda, energy drinks, sweetened ice tea or some combination
like that.
neha_07
Post: 11 of 93
JUN 29 2015
From the American Association of Dental Consultants: There are no established standards
in the diagnosis of carious lesions. Early or incipient lesions are particularly difficult to diagnose
due to the subjective nature of lesion determination. Further, there are no standards for the
treatment of early or incipient carious lesions. This creates a dilemma for clinicians. There is a
fear that if lesions are not treated early, progression can lead to more tooth damage, requiring
more extensive treatment. However, studies have demonstrated that early surgical intervention
in comparison with non-surgical techniques, including re-calcification, results in unnecessary
loss of tooth structure.
Ali, I have too much time on my hands at the beach. But I would not restore any of those
lesions unless I could be sure that extreme prevention would not be successful. I have seen the
results of making holes bigger and sticking some restorative in there. After multiple replacements they end up as crowns, which have their issues, as well.
The patient has to realize that she is at the crossroads in her dental health, and it is our
job to make that clear. If that can be done, I would use this case to demonstrate a better way.
I know it has not been discussed, but I would be looking at getting some SDF into that area,
even to the extent of ortho separators for access. Re-calcification should be considered as another
alternative. I would charge for my time or do the case gratis, if needed, just for the opportunity
to learn something new and show it to others.
dentalwave
Post: 16 of 93
JUN 29 2015
I would restore as well. I would not fault one of observing under close supervision. I see a
high-caries-risk patient whos about to be a very high-caries-risk ortho patient, so Id take a more
hogtooth
Post: 17 of 93
63
radiology
message board
aggressive approach. In an ideal world, patients will listen to us, improve diet and home care,
come in regularly for cleanings, etc. If this patient had a history with you (been coming in for
years so you could track changes) then I may treatment plan differently.
Have a doc I work with who refuses to restore until there is a halo into the dentin. That it
his call, and works for him. He gets upset that anyone would fill lesions like these. In our clinic
I also extract teeth regularly that were never restored when the patient returns after a few years.
Most of these have other lesions that were restored that are still in the mouth and doing fine. I
probably also do fillings on teeth that would have ended up fine without them, but you just dont
know. So I can see why we all choose differently how to treat a case like this.
JUN 29 2015
Dr E
Post: 20 of 93
Id definitely do these:
#3 MO and DO
#5 DO
#14 MO and DO
#19 MO
#29 DO (And you can get a good look at the M of #30 once you open up #29.)
But when talking to the patient I would treatment plan all of them that have the IP radiolucency. Start with #3 and #5. If #3 and #5 are small, then I may watch a couple of the smaller ones,
but if they are larger once you open them up then I wouldnt be so conservative. I would rather plan
aggressively and after the fact, if needed, let the patient know that the radiographs only tell one
part of the story and that we can watch a few. That usually goes over better than the opposite.
JUN 29 2015
primaryteeth
Post: 24 of 93
I would consider restoring some of them. The problem is that once a bur hits those teeth,
they start the downward spiral. I see this presentation in teenagers often, but not necessarily
about to go to braces. These kids are at sports or band practice and chugging the Powerade like
crazy. I warn them of the need to change diet and re-evaluate in six months. Seeing the changes
from one set of XR to the next is way more diagnostics than a snapshot in time.
Lastly, if all or most of these do need restoring, I would graduate the patient to a GP.
JUN 30 2015
dokte
Post: 37 of 93
64
My protocol in such situations:

Orthodontic elastic separators mesial and distal of first molars (patient given some extras to
place at home in case one falls out) or wherever there are suspicious lesions, and return to
office three days later for a direct visual interproximal inspection of the lesions. I have done
this for year for many patients, including adults.
Restore the ones that are either rough or cavitated. I am pretty sure #3 is at a point of no
return and most likely #14, too.
Repeat No. 1 yearly.
If they are to have braces and I am doing the braces, a huge lecture on how only plain water
is allowed during braces as we look at the wonderful Gross and Disgusting Mouth Book
in the presence of parents. Honey, you will have straight rotten teeth if you continue as you
are doing. Even diet pop is like battery acid to your teeth, etc.
Waterpik nightly with braces and brushing with high-fluoride toothpaste as last bedtime
protocol (no rinsing).
Bitewings and anterior PAs on all ortho patients with wire off every six months to check on
decay and root resorption.
radiology
message board
Higher frequency of prophys during ortho and fluoride varnish applications at most ortho
visits. You could build that into your ortho fee to at least cover the cost of supplies.
Some doctors have used 10 percent carbamide peroxide whitening agent as decay prevention
throughout the braces. Googling will provide the article with the protocol. This may be more
likely to be followed by a 15-year-old girl since it gets rid of any staining and yes, penetrates
under the brackets so the entire tooth bleaches.
If the kid does not give you the correct vibes about changing her ways or the parents give you
the she only eats healthy and drinks lots of water story, consider correcting the crossbite only
(no brackets) treating her as you would a 9-year-old crossbite Phase 1 case.
JUL 4 2015
Here is an approach that is more conservative than a restoration and more effective and proactive than watching. It requires no guessing on our part. This approach is taught in both of
the textbooks I use with my studentsthe most
commonly used operative textbook in North
America and the most commonly used cariology
textbook in North America and Europe.
Here is a case I treated with this approach, a
few years ago. Look at the distal of the maxillary
first premolar:
JohnMaggio
Post: 51 of 93
65
radiology
message board
I separated the teeth for 48 hours (I now prefer three days)

with an elastic orthodontic separator:
This is a side chair visit. It takes a minute, and I also give

the patient a few separators and teach them how to replace it if
it comes out.
Here it is two days later, after removing the separator:
Here is another view:
You can see that this lesion, extending to the DEJ on radiograph, is really just a non-cavitated white spot. Would you open
a buccal white spot like this and place a restoration? I dont think
so. Here is another view:
Now, if we find that the lesion is cavitated (which I have only

seen twice ever, probably because of my case-selection criteria),
we could create a small preparation (with a #1 or #2 round bur) only into the lesion and place a
restoration without sacrificing and weakening the marginal ridge for life.
If we find that the lesion is non-cavitated, we have four options:
1. Place a resin sealant, being careful not to place any on the proximal contact.
2. Place a glass ionomer sealant by placing some on a metal band and wiping it across the
surface of the tooth to create a thin coat.
3. Place a resin infiltrant (ICON).
4. Place fluoride varnish and repeat separation and varnish application every three to six
months. I do this when I have many lesions in the same patient, like the original case in
this thread.
There is published evidence that each of these approaches is effective.
For this above case, I chose a glass ionomer sealant. On one-year and two-year follow-up
bitewings, the lesion has not progressed. Now that I have begun to look at these lesions directly,
I have become a lot more conservative!
JUL 4 2015

Too Conservative
66
you should know

feature
YOU SHOULD KNOW

Healthy Grid
by Arselia Gales, Assistant Editor, Dentaltown Magazine
Helping patients maintain their oral health is always a top concern for most dentists. Andrew
Clapp is director of product management for Healthy Grid, a startup that puts the needs of the
consumer first. We spoke with him about his company and its new product, Loloz.
68
you should know
feature
What is your background in dental?
How can a practice begin working with you?
Clapp: I am relatively new to the dental space and

I have been focused on oral health for three years. Prior
to that, my background was in e-commerce and digital
strategy for a number of Fortune 500 companies. I was
looking for a way to apply my skills to an organization
that is committed to making a difference, which led me
to Healthy Grid.
Clapp: Dentists can access our marketing tools at

Dentaloptimizer.com/dentists and gain access to wholesale
prices for our cavity-fighting, consumer-packaged goods
at Loloz.com/wholesale. If a dentist wants to contact us
directly, the best way is to email us at support@healthygrid.
zendesk.com. Or if she or he prefers to call, we can be
reached at (425) 533-9707.
Tell me about Healthy Grid, and what you provide.
What kind of service can dentists expect when

they pick up the phone and call you?
Clapp: Healthy Grid was created in 2013. We provide

innovative products and services focused on improving
peoples health. We are particularly excited about our
flagship product, Loloz, a breakthrough in the anticavity
consumable space.
You are in an elevator. A man asks what your company does. You have 15 seconds before the door
opens. What do you say?
Clapp: We leverage new technology to create personal health solutions with low barriers to entry. Simply
put, we fi nd new and creative ways to help you become
a healthier person.
What is the philosophy at Healthy Grid?

Clapp: Improving your health shouldnt be a chore.
We strive to make being proactive about your health fun
and easy. We do this through easy-to-use technology at
Dentaloptimizer.com and innovative consumer product
goods like Loloz, with our patent-pending Cavibloc extract
that kills the bacteria in the mouth that cause tooth decay.
Clapp: We love our dentists and are always happy

to hear from them. We are a small team, so the dentists
thoughts and suggestions on our products and services are
very important to us. We share a common goal of helping
people become healthier and are dedicated to working
hand-in-hand with dentists to create the best possible outcome for their patients. As a result, we work very hard to
provide a very high level of service for all our customers
dentists and patients alike.
Anything else youd like to add or tell us about

HealthyGrid?
Clapp: We work hard to create innovative products
that improve oral health. To ensure that access to our
products and services is as smooth as possible, we have
created a dentist-specific website for help with ordering our
products at a discount. Dentists can find more information on this program at Healthygrid.com/wholesale.
What would you consider to be the best-kept

secret about Healthy Grid?
Clapp: Our size. We are still very much a startup.
People are surprised when they find out that our director
of marketing and communications, Sam Dyer, and I are
heavily involved in all aspects of the business, right down
to shipping boxes and answering customer-service emails
and calls.
69
prosthodontics
feature
THE BENEFITS
of Mini Dental Implants

by Eric Hanson, DDS
As
dentists, almost all of us have encountered the

patient who comes to our practice to get a new
denture because the old one just doesnt fit.
This usually requires a few more questions to get an accurate idea
of exactly what the patient means, but what it usually boils down
to is this: the lower denture floats around when eating, gets food
under it, creates sore spots, and is generally a nuisance.
Upper dentures rarely, in our experience, have these same
issues. Lower dentures almost universally do. What do you do
when this patient comes in your door? Making a new denture
may or may not improve things, and a careful evaluation of the
existing denture and the patients oral condition is warranted as
the first step in deciding on a solution.
During this evaluation, you may discover that the patient
has worn a denture successfully in the past and has recently
lost weight and now says it is loose. Or you may fi nd out the
denture was originally an immediate denture that had never
been relined and now, after months or years of osseous resorption, the denture is indeed very loose. In these cases, a new
denture alone may improve things. Otherwise, simply making
a new denture will result in frustration on your part and the
patients. It is important to take the time to recognize whether
making that new denture is the only procedure needed to solve
the patients problem.
One thing is universal, however, and that is this: Securing the
denture with dental implants will change your patients life for
the better, and whether or not you currently provide this service
in your practice, letting the patient know it is an option is part
of your obligation as his or her dentist. There are few procedures
we offer that are truly life-changing, but helping a patient return
from the land of the dental cripple is one of them.
70
Providing a service to denture-wearing patients that will

eliminate the majority of their problems and allow them to return
to a normal diet is a blessing most of them wantespecially if it
can be done at an affordable fee.
Denture retention options

The dental cripple (as we will refer to this patient) has many
options. One option is to do nothing, of course. There are millions, perhaps many hundreds of millions of people worldwide
who have few or no teeth and manage to ingest enough calories
to survive. Teeth are not necessary for survival. However, in
North America, the vast majority of people not only want to survive, but they also want to eat what they consider to be a normal
diet and to look good doing it.
The second option is denture adhesive, a multibillion-dollar industry. Most denture wearers will also tell you
they would like to live without the mess and inconvenience of
powder or paste and without the embarrassing possibility of
coughing out a denture at a family party.
Dental implants are the third option listed here, but really
should be the fi rst option presented to patients because almost
every edentulous patient can have his or her life improved
with them.
Implants can be used to support or retain a denture, or to
replace it. Denture replacement is an important option that
involves several dental implants per arch and a fi xed prosthesis to
be fabricated. This should be presented to patients when biological limits allow. Denture replacement is beyond the scope of this
article, but several overdenture systems are available that will be
outlined below. The advantages and disadvantages of each will be
presented, based on our personal observations.
Continued on p. 72
prosthodontics
feature
The implant bar-supported denture
Fig. 1
Implant bar-supported dentures have been in existence for

several decades and have enjoyed a great deal of success. Dental
implants are placed and allowed to integrate, then a bar is manufactured by a dental lab, and the denture fabricated afterward.
Bars can be made with several attachment types, including
the Hader Clip system, Locator-type attachments, and O-ball
attachments. The bar can, in many cases, allow the denture to be
fully supported, not just retained. Each has its own peculiarities
and we wont try to cover all of them in this article.
Advantages
Denture is off the tissue so it can cause no irritation

Denture is usually completely supported
Denture is very stable
Patient chewing ability is very good
Can often be upgraded to a fi xed prosthesis without
additional implant placement
High patient satisfaction
Fig. 2
Disadvantages
Expense
Cleanability
Complicated, multistep process to make or remake prosthesis
Technique-sensitive lab procedure
Technique-sensitive chairside procedure if attempting to
reline denture or pick-up denture attachments
Bone height must be low enough to accommodate implants,
bar, attachments, and denture material
Bone must be at least 7mm wide for a 3mm diameter implant
Two-Locator or Two O-ball system (Figs. 1 & 2)
Increased stability over no implants

Sinus lifts and mandibular bone grafting in the molar/
premolar areas not necessary
Typically, with this system, two root-form implants are

placed in the upper or lower canine areas and are allowed to
integrate. After integration, the abutments are placed, and the
denture attachments picked up either chairside or in the lab, or
a new denture is fabricated with new attachments.
Disadvantages
Advantages
Lower expense
Cleanability
Easier lab procedure
Easier chairside procedure for new denture or reline of old
denture
Taller bone is more easily accommodated, especially by the
Locator system.
72
Two implants are really not all that stable

Two implants on the lower means the denture will eventually
rock mesial-distally, which defeats the purpose
Two implants on the upper means the palate of the denture
probably cannot be cut out, which defeats the purpose
Rocking denture, caused by distal bone resorption, can result
in eventual metal-on-metal wear and prosthetic failure
Lowest patient satisfaction of all systems discussed here
Highest need to replace liners or O-rings frequently
prosthodontics
feature
Four-Locator or Four O-ball system (Figs. 3 & 4)
Fig. 3
Rather than placing two implants in the canine areas only,

two more are placed distally, provided there is enough bone
width to accommodate them. A variation on this is a threeimplant system where one is placed at, or close to, the midline
with two others in the posterior areas.
Advantages
Excellent denture retention

Cleanability
Upper denture can have palate removed
Little to no rocking or other movement of the prosthesis
Easier lab and chairside procedure than bar system
Can be upgraded to a fi xed prosthesis, possibly without
additional implant placement
Replacing liners or O-rings is fairly fast and easy
Fig. 4
Disadvantages
Patient expense
Sinus lift or mandibular bone grafting may be necessary for
adequate bone height
Large O-balls require shorter bone to accommodate the
O-ball and housing
Bone grafting may be necessary to accommodate 3mm-plus
diameter implants
73
prosthodontics
feature
Mini dental implants (Figs. 5 & 6)

Mini dental implants, those described as being <3mm diameter, are used for overdenture retention. Four to six implants are
usually placed and loaded six to 12 weeks later. Some practitioners load immediately when minimal torque requirements are
met. Our experience is that a six-week waiting period results in a
significantly higher success rate than immediate loading. Locators or O-ball systems exist, with the smallest diameter implants
being O-ball type.
Advantages
Excellent denture retention when at least four are used

Cleanability
Lowest patient expense (when one-piece O-ball implants are
used)
Can accommodate the most extensive variation in bone
height and width
Bone grafting is almost never needed

Sinus lift procedures almost never needed
Low-trauma surgical procedure is simplest, requiring about
an hour per arch.
Surgical armamentarium requirement is smallest
Chairside and lab prosthetic procedure is simple
Easiest procedure to replace a failed implant (if necessary)
Shorter healing (integration) period
Palate of upper denture may be removed in most cases
Lowest chair-time requirement
Can be used for claspless partials in many cases
Replacing O-rings (on O-balls) is fast and easy
Fantastic opportunity to obtain experience in implant
dentistry
Disadvantages
Fig. 5
Individual implant failure rate may be higher than for rootform implants
Unchangeable abutment type, not as versatile for upgrade
later
Lower denture will rock somewhat if resorbed posterior
mandible is present
Periodontists and oral surgeons generally dont care for
them, believing root-form implants to be superior, and mini
implants being merely for use as Temporary Anchoring
Devices in orthodontics
Discussion
We have performed all of the above procedures in our
practice. We have also restored implants placed by other practitioners. To us, mini dental implants are the most sensible option
for almost all patients when considering an overdenture. They
require the least amount of trauma, which is advantageous for
the fearful patient, and the least expensive, which gives the procedure wide appeal to the average Joe.
As far as we can tell, patient satisfaction with them is highest, especially when taking into consideration the fact that most
of the time, a denture is more esthetically pleasing than a fi xed
bridge. Patients, even those with a badly resorbed mandible, are
able to chew well and eat most foods with a bit of practice.
We have also observed that once the attachments are placed
in the denture and the prosthesis adjusted, we rarely hear from
our overdenture patients who have had minis placed. Mini
implant retained overdentures appear to be the most problem-free
system we have seen or personally used.
One question that frequently comes up is longevity. The
Fig. 6
74
prosthodontics
feature
first patient for whom I placed minis more than seven years ago
had a severely resorbed mandible with no attached gingiva. Tenmillimeter mini implants were placed. She did not come in to
see us for five years and, as a result of poor oral hygiene, had
some inflammation of the mucosa around the implants. I offered
to remove the implants to relieve it and also offered to have her
see the periodontist for soft tissue grafting. The patient refused
both options and the hygienist has been providing implant
maintenance every three months, with some improvement in the
inflammation. The patient is in very poor health with an undiagnosed wasting disease. The point is, in spite of the imperfect
situation, the patient doesnt want to return to life before minis!
In our practice, we have found Lew mini dental implants

manufactured by Park Dental Researcheffective and reliable.
The companys philosophy of producing implants at an extremely
affordable price meshes very nicely with our practice mission of
providing high-quality dental care at affordable fees. But whatever mini dental implant you choose, we believe that this method
will help you effectively treatand forever change the life of
the dental cripple.
One thing is universal, however,
Dr. Eric Hanson graduated with honors from the University of

Oklahoma College of Dentistry in 2007. Dentistry is a second
career for him, which was made possible through the support
of his long-suffering wife and three children. He is one of
three owners of Smiles Restored, a general practice with emphasis on dental implants and prosthodontics, located in St. George, Utah.
and that is this: Securing the

denture with dental implants will
What is your experience with implants?

Comment online at Dentaltown.com/magazine.aspx
Author Bio
change your patients life for the

better, and whether or not you
currently provide this service in
your practice, letting the patient
know it is an option is part of your
obligation as his or her dentist.
Another example: a patient came in about a year ago with
four mini implants in the mandible, placed by another practitioner. They were clean, in great shape, and had zero bone loss.
All I did was make a new overdenture, because the patient
had paid the highest compliment a denture wearer could pay to
the dentist who provided it: by chewing so many meals that the
overdenture was worn out! Those implants had been in use for
more than 11 years at the time. So much of the longevity of any
implant is dependent on factors beyond the practitioners control,
the most important of which is the patients oral hygiene.
75
prosthodontics
feature
by Ara Nazarian, DDS, DICOI
ne population that has been

overlooked or avoided by
many in the dental profession is denture wearers.
For one reason or another, the denture
patient has caused many frustrations for
the providing dentist, especially in regard
to the mandibular denture. Conventional
mandibular dentures for patients with
severely atrophic mandibles often present
problems of retention, phonetics, function and pain due to instability.
Endosseous implants have been
successfully used to restore edentulous
mandibles with implant-supported fi xed
bridges, hybrid prosthetic dentures and
removable overdenture prostheses. However, atrophy of edentulous ridges might
limit implant placement in the mandible.
Anatomic limitations and resorbed alveolar ridges might compromise implant
number, length and inclination. The
use of traditional implants sometimes
requires extensive surgery, ridge augmentation or bone grafting.
Small-diameter implants placed
with fl apless surgery to support pre-existing conventional dentures present an
alternative method of restoring patients
with atrophic mandibles. Small-diameter implants are an excellent example of
76
this trend. They dramatically broaden

the spectrum of mandibular overdenture patients who can be successfully
treated. These small-diameter implants
(1.8-2.9mm in width) differ from their
full-sized counterparts in a number of
significant ways. The confi guration of
the implant permits a more conservative
placement protocol. No tissue fl aps or
tapping procedures are required, which
results in fewer traumas to both gingival tissue and bone. Their smaller size
also permits placement in ridges that
might not otherwise be suitable for fullsized implants.
The small-diameter implants are
firmly seated in place in intimate contact
with bone. Once they have been fi xed in
place, they can be immediately loaded.
There is no need for a long waiting period
or second-stage surgery. The simplified
protocols, conservative procedures and
elimination of gingival surgery make this
implant ideal for medically, anatomically
and financially compromised patients.
Case history
A woman in her early 60s presented
to our office, frustrated with her lower
complete denture. She complained that
it was non-retentive and non-functional,
always falling out during speech or

during eating. The patient suffered from
hypertension, which was controlled with
medication. She had been a denture
wearer for the last 25 years, resulting in
resorption of the mandible.
Palpation and radiographic examination revealed a moderately narrowed
mandibular ridge. Crestal bone width
and ridge height were sufficient to receive
a length of 2.2x13mm Sterngold ERA
(Zimmer) small-diameter implants. The
mental foramina were located on either
side, and it was determined that four
implants could be safely placed within
the cuspid-to-cuspid area.
All risks, benefits and alternatives
were reviewed with the patient before initiating treatment. The patient was draped
and a clean operating environment established. Local infiltration of anesthetic
was administered (Fig. 1). Markings were
placed to designate landmarks and areas
of insertion. Keeping correct alignment,
the implant drill was advanced through
the gingival tissue and the cortical plate.
During this stage it was very important
to accompany each step of drilling with
generous amounts of sterile water to prevent over-heating of the bone. Once penetration had been achieved through the
prosthodontics
feature
fit. Upon setting the denture was relieved

of flash and any voids were filled (Fig. 6).
The patient was then instructed in denture placement, removal and oral hygiene.
cortical plate, paralleling pins were placed

to check the angulation and position of
the pilot holes (Fig. 2). Once these positions were confirmed clinically and radiographically, a tissue punch was utilized
to atraumatically remove the tissue (Fig.
3) in the areas where the small-diameter
implants were to be placed. After confirmation, the first small diameter implant
(Sterngold ERA) was placed with the
finger driver (Fig. 4) until firm resistance
was met. At that time, the ratchet wrench
was employed, using small, carefully controlled incremental advancements until
the implant was fully seated. Full seating
of all four small-diameter implants was
achieved when the threads and base of the
implants were subgingival and only the
ERA abutment head was exposed (Fig.
5). It was important that the implant be
absolutely tight at that point. If it was
not, the quality of the bone would indicate a poor prognosis.
At that point, the location of each

implant was transferred to the denture using Crown and Bridge Fit Test
(VOCO America). These areas were
relieved to a diameter of 5mm and the
denture was reseated, confirming that
adequate relief had been established to
passively seat the denture.
A small piece of rubber dam was
placed over each implant, allowing only
the ERA abutment head to be exposed.
This step prevented problems of the reline
material locking around the implants.
Sterngold ERA (Zimmer) housings were
then placed over each implant. Retentive
fit and mobility were again verified.
The cleaned and dried recesses in
the denture were filled with cold cure
acrylic, Quick Up (VOCO America),
and seated onto the implants allowing
for full polymerization. Before complete
setting of this material it was important
to border-mold the flanges for an accurate
Fig. 1: Edentulous lower ridge
Fig. 2: Paralleling pins to check angulation
Fig. 3: Utilization of tissue punch to remove

tissue
Fig. 4: Small-diameter implant used for denture

retention
Fig. 5: Small-diameter implants placed into lower

ridge
Fig. 6: Retrofit of lower denture
Conclusion
A small-diameter implant overdenture
service provides clinical and economic benefits to your practice and restores function
and confidence to your patients. Denture
retention and function are dramatically
improved, and the results are immediate.
The advent of the small-diameter implant
has given general dentists an easy, less
costly and more rapid way of solving many
of the difficult problems that arise in dental
practices with complete dentures. It is estimated that more than 36 million patients
in the United States have lost their teeth;
however, only 0.5 percent have received
implant therapy. This striking disparity signifies a huge untapped market for implants
and dentures.
Author Bio
Dr. Ara Nazarian maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a diplomat in
the International Congress of Oral Implantologists (ICOI). His articles have been published in many of todays popular dental publications. Dr.
Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on aesthetic materials and dental implants throughout the United States, Europe, New Zealand and Australia. Dr. Nazarian is also the creator of the DemoDent
patient-education model system. He can be reached at 248-457-0500 or at the website www.aranazariandds.com.
77
corporate profile
feature
Dentaltown Magazine spoke with Jay Geier,

president and founder of the Scheduling
Institute, to discuss how his company
is helping strengthen and empower
independent dentists all over the country.
Geier shares his thoughts on the expanding
presence of corporate dentistry, what it
means for the future of the industry, and
how the Scheduling Institute is tailoring
its educational materials in response to
the changing business climate. Geiers
passionate rhetoric and breadth of
experience solidify his place as one of the
most well-known names in dentistryand
now, he wants to save your practice.
Independ
Day
by Kyle Patton, Associate Editor
Dentaltown Magazine
78
corporate profile
feature
Youve built your business around advocating

for the independent dentist. Why is that
particular type of doctor so much more
important to dentistry?
ence
Ive always been an advocate for the independent

dentist, but in this emerging era of corporate dentistry,
Ive gotten even more fired up about it.
To give you a quick snapshot, heres whats happening in dentistry right now. Big corporations are
spending millions of dollars to buy up smaller practices
in order to turn a quick profit. In my opinion, corporations dont care about quality dentistry or patient care
like independent dentists do. Instead, corporations care
more about their bottom line and their checkbook.
So the fear or assumption that an independent,
private-practice owner could be nonexistent in the
future is completely laughable to me. I have more than
800 doctors in my coaching program today, and these
doctors are ambitious dentists who can not only survive the current landscape, but can truly thrive in it!
So yes, I am absolutely an advocate for that dentist. If I
were a betting man, Id put all my chips in that corner,
because I know the independent dentist will not only
thrive but will successfully grow his or her practice
with the right guidance and information.
The problem is, the majority of dentists dont have
the right guidance. They arent aware of whats really
happening in dentistry right now. Sure, theyve seen
corporate offices popping up and theyve seen the ads
from these big companies in every magazine, but they
dont know how to be competitive in this ever-changing
market. Ive cracked that code and tested my strategies,
so I know what works and Ive compiled a series of
free webinars that will educate any independent dentist
on the high-level information he needs to know to outperform the competition.
What kind of impact are those big corporate
t having n the in epen ent enti t?
Right now, with the emergence of corporate dentistry, private equity funds, and large group practices,
we are seeing firsthand that what our country was
founded on (the freedom of both money and time)
has become jeopardized for dentists. Many dentists
are deciding to sell their practices without really
knowing what the fine print of that signed agreement
means. Thats the big motivating factor behind the creation of my 7-Part Practice Protection Webinar Series.
[Editors note: See sidebar for more information.]
79
corporate profile
feature
Every independent dentist has put her blood, sweat, tears (and
a lot of money) into her practice. Ive made it my personal mission, and the mission of the Scheduling Institute, to work with the
smartest, most ambitious, and hardest-working independent dentists to grow their practices to a level where the quality of service
and profitability of the practice increase togethercreating the
best practice in any town. This creates an energized and unstoppable practice that the corporate model simply cant compete against.
corporation and its investors, as opposed to making an investment that benefits the practice or individual doctor who founded
the practice and spent her life building the patient base.
Now, Ill admit, these corporations do provide good marketing for their practices, but by and large, the ability to retain the
patient long-term is a big problem for them. Any dentist knows
that getting a patient in the door is great, but if you dont get him
coming back again and again, youre in big trouble.
ve een r than
hat happen t a practice hen a
c rp rate
t ta e p ace hat have
n tice ?
an
ct r re rt t the ec rp rate
t eca
the thin that their n
pti n r e iting enti tr
that rea the ca e?
Commoditization would probably be the best descriptor of

the impact corporate dentistry is having on the indusry. In other
words, the service level is not going up.
Maybe convenience is going up in some situations. But what
a patient really wants is quality care, an incredible in-office experience, and personalized relationships that make him feel valued
and important. Those big corporate offices know that they cant
replicate that on a big scale, so they just dont do it. This is great
news and an opportunity for the independent dentist.
One other major thing that is happening is that the equity is
being taken out of the practice and leveraged to the benefit of the
Be Prepared
Dentistrys fi rst-ever 7-Part
Practice Protection Webinar Series
is designed specifically with strategies for independent
dentists as they ready their practices for the drastic
changes coming to dentistry. Its no surprise that corporate dentistry has infiltrated the industry. But you and
your practice are not doomed to failure.
Easily reproducible strategies are available to build up
your defenses so you can not only survive, but thrive. This
free webinar series covers some of the hottest and most
controversial topics in dentistry, and shows you how to
protect yourself, your practice, and your financial future.
Heres a sneak peek at what youll learn:
The new rules of practice growth and financial security
Financial mastery and understanding wealth
The unstable future of dentistry
Consumer trends and case acceptance
Why practices dont grow
Dentistrys corporate takeover
Retirement planning and exit strategy
The brand-new 7-Part Practice Protection Webinar
Series is launching Nov. 3, 2015, but space is limited.
Learn more about this informative series and reserve your
seat today at ProtectMyPractice.com.
80
The truth is that the return on a family-owned, privately held

corporation is greater than that of publicly traded corporations.
Which means that, instead of seeing buyout money as the answer,
doctors should begin to respect the value and the long-term benefit
of holding the stock in their company and building the equity in that
company instead of (in some cases) selling it at rock-bottom price.
Corporations claim theyre offering a fair price, but just to be sure,
get your practice appraised by an independent appraisal company.
As a practice owner, what you should be doing is spending
time creating a strategy to maximize the value of your businesses
stock. There are a lot of ways to grow that stock, but some methods produce a better return than others. I go over some of those
highest-producing investments my new webinar series.
One quick example is how growing your patient base builds
your practices value and increases production, collections and cash
flow. Whereas adding an expensive piece of equipment doesnt. In
the long run, growing the value of a practices stock means that if
a dentist wants to sell in the future, he can do so on his terms. It
just needs to be done at the right time and at the height of value, as
opposed to the first time a buyer comes into town.
r the a t
ear
g
in the enta in
rea
ean ?
ve ec
tr
an
e n n a the ph ne
e p ain hat that
Well, let me start out by clearing up one thing: we deliver

new patients to dentists. Period.
When you invest in our New Patient Generation Telephone
Training, we arent merely teaching you about telephones. Were
giving you a fully comprehensive overhaul of the new-patient
entry points that produce the biggest results for your practice.
There is a big difference between those two things. One is
focused on telephones, and one is focused on the resultnew
patients. We are a results-focused company, so everything we do provides a return on your investment, and we guarantee that. Its been
nearly 20 years since I started the Scheduling Institute, and more
than 30 years since I created the New Patient Generation Telephone
Training, and we have guaranteed our results since day one.
Our new-patient trainings and solutions are so widely used
and are so effective with the results they produce that this has
corporate profile
feature
Right now, my most elite

coaching group includes doctors
who are growing their practices
ve times larger, and theyve
proven that they can do that in
any town, with corporate dental
practices present or not.
actually overshadowed some really significant things that the
Scheduling Institute has done in the last decade.
While our new-patient training is certainly what were most
known for, we also have the largest coaching program for dentists
(with more than 800 doctors enrolled), the largest dental-staff
training university (more than 7,000 staff members enrolled),
the largest private-practice growth events and workshops in the
industry (more than 17,000 dentists attended our events last year
alone) I could keep going, but you get the point.
While were widely known for our new-patient solutions, we
are actually the best in the industry at practice-growth solutions
for every area of your dental practice. Twenty years ago when I
started the Scheduling Institute, I set out to build a business that
would serve independent dentists, grow private practices, and
significantly improve the care and experience for their patients.
Youre telling dentists they dont need corporate dentistry
to build a thriving practice. What are you teaching your
clients that backs this up?
Right now, my most elite coaching group includes doctors who

are growing their practices five times larger, and theyve proven
that they can do that in any town, whether corporate dental practices are present or not. We are able to create significant growth
and substantially improve the equity position of a doctor who is
willing to put forth the effort. As well as dovetail the real estate
investment, which is a unique opportunity for most dentists. In
other words, she is able to fund and pay off real estate through the
practice, which if you get outside of dentistry is a very common
practice for people who own and keep businesses in the long term.
Most wealth really comes from holding businesses long term
and maximizing their value. Another major advantage weve
been working on with our coaching clients is to expand their
practices, so weve been able to put 400 to 500 associates in our

independently owned clients offices over the last two years.
That is one big benefit of what corporate dentistry is doing
allowing independent dentists to be able to hire associates very
easily in the marketplace.
Again, there are hundreds of strategies for maximizing practice value, but the Scheduling Institute has conducted tests over
the last decade to narrow down the ones that produce the best
long-term results for our clients.
What should dentists expect to see from The Scheduling
Institute in the coming years?
Our commitment is to provide the unbiased resources for the

individual doctor who is working to develop a high net worth,
and a high-service-oriented practice in the current marketplace.
So our commitment is to provide all services, to truly be
a clearinghouse of services so that doctors can deal with the
space and equipment issues that they will be challenged with,
the human capital issues that they will be challenged with, the
training functions, and the financial mastery that is required to
successfully execute a full and abundant life.
And we keep building services based on the needs of our clients, and will continue to do soas opposed to what we think the
client needs. Our client base is truly our laboratory, because they
tell us what they need, and we develop and test a product over and
over until it is perfected to a level that surpasses their expectations.
We are doing this every day, with clients in every state, clients
in more than 20 different countries, some who are just starting
their practice, others who have been around for decades. Its the
single most effective product and service development strategy for
the Scheduling Institute, because it simply requires listening and
watching for the needs of our clients and their growing practices.
How can a doctor get more information about you, The
Scheduling Institute, and your solutions for building
athriving practice?
If you are an independent dentist wanting to grow and protect your practice on your terms, with maximum compensation
and minimum stress, then the brand new 7-Part Practice Protection Webinar Series is the best next step for you. Its free and
online, so its easy and convenient for you to join from anywhere.
This is a series that I felt compelled to create because dentists
deserve to be prepared as they enter the corporate dentistry era.
Space is reserved for independent dentists in private practices, and
you can register or learn more online at ProtectMyPractice.com.
And of course, if youre interested in growing your practice
with more new patients, my New Patient Generation system is
(and always will be) guaranteed to increase your new patients by
10 percent to 40 percent in 90 days or less, with no additional
marketing or advertising. You can learn more and get a free New
Patient Opportunity Assessment at The5StarChallenge.com.
81
orthodontics
feature
by Gerald Nelson, DDS
What happens after the braces come off? Post-orthodontic stability is a bit of a
mystery. Research to date has given us little to rely on other than indefinite retention.
In this article, I will discuss the management and efficiency of this period of
patient care. The information comes from having partnership practices with three
remarkable orthodontist colleagues, Michael Meyer, Earl Johnson and Paul Kasrovi,
and from decades of collaboration with Karen Moawad, orthodontic consultant.
When I came out of residency and entered practice with these UCSF colleagues,
we provided an extraordinary amount of doctor time to our retention patients, seeing them four or five times in the first year, three the next and biannually after that.
Current ideas on efficiency suggest that comprehensive treatment should involve
less than 25 times, from the very first visit to the final retention visit. Before our
efficiency makeover, we used 20 visits during retention alone.
It really changed when Mike and I decided we each needed a three-month sabbatical from the office. At the time we were each working four days per week in two
office spaces. We preceded scheduling our sabbatical with a thorough analysis of
our efficiency, figuring we could pare clinic time requirements to the point that one
of us could manage for three months. We made many changes, and our retention
protocol was radically revised.
82
Continued on p. 84
orthodontics
feature
Our current retention protocol looks something like this:

Flossing a fixed retainer.
Retainer for mixed-dentition patients.
If a patient loses a
removable retainer,
or the fixed retainer
becomes loose, and
there has been some
movement, our typical
choice is to bracket the
anterior teeth involved,
align for two months
and then replace the
retainers.
84
Hardware
Non-extraction patients: Maxillary pressure-formed (as opposed to vacuum-formed) slip-cover retainer, lower 3-3 lingual fi xed retainer bar with bonded pads
on the cuspids. Reasoning is this combination is ideal for a good finish that doesnt need
any touching up with active springs on a Hawley. The slipcover holds spaces closed, and
doesnt need any adjustments (no doctor time). If the patient is a bruxer, you can use
2mm of Biostar (Great Lakes Orthodontics) material, which is almost indestructible. We
spot the occlusion so that there are some bilateral contacts in CR. The lower bonded
retainer is more secure if you lay a thin coat of composite over the bonding pads to cover
most of the lingual surface of the cuspidmore comfortable to the tongue as well. Prior
to bonding, we might do some IPR to flatten the interpoximal surfaces. Patients can floss
with this retainer by looping the floss around each individual incisor to floss all the way
down to the sulcus.
We tell young patients with fi xed retainers that they must keep the bonded retainer
until they are out of college, at which time they can come to see us and discuss the pros/
cons of keeping it in place. We tell adult patients that it should be considered a permanent fi xture.
Extraction patients: Need to keep that extraction site closed. We usually place an
upper Hawley and lower slipcover retainer. Both require almost no doctor time, and the
lower slipcover can act as a night guard. At one time we tried upper and lower slipcover
retainers. I dont recommend this, as the occlusion does not settle well. I learned the hard
way as I tried to find my ABO cases.
Mixed dentition patients: This retainer will hold incisor alignment, arch-length molar
width and can be worn through transition without affecting the emerging buccal segments.
Retainer wear requirements

We ask patients to wear the retainer full time for four weeks and then just at night.
Many practices use full-time retainers for a much longer period. I think this just adds to
doctor time and to broken or lost appliances without any benefit to stability. After fixed
appliances are removed, the circumferential fibers tighten up in response to mastication
without the support of archwires. If the retainer is worn full time, this adaptation is delayed.
Retention period visits

Our basic plan is three to four visits after the deband/retainer delivery appointments.
Retainers are delivered the same day as deband or the day after. You must have an
in-house lab to do this, but it is pretty easy if the retainers are an upper slip-cover and
lower fi xed.
1. Eight weeks to check cooperation. At this point the patient has been using the removable retainers at night only for one month. Final records have been reviewed by the
doctor, and copies of photos and radiograph were sent out to the dentist. The patient
can be shown the beginning records at this visit, and a testimonial form completed.
2. Four months later. Confirm cooperation, follow up on referrals, e.g. third molars.
3. Twelve months later. Some patients will be dismissed at this visit, often those with
fi xed lower lingual bars. At this time we advise the referring dentist that the patient
continues to use the retainer without visits in our office and has been told that he or
she is welcome to come in if there are any concerns.
orthodontics
feature
We ask patients to wear the retainer full time for four weeks and then just at night.
Many practices use full-time retainers for a much longer period. I think this just
adds to doctor time and to broken or lost appliances without any benefit to stability.
Minor tooth movement
Final records
If a patient has a need for some minor tooth movement after

deband, such as closing a slight space or controlling a rotation
tendency, we consider this an active phase, and see the patient
every six weeks until our minor tooth movement goal is met.
Then we start our normal retention protocol. Consequently, we
try pretty hard to avoid any discrepancies at deband.
We use final records to plan the retention period, to evaluate

interproximal bone, to look at the cortical bone layer of the condyles
and verify the condition of the root forms. Because of a carefully
crafted approach to obtaining them, we rarely have any resistance
to final records. Heres the sequence: When the deband visit is put
in the schedule, the computer sends a letter home and to the dentist
explaining that treatment will end on (date) and that if there are
any concerns about the finish, we should be notified. The letter
explains the need for the X-rays, models and photos, which will be
done at the deband appointment. Combining final records with
this appointment makes the most sense to the patient family, who is
typically quite agreeable to any procedures involved with removal of
the braces. The excitement of the deband appointment is enhanced
by the ceremony of taking photographs (copies of which are sent
home) and radiographs. Naturally this works best if all records are
Retainer loss
If a patient loses a removable retainer, or the fi xed retainer
becomes loose, and there has been some movement, our typical
choice is to bracket the anterior teeth involved, align for two
months and then replace the retainers. This choice uses much
less doctor time than using an active spring retainer. We know
this from experience.
85
orthodontics
feature
taken in-office. If you delay final records to some other time, there
will often be resistance.
Key entries during the retention period

Each patient should have at least these four topics included in
the treatment notes during the retention period:
1. Retainer cooperation status. Notes showing whether the patient is
fully following instruction, that the dentition stability is/is not
satisfactory, or any caveats that are observed, and advice given.
2. TMJ status. Notes should show that a TMJ screening was
done, and the result; WNL, or any departure from that, and
what advice was given, or referral made.
3. Wisdom teeth. Notes must show that the status of these teeth
was observed using proper records, and that appropriate

recommendations were made.
4. Periodontal status. Any caveats noted in treatment planning,
or during treatment, should have a follow-up note during
retention. Especially note food impaction due to loose
contacts and make recommendations. If all is well, a note
should indicate that.
Final thoughts
The retention period is an important responsibility of an
orthodontist. The protocol above allows one to meet this responsibility efficiently, and will maintain the approval of your patient
families and referring dentists.
Questions about retention? Join the conversation online at Dentaltown.com/magazine/aspx.
Author Bio
Dr. Gerald D. Nelson, health sciences clinical professor, Orthodontic Division, Department of Orofacial Sciences, UCSF Dental School, is a 1965
graduate of UCSF. He currently supervises treatment in the resident clinic, lectures on mixed dentition, skeletal anchorage and biomechanics.
He is editor of the PCSO Bulletin. He is a PCSO board member and delegate in the AAO House, and serves on the editorial board of the AJO/DO.
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86
practice management
feature
HOW TO TRACK
True Treatment
Acceptance
by Kirk Sweigard
Most doctors prefer predictable outcomes, rather than surprises.

Over the past decade, Ive had the
opportunity to speak with hundreds of
dental educators who have shared ideas
they believe can help dentists and their
teams get their patients and practices to a
healthier state.
A common theme of many of these
conversations is that many doctors are not
tracking treatment acceptance. Additionally, they find that those who are tracking
their treatment acceptance are doing so
inaccurately. Therefore, doctors may
believe their acceptance rate is higher than
it actually is.
When practices consistentlyand
accuratelytrack true case acceptance,
they often fi nd the results surprising, to
say the least.
Tracking helps encourage

accountability
Let me share with you an example of
a dental team that accurately tracks and
manages its treatment acceptance. Lisa
Barrera is the office manager for 21st

Century Dental. Lisa had been tracking
treatment acceptance through a tool she
got online, but found the reporting a bit
limiting. So she created and implemented
her own committed care tracking form,
which measures the outcomes from every
Our tracker includes the patient name, total treatment

amount presented, total treatment amount accepted and,
if a patient chose not to accept care, notes indicating why
along with a plan of action to follow up.
person who presents fi nancial arrangements. This is the point in the patient
experience when commitment to care
happenswhen patients accept treatment, make necessary appointments and
make payment arrangements.
With our custom form, we track
two different outcomes: the percentage
of patients scheduled for any level of care,
87
practice management
feature
For us, using a

treatment tracker
has simply given us
the information we
needed to make
positive changes
and additional
improvements. We
now know how we
are doing. We are no
longer guessing.
and the percentage of treatment fees that

are accepted, Barrera explained. Because
we have a larger practice, we track who the
patient interacts with through the entire
processthe doctor and clinical team,
including the hygienist and the team
member leading the fi nancial conversation. This helps us identify trendsgood
and badand the best practices that lead
to healthier patients. We also capture
notes that indicate the patients mindset,
especially if she or he did not schedule
or commit to care. This helps guide our
follow-up conversations with the patient.
One key insight Barrera found
through tracking was that the way
comprehensive care is presented to the
patient often determines whether or not
the patient will commit to care. Patients
are given an overview of everything
they need to achieve oral health, but the
practice immediately breaks it down into
manageable portions, both clinically
and financially.
Our goal is to have 80 percent of
patients who are seen, subsequently schedule some level of care; and 60 percent of
needed dentistry that is presented, committed to by the patient, Barrera said.
We look at the numbers daily, weekly
and monthly. It gives us accountability
on how we are performing individually
and as a team, which helps empower and
motivate us to achieve our goals.
Tracking helps facilitate

positive change
Another good example of how
tracking true treatment acceptance can
positively impact a practice comes from
Christian Perez, a practice administrator
in a well-established practice. He began
using a treatment tracker when they found

they were not meeting their goal of being
booked out two weeks in advance.
Its hard to understand why people
arent accepting treatment unless you
track it for a period of time and can see
trends and areas that need improvement,
Perez said. Our tracker includes the
patient name, total treatment amount presented, total treatment amount accepted
and, if a patient chose not to accept care,
notes indicating why along with a plan
of action to follow up. Before we started
tracking this way, we all thought the biggest barriers to care were cost and time.
But we were wrong. The largest reason
was that people didnt feel treatment was
necessary. In our case presentations we
found we were using words like, Its not
that urgent and its just a crown which
led patients to believe it wasnt necessary.
This was information we could all use,
including the clinical teams, to improve
the way were communicating the value of
dentistry to patients.
Perez also found that his team was
incorrectly assuming that some of the
patient base would shy away from using
something like CareCredit as a payment
option.
But the tracker showed us that
we were missing opportunities to help
patients get healthy, and we began introducing the CareCredit credit card to
patients and using the payment options
form so they could easily see how to fit
care in their family budget, Perez said.
For us, using a treatment tracker has simply given us the information we needed
to make positive changes and additional
improvements. We now know how we are
doing. We are no longer guessing.
How important is treatment acceptance tracking in your practice? Continue the discussion Dentaltown.com/magazine.aspx.
Author Bio
Kirk Sweigard has nearly 15 years of sales and marketing experience and is the strategic partners director for CareCredit, one of the largest
health, wellness and beauty credit cards in the nation.Collaborating with dental professionals, including consultants, associations and suppliers, Sweigard provides the opportunity todevelopandenhancerelationships that support association members and dental practices.
88
radiology
feature
CAD/
CAD/CAM as a Marketing Tool
Practice at Your Best with Technology
That Sells Your Practice by Michael Kelly, DMD
Doctors know that computer-aided

design and computer-aided manufacturing (CAD/CAM) eliminates the
time-consuming mess of traditional
impressions and gives practitioners more
control when designing restorations.
Patients, on the other hand, value
CAD/CAM for slightly different reasonsnamely, its cool and its quick.
CAD/CAM is an indispensable part of
my practice that caters well to a modern
patient base that is technologically driven
and demands instant gratification. It not
only allows for improved diagnoses and
enhanced patient care, but the wow factor behind the technology keeps patients
in awe and keeps them coming back.
In fact, Ive found that my CAD/
CAM system has allowed me to cut back
on marketing, thanks to word-of-mouth
referrals and online reviews.
90
Technology as a marketing tool

In the past, my practice invested
approximately 2.5 percent in print advertising. However, now we have been able to
reduce our marketing budget to less than
1 percent, due to the improved internal
marketing our technology does for us.
When creating restorations, I use an
intraoral scanner to create a digital impression. In my opinion, theres not a single
doctor out there who shouldnt be using
digital impressionsthe technology is an
absolute must in todays society. Scanners

are faster and more accurate, and cut back
on the mess and cost of consumables
associated with traditional impressions.
Eliminating the need to fill patients
mouths with alginate, polyvinyl or even
the powder required by some intraoral
scanners is also a selling point when it
comes to case presentation.
For example, I recently had a patient
who only agreed to go forward with extensive comprehensive treatment as long as I
promised not to put that gooey stuff in
her mouth. Modern scanner technology
allowed me to make good on that promise,
and the patient accepted treatment.
Attract patients with procedures

that fit their schedules
The scanner lets me be known around
town as the doctor who does goo-free
Continued on p. 92
radiology
feature
impressions, but where my patients
appreciate CAD/CAM technology the
mostand let their friends and co-workers know itis the speed of the in-office
milling machine. I even keep a glass jar of
the stubs from the milling blocks on the
counter as a conversation starter about
same-day restorations.
Many of my patients travel internationally for work for months at a time.
Such an intense travel schedule does not
allow for the traditional restoration workflowa two- to three-week turnaround;
an unreliable temporary; and a second follow-up appointment. Instead, after using
the scanner to create a digital impression,
I use intuitive CAD software to design the
restoration in two to five minutes. Then,
the mill takes anywhere from 20 to 40
minutes to fabricate the restoration.
During that time, patients wait comfortably in our offices conference room,
checking work emails or making phone

calls. We even offer the patient the
chance to see the mill at work as he or
she waits for the restoration to be completed. From start to fi nish, the whole
appointment takes about 70 minutes.
This efficient workflow even allowed
me to fabricate two restorations for a
patient who was on an eight-hour layover
between fl ights.
Now, I dont do every restoration
in-house, but for my jet-setting patients,
my being able to design and mill in the
office is a perk that gets them talking,
and sends their co-workers my way.
Five-star technologythe
importance of online reviews
Giving my patients that up-close look
at the CAD/CAM system plays a huge
role in word-of-mouth referrals. We follow up with our patients through surveys
that are published directly to Yelp and

Google+, and patients often thank us for
the tour of the back office and comment
on how grateful they are for the quick
turnaround of their restoration, e.g., It
was so great to see that amazing technology, The doctor can deliver my crown
in one day, etc. These days, people wont
even visit a burger joint if it has bad
online reviews. How much more important is it, then, for potential patients to see
good online reviews of a doctor?
Were also excited to start a new social
media campaign, and have created small
signsCrowns in one day, No goo,
etc.to encourage patients to take pictures with them and then tweet or post
the image to their personal Facebook
page. Considering that most peoples
friends and followers live in the general
area, posting the picture and tagging our
practice puts us in front of hundreds of
potential new patients.
As a doctor, my priority is to offer
accurate diagnoses and propose the most
efficient and effective treatments. My
scanner, design software and milling
machine help me to do that. Its a great
side benefit that the technology that helps
me practice at my best also helps with
marketing my practice.
Patients know were a cutting-edge
office that uses the latest technology to
provide exceptional care while keeping
their appointment length at a minimum.
Im happy if my patients are happy, even
if that means theyre happy because the
speed and efficiency of CAD/CAM
technology lets them see less of me and
my chair.
Has CAD/CAM technology benefited your practice? Comment on this article at Dentaltown.com/magazine.aspx.
Author Bio
Dr. Michael Kelly practices at Aesthetic Dentistry of Scottsdale in Scottsdale, Arizona, and also serves as senior clinical instructor for Aesthetic
Vision Seminars. He attended Stetson University in Florida for his undergraduate training in chemistry and then graduated from Medical College of
Georgia School of Dentistry in 1993. Before moving to Scottsdale in 2010, Kelly practiced in in Florida for more than 17 years. He is committed to
being a leader in the dental profession, evidenced by his serving as president of the Central Florida Academy of General Dentistry and serving as
the dental director of the Good Samaritan Dental Clinican all-volunteer clinic for patients without the ability to pay for dental care.
92
new product
profiles
Znext Anterior Zirconia Crowns

Vista Color-Coded
Syringes
Vista Dental Products has
expanded its line of luer lock
syringes, now offering 12cc and 3cc
color coded syringes. Vistas ColorCoded luer lock syringes provide a
fast and easy way to organize and
identify irrigants and solutions,
helping to reduce incidences of syringe swap.
A box of Vistas Color-Coded Syringes cost no more than a box of
standard luer lock style syringes. Vista Color-Coded Syringes are latexfree, and available in four colors: blue, red, yellow and white.
For more information, call (877) 418-4782 or visit Vista-dental.com
Exclusively from Keller Laboratories, Znext Anterior delivers the

natural translucent esthetics required for anterior placement, while
providing the strength and durability of monolithic zirconia. Znext
Anterior combines CAD/CAM technology for superior fit and margins,
an average flexural strength of 650 MPa for durability and are guaranteed for eight years.
Znext Anterior is fabricated from models, impressions and digital
files with only four lab working days
required. Model-less production is
available for Znext Anterior, reducing
fee and in-lab time to one day.
For more information, call (800)
325-3056 or visit Kellerlab.com.
New Products
If you would like to submit a new product for consideration to appear in this section,
please send your press releases to arselia@farranmedia.com.
www.dentaltown.com
Relyant VIP Starter Kit

Nordent Manufacturing has introduced the new Relyant VIP Starter Kit. All
Relyant scalers and curettes come with free, unlimited, professional sharpening
for life. Any Relyant scaler or curette may be traded in to receive a 40 percent
discount on a brand new Relyant instrument, which also comes with the same
free sharpening benefits.
Now it is even easier for offices to get started with the Relyant program. The
Relyant VIP Starter Kit contains six standardized kits of Relyant scalers and curettes.
Each kit includes a 6/7 anterior scaler, 204S posterior scaler, Barnhart 5-6 curette,
Gracey 11-12 and Gracey 13-14 curettes. Customers also receive six of their current
hygiene kits (any brand) professionally sharpened for free, the option to trade in any
brand scaler to receive a 40 percent discount on a new Relyant instrument, and free
shipping (UPS Ground) on their first
six sharpening shipments.
The Relyant VIP Starter Kit
provides offices with a complete,
hands-off, sharpening solution,
while lowering replacement costs.
To learn more about Relyant
Scaler and Curettes, please visit
Neversharpenagain.com.
94
Futurabond M+
VOCO introduces Futurabond M+, a universal single-bottle
adhesive. The new adhesives versatility allows it to be used in
self-, selective- or total-etch mode without any additional primers,
on virtually all substrates.
Futurabond M+ achieves total-etch bond strength levels with all
light-, self-, and dual-cure resin based composites, cements and core
buildup materials. With a dual-cured activator, Futurabond M+ will
self-cure without any light activation, which offers a big advantage
for endodontic applications such as post cementation where it avoids
the pooling effect, a problem with light-cured adhesives. Futurabond
M+ also adheres well to metal, zirconia and ceramic making extra
primers unnecessary.
Futurabond M+ needs only one coat and takes 35 seconds from
start to finish. Its low film thickness of only nine microns makes
bonding margins invisible (i.e., no halo effect) and prevents pooling
problems. Additionally the material does not need to be refrigerated.
For more information on Futurabond M+, visit Voco.com.
practice solutions
Dont Just Watch The

Disease ... Manage It!
by Parag R. Kachalia, DDS
Dr. Parag Kachalia is the vice chair of
simulation, technology and research
at the University of the Pacifics
Arthur A. Dugoni School of Dentistry.
He is a fellow of the American Dental
Education Associations leadership
institute, is a researcher, and a published
author in the areas of digital dental
photography, digital fi xed prosthodontics,
and financial management. He has
lectured internationally in the areas of
adhesive dentistry, cosmetic dentistry,
photography, CAD/CAM technology, fi xed
proshthodontics, and new concepts
within local anesthesia and diagnostic
technologies. He maintains a private
practice geared toward restorative
dentistry with his wife and fellow Pacific
alum Dr. Charity Duncan.
Case No. 1
Case No. 2
Each and every month in practices around

the world, numerous patients hear the dentist
say the word, watch.
Generally speaking, this term is used
when a clinician sees an early cavitation or an
area of erosion. The question should be asked,
What does the clinician expect to happen to
the dentition during the watching period?
The clinician generally has the patients
best interest at heart, and does not want to
surgically treat an area before he or she believes
it is justified. In order to truly move dentistry
forward, we must think critically about changing this watch-and-wait paradigm. Dentistry
should move toward an active-management
approach, in which cliniciansalong with
their team membersevaluate a patient as an
individual and decide if surgical or chemical
intervention is needed when a cavitated lesion
or an area of erosion is discovered.
Thankfully, products are on the market
that allow remineralization of tooth surfaces.
Historically, remineralization focused primarily on fluoride. However, today we can combine the advantages of fluoride with xylitol
and nano-hydroxyapatite in a simple paste.
VOCOs Remin Pro contains all three
ingredients to allow for easy application by
both members of the dental office as well as
the patient.
prevent caries and change damaged tooth

structure into a more acid-resistant fluorapatite. Traditional enamel is demineralized
when exposed to a pH of 5.5, and dentin
demineralizes at a pH below 6.7.
However, fluorapatite can take a more
significant acid challenge and does not demineralize until the pH reaches 4.5 in the oral
cavity. Remin Pro contains about 1,450ppm
of fluoride compared to 1,000ppm in overthe-counter toothpaste.
Key ingredients and benefits
Nano-hydroxyapatite (nHAP)
Fluoride
Through numerous studies, fluoride
has proven to be an agent that helps to both
Xylitol
Xylitol is a natural sweetener that tends
to be more forgiving to the dentition compared to sugars such as sucrose. Over the
years, the literature has been mixed as to
whether xylitol can also aid in remineralization of enamel and dentin, and the literature
has shown that approximately 6 grams of
xylitol must be consumed per day to show
remineralization benefits.
Regardless of the efficacy of remineralization, the clear benefit of xylitol is that it
decreases the growth of bacteria such as strep
mutansand possibly lactobacilliand
increases the production of saliva. This mechanism allows for less acid to be produced and
creates a more favorable oral environment for
sustained health.
Nano-hydroxyapatite can be thought

of as the special sauce in Remin Pro. The
beauty of nHAP is that, because of its small
molecular size, it has the ability to penetrate
95
practice solutions
deeper into demineralized enamel and dentin. This

molecule has the ability to fi ll enamel irregularities,
as well as provide a surface sealing to dentin on
exposed root structure.
The resulting smooth surface makes the adhesion of dental plaque much more difficult. The
secondary benefit is that the visual increase of tooth
gloss becomes apparent. In addition, in a recent
in-vitro study published in the Journal of Dental
Research, biofi lm actually enhanced nHAPs ability
to reduce demineralization effects. Penetrating biofi lm can be very difficult and the fact that nHAP
can work in the presence of this biofi lm is very
promising for dentistry.
Cases
Patients who show signs of erosion or decay are
routinely prescribed Remin Pro to help mitigate the
destructive process.
In case No. 1, a man presented with a dentition
that has been completely free of decay for more than
96
40 years. Unfortunately, while he has been decay-free

he has been battling gastric esophageal reflux for
many years, and an extensive amount of enamel and
dentin loss is now present. In conjunction with ultimate restorative care, disease management was also
of paramount importance. A custom splint was fabricated to deliver Remin Pro and to help slow down the
erosive process.
In case No. 2, a patient presented with rampant
decay on a significant number of facial surfaces due
to extensive soda consumption. This patients treatment consisted of restoring the cavitated lesions with
resin, and managing the demineralized areas with
Remin Pro.
No single magic bullet exists that can solve
the issues we see with erosion and caries in our
patient population. However, products like
Remin Pro by VOCO allow clinicians to positively inf luence the oral environment and actively
manage the disease process, instead of taking a
watch and wait approach.
Say YES to ortho in your practice!

Stop letting orthodontic patients walk out your door. With SmileCareClub
Invisible Aligners, you can add an orthodontic solution to your practice.
Even if you already offer invisible aligners, with our aligners, you can help
price-sensitive patients get the smile theyve always wanted.
JOIN OUR NETWORK TODAY.
SmileCareClub.com/provider | (800) 689-1394

dentaltown
poll
MARKETING
Isnt it helpful to know what other practices are doing? With our monthly poll you can see how other practices operate, what works, what doesnt and
how dentistry is evolving. The information we gather each month helps us measure trends in the profession. This marketing poll on was conducted on
Dentaltown.com from August 20, 2015 to September 15, 2015.
Do you use paid ads on Facebook for your practice?
2 7 %
7 3 %
Yes
No
Do you have a display ad

in any phone book?
19%
81%
Yes
40%
No
Yes
60%
No
65%
62%
58%
Have you ever paid for search engine

optimization (SEO) for your practice?
If so, did you have success?
In the last six months, the trend for

new patients in my practice has
65% No
35% Yes
98
Do you utilize any special offers

in your marketing?
62% I have never paid for SEO

24% Yes
14% No
58% Increased
35% No Change
7% Decreased
dentaltown
poll
When was the last time you sent a direct-mail piece to promote your practice?
Not for a long time/never
74%
Within the last three months
13%
Within the last year
13%
0%
Within the last six months
Do you spend any marketing dollars with review sites such as Yelp, Angies List, etc.?
9 4 %
0 6 %
No
Yes
99
general practice
feature
SURGICAL CROWN
LENGTHENING:
An Integrated Approach
in Esthetic Treatment
of Altered Passive Eruption
by Dr. Cirimpei Vasile
Case presentation
Fig. 1
Altered passive eruption is a condition that frequently brings

patients into the dental office seeking a solution to esthetic
problems.
Most of the patients I see in my office who are willing to
solve these problems are women between the ages of 20 and 35.
Below I will present a case of a 27-year-old woman diagnosed
with an altered passive eruption (Type I, Subtype B1).
The patient presented with signs of both a gummy smile and
poor dental morphology (Fig 1).
Fig. 2
We arrived at the understanding

she wanted to have a unique, nonpatterned smile The patient was
pleased with the result.
With this in mind, surgical crown lengthening alone could
not solve the esthetic demand. Further restorative implications
were imperative. Surgical planning was done upon a dye cast.
This was a crucial part of the procedure. For good outcomes,
100
Continued on p. 102
general practice
feature
clear visualization of the final result is mandatory.

A gingivectomy was performed with a 15c blade. The blade
followed the outlines which were transferred via a surgical stent.
After the plain removal of gingival tissues a new tooth morphology could be visualized (Figs. 2 & 3).
One thing to mention is that in this particular case, the
gingivectomy could be performed safely, due to a very large
amount of keratinized tissues that were present apical to CEJ. It
is important to consider that in some particular cases, a gingivectomy is not a viable option, especially when there is a minimal
amount of keratinized tissues.
Those cases require a split mucosal flap and an apical reposition of gingival margin. Of course, this technique would be
anticipated after treatment planning.
Fig. 5
Fig. 6
Fig. 3
Fig. 7
Fig. 4
102
general practice
feature
Fig. 8
Fig. 9
Keratinized tissues are not a prerequisite of odonto-perio

homeosthasis. However, they might induce certain clinical situations like tooth sensitivity, poor mucosal perio response (if restorative margins are close to gingival margin), poor esthetics, etc.
Tooth 2.2 is a good example of the plaque harbo. This was
subgingival plaque which expanded .5mm below the gingival margin. A total of 1mm of gum was removed. The total
distance from the former gingival margin to the bone level
consisted of 3mm.
Following flap reflection, an osteotomy was performed in order
to gain new bone morphology and compensate further gingival
margin rebound. Considering this stage as an irreversible one, it
is important to proceed meticulously. Again, a surgical stent is a
powerful tool to gain a certainty in bone reduction (Figs. 5 -11).
Fig. 10
Fig. 11
103
general practice
feature
Fig. 12
The patient wanted something to

be done with her smile but she
did not know how to express her
concept of it. We arrived at the
understanding that she wanted to
have a unique, non-patterned smile.
Fig. 16
Fig. 13
Fig. 17
Fig. 14
Fig. 15
104
general practice
feature
Fig. 18
Fig. 22
Fig. 19
Fig. 20
Fig. 21
105
general practice
feature
In this case, at 12 days, teeth where restored in a mock-up

manner via injection molding. Going forward my plan is to
deliver Emax veneers on the central incisor and upper right
canine, and also a full coverage Emax crown on upper left second
incisor. Mockups allow a great visual as to what further definite
restoration results will look like. Additional images are included
for better visualization (Figs. 12-22see pp. 104 & 105).
Flap approximation via suturing was identical to the position
desired and transferred on the surgical stent Soft tissue maturation after surgical crown lengthening does require time, in some
cases even as long as 12 months. Clinically, this parameter typically does not take that long. One month post-op soft tissue was
present (Figs. 23 & 24).
Certainly, further soft-tissue maturation was going to follow.
This is why most of the cases I restore in the frontal sector, and
where previously surgically lengthened work was done, a period
of six months is needed for full maturation of gingival margins.
One thing to mention is that in this

particular case, the gingivectomy
could be performed safely, due to
a very large amount of keratinized
tissues that were present apical
to CEJ. It is important to consider
that in some particular cases, a
gingivectomy is not a viable option,
Conclusion
especially when there is a minimal
The patient wanted something to be done with her smile but

she did not know how to express her concept of it. We arrived
at the understanding that she wanted to have a unique, non-patterned smile. In order to achieve that, gingivial zeniths were
translated distally, and the long axis of the teeth were orientated
in a divergent manner.
Final smile line presented a totally new smile with a totally
different morphology. The patient was pleased with the result.
amount of keratinized tissues.
Another important stage with this patient was flap suturing.

In this particular case a vertical mattress suture was used. This
type of suture is quite simple to perform.
If moderate pressure is applied to the flap, and the needle
penetrates the flap in the correct position, flap approximation to
underling bone can be achieved in a very predictable manner.
References
1. Coslet JG et al., Diagnosis and classification of delayed passive eruption of the dentogingival junction
in the adult. Alpha Omegan. 1977 Dec;70(3):24-8.
2. Proceedings of the world workshop in clinical periodontics (1996). Consensus report on mucogingival
therapy. Annals of Periodontology 1, 702-706
3. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-month clinical wound healing study. J
Periodontol. 2001 Jul;72(7):841-8.
Whats your method of surgical crown lengthening? Comment after this article at Dentaltown.com/magazine.aspx.
Author Bio
Dr. Cirimpei Vasile is a practicing dentist in the Republic of Moldova. He has been a member of the European Association of Dental Public Health since 2010.
Vasile has published 13 articles nationally and five internationally. His primary focus is periodontal stability after pro-prosthetic periodontal surgery. He
speaks five languages.
106
product profile
feature
Umbie Dental Care:

Cloud-Based Practice
Management Software
That is Above the rest
Umbie DentalCare is a complete practice management

platform designed to enhance your experience and grow
your practice. Umbie DentalCare includes advanced features
like scheduling, patient notications, treatment planning,
and cloud-based X-rays to the third-party API access.
Umbie DentalCare is constantly adapting to remain the
most advanced software on the market.
Through Umbie DentalCare, you can manage multiple locations from one desktop, iPhone, iPad or any other mobile
device. Umbie DentalCares cloud-based software provides
comprehensive practice management for a at monthly
fee. As a result, it enables a dental ofce to eliminate on-site
servers that have costly ongoing maintenance, upkeep and
updates. The solution optimizes ofce workow, increases
productivity and structures communication. It also provides
complete practice oversight that measures, monitors, and
protects the practiceall with remote access from any device with an Internet connection.
Umbie DentalCare includes patient charting, billing,
scheduling, imaging, patient data and communication, all
in one system. The unique Huddle component provides a
direct connection between ofce staff and their daily responsibilities, but closes the loop with practice performance
and patient engagement.
The customized and secure remote-access modules
and role-based user privileges provide unique visibility for
dentists, ofce managers, and patients alike.
For more information, call (855) 835-5424 or visit Umbie
dentalcare.com
107
hygiene
feature
And
Sealants
for
All
How to serve your patients,

increase your value and help
your practices bottom line
Are you offering sealants to all of

your patients?
by Emilee Berger, RDH
108
When it comes to reducing a patients caries

rate, sealants are one of the best lines of defense
dental providers can offer. So why is it that
many hygienists only suggest them for children,
and only on first and second molars?
Many adults are also prone to occlusal decay
on all posterior teeth. Because many patients
automatically decline preventive treatment if
their insurance doesnt cover it, many hygienists
wonder if we should waste precious minutes

suggesting treatment that will be ignored. Lets
face it, we already have a busy schedule and it
seems like more practices are demanding us
to work faster. How are we supposed to add
sealants to our appointments when some of us
are only getting 30 to 40 minutes to complete
a prophy?
I once felt like this, too, but recently I
have taken an entirely new approach. I spend
a majority of my appointments educating my
Continued on p. 110
hygiene
feature

patients on all areas that pertain to them. I make the
same recommendations for my patients that I would
make for my family. I have noticed that when I educate
my patients and spend an extra minute making sure they
understand my suggestions and treatment plans, they
respond well to me, and every appointment that follows
goes a little bit more smoothly.
Whenever a hygienist says to me that she or he feels
like a salesperson by suggesting treatment that may not
be covered by insurance, I always laugh and tell them,
thats where they are going wrong. We have to change
our attitude. We are not in sales. We are in health care
and our main goal is preventing oral diseases.
Its all in the approach

If I have an adult in my chair and he or she is caries-prone, I spend a minute educating on how to prevent
future caries by using sealants on non-filled teeth, and
keeping up with regular fluoride treatments. If finances
and insurance coverage are a concern, I simply say
that the cost for a sealant and fluoride is similar to or
less than the copay for a filling. If multiple sealants are
needed, I may suggest doing one at time. This is helpful
for the patients finances, and great for us when time is
not on our side. This is not a sales technique; its educating my patient on preventive services that will provide a
benefit and save him or her money in the long run.
I have noticed that if I approach my patients with
this attitude, I have a much better acceptance rate and
I feel like an educatornot a salesperson. When I feel
like my patients are leaving my chair with a little more
knowledge than when they came in, I know I have done
my job.
Add value for themand you

There will always be one or two patients who simply
cannot afford preventive treatment that isnt covered.
However, dont let those patients hold you back from
providing exceptional care for everyone. If we are not

offering services or products like sealants, fluoride treatments, prescription toothpastes, and chlorhexidine to
our high-caries-risk patients, then we are doing them a
disservice and not treating them with the standards of
care set by the ADHA.
If youlike mework in a busy practice where
they keep trying to shave minutes off of your appointments, dont let that hold you back, either. The reason
your office manager is shrinking your appointments
is because a prophy doesnt produce much. Adding
sealants to your appointments will provide you with
more production.
We have to change our attitude.

We are not in sales. We are in
health care and our main goal
is preventing oral diseases.
Even though we are not in sales, I do think its
important for hygienists to be aware of our production.
Without knowing our worth, how can we ask for a raise
or seek a new position in todays competitive job market?
Most patients will gladly pay for a sealant instead of a
filling, and there really is no reason not to offer sealants
to all patients at risk for caries. Adding sealants to our
treatment plan is an easy way for us to increase our
production, make ourselves more marketable, and better
serve our patients who trust us with their oral health.
How often do you offer sealants to patients? Comment on this article at Dentaltown.com/magazine.aspx.
Author Bio
Emilee Berger has been a registered dental hygienist for more than nine years. She has experience in clinical practice,
education and sales. She currently works part time for a private practice in Peoria, Arizona. She recently started a blog
and invites you to follow her at EmileeRDH.wordpress.com.
110
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Human Herpesvirus Infections

and What They Mean for Dentists
by Ronald Keeney, MD
he human herpesviruses
(HHVs) are the cause of a
wide range of illnesses in large
numbers of people around the
world. The diseases range from trivial and
self-limited to lethal. The common coldsore virus can cause encephalitis and others increase the chances of acquiring HIV.
Relief of suffering and shortening the time
of viral replication and perhaps even some
cures are possible in the foreseeable future.
HHVs are ubiquitous viruses that have
been around at least as long as human history has been recorded. Some have only
recently been recognized, and there will no
doubt be more to follow. Herpesviruses are
present throughout the animal and plant
kingdoms. A herpesvirus may have caused
the Irish potato famine. It can certainly
kill off the genetically engineered clones
that are used to begin the tiny plants that
become one of the worlds major food
crops. A herpes virus was responsible for
the loss of nearly all oysters in France
in 2007. Equine anemia is caused by a
herpesvirus and poses a major threat to
breeders, racers and showers of the worlds
fi nest horses. Simian Herpes B virus,
another herpesvirus, causes lesions in
monkeys similar to human cold sores. In
humans, the same virus can cause a form
of encephalomyelitis that is lethal in 75
percent of cases.
The origins of HHV are lost in antiquity, but our imaginations allow us to
speculate that at the beginning of human
time, intracellular genetic accidents may
have occurred during normal cellular
growth, metabolism and replication.
These accidents might have resulted in
sub-microscopic, viable particles of DNA
that got trapped in an outer coating of

normal cell membrane, as apoptotic cells
collapsed upon themselves. Upon contact
with other live cells, these particles might
have fused their membrane with familiar
host-cell membranes, thus gaining entry
into the live cell to begin a new life cycle
of latency, reactivation, replication and
future movement to other cells.
The HHV causes a variety of infections and disorders that range from mild
and self-limited to morbidity-causing,
sight-threatening, debilitating and
life-threatening diseases. They are the first
human viruses to have been successfully
treated with disease-specific drugs. Most

of historys successes against viruses have
been achieved with vaccines. The HHV
has opened the door to specific and effective treatments not just for HHVs, but for
human immunodeficiency virus (HIV),
human hepatitis viruses, influenza viruses
and in the very near future, quite possibly
the respiratory syncytial and the rhinoviruses (common cold virus).
During the early 1980s, HHVs, particularly HSV-2, received widespread media
attention. The magazine Time ran a story
with the cover proclaiming genital herpes
as the new Scarlet Letter. However, the
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emergence of what later became known

as AIDS diverted attention and research
funding away from the study of herpes.
Recent information has implicated various herpes virus strains as being involved
in the transmission and/or progression
of deadly diseases including HIV/AIDS.
This new mechanistic information was
not known in the early 1980s and is just
beginning to be explored and understood.
Diversion of research assets away from
herpes in the past two decades may prove
to be an extremely regrettable error.
Dental-practice issues
There are special issues for the dentist
to consider when it comes to HHV. The
most obvious might be that dentists and
dental hygienists are constantly exposed to
the possibility of becoming infected with
HSV-1, as cold sore sufferers are known
to have the virus in their saliva five to 15
percent of the time when they have no
apparent cold sore. Of course, the risk is
especially acute when a cold sore is present
during dental procedures. Infection of the
fingers can lead to herpetic whitlow that
can interfere with the dental professionals
day-to-day practice. In addition, infection
of the eyes by contact with infected spray
or drilling particles can lead to blindness.
Acquisition of infection from an active cold
sore is easy to guard against by postponing
the procedure until after the cold sore heals,
but acquisition of infection from salivary
silent shedders can only be avoided by
wearing protective equipment, such as
latex gloves, full-face shields, or mask and
eye protection. The prudent dentist may
consider patient protection measures as
well, particularly when patients with a documented history of cold sores are involved.
Collateral damage due to the presence of an
active cold sore in a scheduled patient is the
loss of income when a major procedure has
to be postponed.
The dental professional must also
be aware of the possibility of inducing
active, recurrent orofacial HSV-1 disease
as a result of performing a dental procedure. While the causes of reactivation
114
of latent HSV-1 in the ganglion cells

has not been completely elucidated, it is
clear that trauma to the anatomic region
of original infection can and does induce
reactivation and recurrence of cold sores.
It is not unusual for a patient with a coldsore history to report onset of an episode
immediately following procedures of
two or more hours duration, or one that
involved a great degree of manipulation
resulting in lip trauma.
The typical activities of a dental practice usually do not include the treatment
or prevention of a medical condition
associated with significant morbidity and
mortality. In the case of treatment of cold
sores, the dental professional does have the
opportunity to not only prevent significant
disease but also to educate patients to
prevent the transmission of their HSV-1
to other parts of their own bodies or to
vulnerable individuals at risk of life-threatening disease. In this instance, the dental
professional can be a life-saver. There have
been cases where young children have died
from HSV-1. This sad occurrence can be
prevented with education and effective
cold sore treatment. Yes, the everyday
dental practice can save lives! But in order
to educate the public, dental professionals
must first educate themselves.
Human herpesviruses
There are eight known human herpesviruses. Each DNA lipid-coated human
herpes virus is morphologically identical

and indistinguishable under an electron
microscope. The most common are herpes
simplex, type 1 (HSV-1), herpes simplex,
type 2 (HSV-2), Varicella zoster (VZV),
Epstein-Barr (EBV) and cytomegalovirus (CMV). Less commonly known, are
Kaposis sarcoma virus (KSV, HHV-8),
human herpesvirus 6 (HHV-6) and
human herpesvirus 7 (HHV-7).
Of these, HSV-1, HSV-2, and VZV
are neurotropic and share a characteristic
infection cycle that involves infection of
the nerves, latency within the nerve body,
and reactivation leading to recurrence.
The remaining blood-borne HHV share
a similar latency and reactivation cycle,
except that immortalization involves leukotropic cells rather than nerve cells.
Recurrence cycle of the

neurotropic HHV
HSV-1, HSV-2 and VZV share an
infection and recurrence cycle that is
identical except that the infected ganglion
cells vary in their anatomic location with
the type of disease. Following primary
infection, the herpes virus continues
to infect adjacent epithelial cells until
it encounters the terminal neuron of a
sensory nerve. The virus sheds its lipid
envelope and transverse buds across the
terminal neuron. By a process that is not
well understood, described as retrograde
axonal transport, the virion journeys up
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the shaft of the nerve axon and comes to

rest in the nerve cell body where it goes
latent. Latency involves the DNA closing
on itself in a circular fashion and becoming invisible to the body.
Upon experiencing a stressor or stimuli
such as UV-B, weakened immune system
(with or without febrile illness), localized
trauma (such as dental work), or extreme
emotional stress, the lytic gene expresses
and the DNA unravels from its circular
orientation, reforms into a virion, travels
back down the axon (anterograde axonal
transport) and buds out the terminal neuron, re-assembling its lipid envelope as it
does so. The now-reconstituted virus infects
the nearest adjacent cell and the recurrent
infection begins as the infected cell lyses
and more adjacent cells become infected.
Herpes simplex, type 1

HSV-1 most commonly causes cold
sores, also referred to as fever blisters,
but technically known as herpes labialis.

HSV-1 is the herpes virus most frequently
encountered by dentists. Cold sores/fever
blisters are a manifestation of a recurrent
HSV-1 infection. They occur following a
primary orofacial HSV-1 infection. The
primary infection most often occurs in
the toddler and teen years. The former is
thought to be associated with the relatively
non-fastidious, oral exploratory behavior
of toddlers, resulting in the transmission
of viruses in the oral secretions of some
to other children by way of contaminated
toys, eating utensils and drinking vessels.
The latter is thought to be associated with
kissing, or the sharing of cosmetics or
facial towels. By the time full adulthood
has been achieved, more than 85 percent
of American adults have been exposed to
HSV-1, as shown by positive serology to
the virus, and 40 percent or approximately
100 million persons experience recurrent
cold sores.
Primary infection can involve the

perioral skin and the intraoral mucosa.
Regional lymphadenopathy and systemic
signs (fever) and symptoms (malaise,
myalgia) may accompany the primary
infection. On uncommon occasions, the
severity and duration (up to six weeks) of
the primary infection may require hospitalization, intravenous hydration and
intravenous antiviral chemotherapy. Oral
secretions are highly contagious during the
primary episode and remain so for up to
three or more weeks.
Recurrent disease is usually discrete
with a wide range of clinical expression of
severity. Some patients will have a single
locus of recurrent lesions for all future
episodes, while others will experience
multiple sites of recurrence, some or all of
which activate with each new recurrence.
The mildly affected will have an episode
every few years while those at the opposite extreme of severity will experience
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episodes occurring so frequently that they

are virtually never free of lesions. The
average for those who have overt, recurrent
episodes is about four episodes per year.
Systemic signs and symptoms are not typical of recurrent disease.
Epidemiologic concerns include
recent findings that five to 15 percent of
recurrent disease patients have the virus
present in their oral secretions when they
are not experiencing an active cold-sore
outbreak. During these times of silent
shedding the infection may be spread to
an unsuspecting contact. The viral counts
at the surface of lesions when one is experiencing an active outbreak are very high
during the first day or so and usually low
to absent by day three to four.
Additional epidemiologic cautions
present themselves in the knowledge
that HSV-1 is capable of causing a form
of necrotic, focal encephalitis that is 70
percent lethal when untreated in immunocompetent patients and can cause
life-threatening, progressive local (necrotizing esophagitis and eczema herpeticum)
and blood-borne (hepatitis and pneumonitis) infection in immune-compromised
patients and neonates.
During episodes of active infection,
one must exercise caution to avoid transmission to others or self-inoculation of
the cold-sore virus to other parts of ones
own body. Transmission to fi ngers can
lead to herpetic whitlow that sometimes
recurs with work-related use of the fingers.
Transmission via fingers to the eyes can
lead to herpes keratitis and possible blindness. HSV-1 seronegative wrestlers who are
exposed to an infected wrestler during a
match can develop a generalized cutaneous
form of primary infection known as herpes gladiatorum that can be as severe as a
case of smallpox.
Transmission to the genitals can lead
to non-sexually transmitted genital herpes. Genital herpes caused by HSV-1 has
recently come to be recognized as result
of orogenital sexual activity superimposed
upon ignorance that cold sores are caused
by a transmittable herpesvirus. Those
116
- Dormancy
The cold sore virus lies dormant in the trigeminal
nerve where the immune system cant reach it.
- Activation
Stress, sunburn and other stimuli can cause the
virus to activate. The virus then travels down the
nerve in a process that takes about three days.
- Replication
The virus exits the nerve, and invades healthy
tissue where it begins to replicate. The bodys
immune system fights the virus in a process
that takes about 10 to 11 days without treatment.
Secondary Outbreak
A person can experience multiple outbreaks a
few hours to a few days apart if they experience multiple sunburns, stressful events, or
other stimuli close together. This is known as a
secondary event.
A symptom of a secondary event could include
a cold sore that suddenly worsens after it began
to heal. In this example a cold sore could take
much longer than the typical untreated 11 days
to heal.
between the ages of 12 and 30 make up

approximately 70 percent of primary genital herpes infections in the United States
and Europe with HSV-1 as the etiological
agent. HSV-1 and the cold sores they cause
should not be underestimated as a disease-causing risk of significant proportion
to oneself and to vulnerable populations.
A case historyinfant mortality

due to HSV-1 in the mother
Baby Jennifer Schofield died from
mums cold sore kiss of death. From
correspondents in London Agence FrancePresse Feb. 27, 2009, 09:36 a.m.

An 11-day-old baby girl died after
her mother unwittingly infected her with
the virus that causes cold sores, probably
through a kiss or breastfeeding, a British
coroner has ruled. An inquest found newborn Jennifer Schofield died from herpes
simplex virus (HSV). Her mother Ruth,
35, probably caught it late into her pregnancy, the coroner said, most likely for
the first time in her life, meaning she had
not developed immunity and nor had her
child. The virus attacked the babys major
organs and she died within days.
Ms. Schofield fell ill with flu-like
symptoms a few days before giving birth,
and was treated for several mouth ulcers.
Her daughter subsequently became unwell
and was admitted to a hospital because she
was sleepy and not feeding. Coroner James
Adeley said no one could be blamed for
failing to identify the virus. Ms. Schofield
is now campaigning to raise awareness
of the condition which she said kills six
babies a year in Britain. I have been left
totally devastated and heartbroken by the
death of Jennifer. Its more than a year
since she died but the pain has not lessened, she said.
Herpes simplex, type 2

HSV-2 is the most common cause of
genital herpes. Even though the majority
of first episodes of genital herpes have been
caused by HSV-1 in recent years, HSV-1
is much less likely to cause frequently
recurrent genital herpes. Thus, the majority (80 percent to 95 percent) of patients
presenting to STD clinics and other care
centers are suffering from recurrent HSV-2
infection. The Centers for Disease Control
(CDC) report that one in five Americans
over 12 is infected with HSV-2 genital herpes. One in four women is infected (> 50
million). The rates are substantially higher
for urban minorities.
Quite like HSV-1 orofacial infection
in immunocompetent persons, HSV-2
genital infection also has primary and
recurrent disease phases in which the
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primary disease is much more severe, more

locally extensive and often associated with
systemic signs and symptoms. Unlike
HSV-1, a third clinical type of disease in
genital herpes is called initial genital
herpes. Initial disease occurs when the
HSV-1 seropositive individual is infected
for the first time with HSV-2. The severity
of disease expression in these individuals
falls somewhere intermediately between
primary and recurrent disease. An ominous finding of recent serologic surveys
of the general population has revealed
that many people have been infected with
HSV-2 and dont know it. They dont
know it, because they either do not experience clinically apparent genital infection,
or they mistake their symptoms for some
other disorder. Some do, however, experience some form of genital dermatosis or
genital discharge that they do not attribute
to HSV-2, often because medical examination is not sought and the opportunity for
a specific diagnosis is missed.

The phenomenon of silent shedding
is present in genital herpes sufferers, too.
Studies utilizing PCR have demonstrated
that recurrent genital herpes patients shed
the virus in the absence of clinically apparent lesions approximately 15 percent to 20
percent of their lesion-free days. This makes
the risk of unsuspecting transmission a very
important part of the epidemiologic story
with genital herpes and leads to risk of
infection of unsuspecting sexual partners
and vulnerable populations. This risk is
present for those who have been diagnosed
as well as those who have the disease and
are not aware of their specific diagnosis.
Vertical transmission to neonates from
infected mothers during the perinatal
period can lead to life- and sight-threatening infection in the newborn. Transmission to vulnerable populations can lead
to life-threatening, blood-borne infection
and to progressive, localized disease.
Even more ominously, it has been

recently observed that the presence of
genital ulcers caused by HSV-2 during a
sexual encounter can substantially increase
the risk of acquisition of human immunodeficiency virus (HIV) infection, and reactivation of recurrent HSV-2 genital herpes,
or recurrent HSV-1 oral lesions in persons
already infected with HIV can result in a
marked increase in the number of HIV
particles circulating in their bloodstream.
The clinical significance of the latter finding is its potential for causing conversion
of healthy HIV-infected persons into
persons with AIDS.
Varicella zoster virus

VZV is the virus that causes chicken
pox in its primary form of disease expression and shingles (zoster, varicella zoster,
herpes zoster) in its recurrent or reactivation
form of infection. As with the previous two
HHVs, in vulnerable populations, VZV
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can cause morbid, disabling and life- and

sight-threatening disease. However, silent
shedding does not play a significant role
in its transmission with the exception that
for the 24-72 hours prior to the appearance
of the skin lesions of chicken pox, the nasal
secretions contain VZV particles that contribute to the epidemic spread of chicken
pox through enclosed and closely affiliated
seronegative populations.
It is also thought that exposure of a
seronegative child to an adult with shingles can lead to chicken pox in the child,
thus kicking off an epidemic of chicken
pox in the childs schoolmates. The adult
who escapes the primary infection of
chicken pox during childhood is at risk
of much more clinically severe disease,
and if the adult is a seronegative, pregnant woman, there is significant risk of
life-threatening disease. Shingles is a
disease usually associated with advancing age, with an approximate 10 percent
increase in incidence per decade of life,
making the elderly most likely to express
recurrent VZV infection as shingles. The
most debilitating consequence of shingles
is persistent nerve radical pain or post-herpetic neuralgia (PHN). PHN is a severe,
intractable pain syndrome that lasts from
a few weeks to the remainder of ones lifetime. It can be debilitating and disabling,
not infrequently leading to suicide in its
more severe expressions.
VZV is the only HHV for which
there is an effective vaccine to prevent or
significantly modify the clinical expression
of the primary infection. Recent data from
ongoing studies, though, are suggesting
that unlike the natural infection, immunity to the vaccine strain is neither absolute nor life-long.
Epstein-Barr virus
EBV is the etiologic agent of infectious
mononucleosis (IM). Its skin manifestations are not pathognomic, and not always
present in the IM patient. However, the use
of ampicillin in a patient with IM is likely
to result in the appearance of a florid rash
that is typical of the circumstances and
118
thought by some to be diagnostic of the disease. IM is a systemic infection commonly

affecting the lymph nodes, spleen and liver,
but is also capable of other organ involvement. It is most commonly transmitted
through oral contact, and it has a silent
shedding period before the appearance of
diagnostic signs and symptoms occur. It
can be debilitating, resulting in extreme
fatigue and exercise intolerance that has
been known to cause students to miss an
entire year of school. EBV does not cause
the same pattern of primary and recurrent
disease expression like HSV-1, HSV-2 and
VZV. However, in immunocompromised
patients, the virus can reactivate from its
latent form and begin to replicate and reappear in the blood stream. Over time, it can
stimulate transformation of lymphocytes
into malignant cells that cause an aggressive
form of lethal lymphosarcoma.
Cytomegalovirus
Cytomegalovirus (CMV) is found
nearly everywhere and cuts across all socioeconomic groups. CMV infects 50 to 85
percent of adults in the United States by
age 40 and is the most common HHV to
cause infection in newborns. The risk of
transmission from mother to neonate is
greatest when the mother has only recently
been infected. (The incidence of primary
infection in pregnant women in the United
States varies from one to three percent.)
The risk of transmission appears to be
nearly entirely associated with recent infection in the mother, and for those pregnant
women whose infection took place six or
more months prior to conceptionthe
neonatal CMV infection rate is one percent. Generally, the infection does not
cause significant clinical disease. However,
it has become appreciated in recent years
that CMV infection in infancy is associated with a high rate of deafness, and it
can cause systemic disease involving multiple organ systems and degrees of residual
central nervous system (CNS) damage,
ranging from mild to moderate as the
child ages. In organ transplant, bone-marrow-transplant recipients and other
immune-compromised patients, CMV

can cause debilitating and life-threatening
infection. It shares the characteristic common to other HHV, that of establishing a
latent life-form in the body after the primary infection and reactivating to cause
recurrent infection in later life and under
situations that render the host vulnerable
to recurrent infection. Disease expression
usually takes the form of pneumonitis,
hepatitis or meningoencephalitis. CMV
parotitis is often mistaken for mumps.
Kaposis sarcoma human herpesvirus (KSHV or HHV-8)

Kaposis sarcoma has been a long-recognized form of skin cancer in the elderly.
When AIDS emerged as a new human
disease, Kaposis sarcoma became one of
the AIDS-defining conditions. Unlike its
natural history pre-AIDS, Kaposis sarcoma
was suddenly a young persons disease.
Virologic studies led to the identification
of the Kaposis etiologic agent as the eighth
human herpes virus (HHV-8). Effective
AIDS treatments have reduced the prominence of Kaposis sarcoma as a progressive
disease of the AIDS population.
Human herpesviruses 6 & 7

HHV-6 was recently identified as the
cause of roseola infantum contagiosum
(roseola). HHV-7 has recently been found
in surveillance cultures of human cervices. Neither will be discussed in further
detail here.
Virology
HHV are large, double-stranded,
DNA viruses with a common virion structure with a few, highly conserved genes.
The virion consists of an icosahedral DNA
core (nucleocapsid) wrapped around a
donut-shaped protein core. The nucleocapsid is encased in a protein layer (tegument) that is covered by a lipid envelope
from which radiates spikes of glycoprotein
(Viruses, Ed. Levine, Scientific American
Library, 1992, page 70).
All eight HHV appear identical under
the electron microscope and share many of
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the same DNA base pairs. However, they

appear very different to the human immune
system and cause a wide variety of human
diseases ranging from trivial and self-limited to lethal. All HHV also share the ability to establish latency in immortalized cells
of either the nervous or hematologic system,
and all are capable of causing recurrent
disease weeks, months and years after the
primary infection. Their biggest mystery
is their ability to take on structural forms
during latency that are not recognized as
intruders by the hosts immune system, thus
assuring their immortality.
Prevention
From the results of the serologic
screening studies done in many parts of
the world, it can readily be seen that the
key to stemming the epidemic of HHV
infection caused by HSV-1 and HSV-2
is education. A significant portion of the
population is ignorant of the fact that the
common cold sore is actually an orofacial herpes lesion. The knowledge that
the viral cause of a cold sore can be transmitted to unsuspecting and vulnerable
populations can allow the cold sore patient
to exercise caution to avoid transmission
to others and to other parts of their own
bodies. Such knowledge would be especially helpful in preventing most of the
initial genital herpes infections currently
occurring, as it is now recognized that a
significant number of these are caused by
HSV-1. Frequent hand washing can go a
long way toward reducing risk of auto-infection. Herpes is extremely sensitive to
soap and warm water when on intact skin.
A better understanding of what genital herpes is can prevent the inadvertent
transmission from infected to non-infected
sex and life-partners. Armed with the
knowledge that one has genital herpes or
could be exposed to someone who does

permits the conscientious individual to
introduce the use of barrier protection
in the form of condoms into her or his
sexual encounters. The knowledge that
the cold sore virus can be transmitted to
a partners genitals during orogenital sex
can prevent that method of transmission.
Precautions taken during the perinatal
period by pregnant women can prevent the
life-threatening, vertical transmission of
their genital herpes virus to their newborn
infant. Avoidance of contact with immunocompromised relatives, friends and
associates can prevent cold-sore sufferers
and people with chicken pox or shingles
from spreading potentially life-threatening
infection to these vulnerable populations.
The suppressive use of oral nucleoside
antivirals can be an effective means of
helping to reduce one, the frequency of
active infection, two, the frequency of
silent shedding and three, the potential
for being transmissible at any given time.
This means of preventing transmission has
been most systematically studied and utilized in genital herpes sufferers, but may
also apply in selected cases of frequently
recurrent cold sores, as well. True prophylaxis in seronegative partners of people
with genital herpes has also been shown to
be partially effective.
Summary
Much relief of suffering and perhaps
even some cures are possible in the foreseeable future. The most recent player in this
arena is Viroxyn Professional, an exciting,
new addition to the anti-HHV armamentariumthe fi rst treatment system
to capitalize on the topical, microbicidal
approach in a field currently dominated by
systemic, anti-DNA nucleosides. Effective
application of these treatments and how
you apply your knowledge to the care of

your HSV-1 patients and their families can
and will save lives.
References:
Abreva New Drug Approval, NDA20-941, Source: www.fda.gov
Belec L, Tevi-Benissan C, Cotigny S, Beumont-Mauviel M,
Si-Mohamed A, Malkin J, In Vitro inactivation of Chlamydia
trachomatis and a panel of DNA (HSV-2, CMV, adenovirus,
BK virus) and RNA (RSV, enterovirus) viruses by the spermicide
Benzalkonium Chloride. Journal of Antimicrobial Chemotherapy,
2000(46) 685-693
Block, S. editor - Principles of Viral Control & Transmission
(Prince H, & Prince D), Chapter 28 in Disinfection, Sterilization,
and Preservation, 5th edition. Lippincott Williams & Wilkins,
2001; Table 28.2 pg. 525.
Federal Register of January 31, 1990. Skin Protection and External
Analgesic Products for Fever Blister and Cold Sore Treatment
Products; Notice of Proposed Rulemaking.
Heng M, Heng Sy, Co-infection and synergy of human immunodeficiency virus-1 and herpes simplex virus-1. Lancet, 1/29/94,
343:8892
Kawada R, Kitamura T, Nakogomi O, Matsumoto I, Arita M,
Yoshihara N, Yanagi K, Yamada A, Morita O, Yoshida Y, Furuya
Y, Chiba S. Inactivation of Human Viruses by Povidone Iodine in
Comparison with other Antiseptics, Dermatology 1997; 195(Supl
2):29-35
Mendez F, Castro A. Prevention of Sexual Transmission of AIDS
/ STD by a Spermicide Containing Benzalkonium Chloride. Arch
AIDS Research. 1990; Vol. IV: 115-135.
Menendez R., Lowe RS., Kersey J. Benzalkonium chloride and
bronchoconstriction. Journal of Allergy and Clinical Immunology.
1989: 84: 272-274.
Roberts C, Pfi ster J, Spear S. Increasing Proportion of Herpes
Simplex Virus Type-1 as a Cause of Genital Herpes Infections in
College Students. Sexually Transmitted Diseases; October 2003;
30(10): 797-800
Serwadda D, Gray H, Sewankambo N, Wabwire-Mangen F,
Chen M, Quinn T, Lutalo T, Kiwanuka N, Kigozi GF, Nalugoda
F, Meehan M, Morrow R, Wawer M. Human Immunodeficiency
Virus Acquisition Associated with Genital ulcer Disease and Herpes
Simplex Virus Type 2: A Nested Case-Control Study in Rakai,
Uganda. JID 2003:188 (15 November 2003)
Silverman S, Eversole R, Truelove E, Essentials of Oral Medicine,
2009, BC Decker, Hamilton, Ontario, Canada, Table 13-2,
Page 122
Smith J, Robinson J, Age-Specific Prevalence of Infection with Herpes Simplex Types 2 and 1: A Global Review. JID 2002 282:186
(Supl 1): S3-28
Wald A, CoreyL, ConeR, et al, Frequent genital herpes simplex
virus 2 shedding in immunocompetent women; effect of acyclovir
treatment. J Clin Invest. 1997; 99:1092-1097
Wald A, Zeh J, Selke S, Ashley RL, Corey L, Virologic characteristics of subclinical and symptomatic genital herpes infections. N Eng
J Med, 1995; 333:770-775
Wood A, Payne D. The Action of Three Antiseptics / Disinfectants
Against Enveloped and Non-Enveloped Viruses, Journal of Hospital
Infection. April, 1998; 38(4) 283-295
Wynn R, Meiller T, Crossley H, Drug Information Handbook
for Dentistry, 15th Ed. 2009, Ledi-Comp, Hudson, OH, Viroxyn
Drug Monograph, Page 214, and Treatments For Herpes Simplex,
Page 2033
Authors note: a version of this article was originally released in 2007.
Author Bio
Dr. Ronald Keeney, now retired after more than 40 years of experience with pharmaceutical clinical research, received his MD from the University of Missouri School of Medicine. He then continued his education with the University of Michigan and Washington University. Dr. Keeney
has a range of employment that extends from the largest multinational pharmaceutical companies in the world to startup and early-stage
micro-companies, contract research organizations and university faculty positions.
119
Approved PACE Program Provider FAGD/

MAGD Credit
Approval does not imply acceptance by a
state or provincial board of dentistry or
AGD endorsement.
10/1/2015 to 10/1/2018
Provider ID#304396
feature
Abstract
Quick, Conservative
and Highly Esthetic
Treatment Planning
for Severe Anterior
Tooth Wear
by Brent Engelberg, DDS
AGD
Code:
250
120
Severe tooth wear can lead to functional and esthetic

complications. For young patients who desire a quick,
conservative, and highly esthetic treatment plan, alternatives to orthodontics and invasive restorations are
necessary. Using occlusal equilibration, very thin lithium
disilicate veneers, and composite resin, this case presentation demonstrates a logical treatment plan that works
well to ensure proper function, occlusion, and restoration
of the patients esthetics.
Learning objectives
After reading this article, the reader should be able to:

Describe the steps necessary for treatment of severe
tooth wear.
Identify different types of tooth wear.
Explain the complications associated with
tooth wear.
This print or PDF course is a written self-instructional article with adjunct images and is
designated for 1.5 hours of CE credit by Farran Media. Participants will receive verification
shortly after Farran Media receives the completed post-test. See instructions on page 126.
feature
Introduction
Although tooth wear frequently
accompanies aging, parafunctional activities can exacerbate deterioration, leading to
compromised esthetics and function.
According to National Health and
Nutrition Examinations Survey data,
between 2003-2004, 80 percent of adult
subjects showed evidence of tooth wear.1
Additionally, a literature review in the
International Journal of Prosthodontics
found that the percentage of adult patients
presenting with severe tooth wear increased
from 3 percent at 20 years of age to 17 percent at 70 years of age.2
Severe or excessive tooth wear is identified when the patient expresses function or
esthetic concerns, wear is disproportionate
to the patients age, symptoms of discomfort are present, or the dentist deems the
rate of tooth wear to be severe.3
Tooth wear results from three processes: abrasion, attrition, and erosion.4
Abrasion is produced by the interaction
between teeth and other materials, and erosion is the dissolution of hard tissue by acidic
substances.4 Unlike abrasion and erosion,
attrition results from improper tooth-totooth contact.4 Occlusal and incisal attrition
may result from physiological wear and may
be severe if parafunctional habits such as
bruxism or clenching exist.5
Excessive occlusal attrition can lead to
functional and esthetic problems.6-8 Thus,
managing tooth wear and attrition is critical and complex.9 With tooth wear, dental
professionals must derive an accurate diagnosis and determine the precise stage to
implement active intervention, as opposed
to passive monitoring and management.3
Avoiding intervention of anterior attrition
can lead to further posterior complications
(e.g., attrition, lesions, loss of vertical
dimension of occlusion, etc.).10
However, early restorative intervention
may cause unnecessary damage to healthy
tooth structure during tooth preparation.
Additionally, a lack of understanding

about how to restore severely worn tooth
structure to maintain functionally and
esthetically stable teeth further compounds
the difficulties associated with tooth-wear
management.3
Treatment options for severe tooth
wear include occlusal positioning, vertical
dimension increase, and restoration.11
Restoration of severely worn anterior dentition requires clinicians to be familiar with
normal anatomical proportions and relationships.7 Clinicians must not only restore
the esthetics of the anterior teeth, but also
functionality in order to ensure restoration
Severe tooth wear can lead to functional and

esthetic complications. For young patients who
desire a quick, conservative, and highly esthetic
treatment plan, alternatives to orthodontics
and invasive restorations are necessary.
longevity. Properly planned anterior restorations have been shown to provide good
predictability, load resistance, longevity,
and preservation of healthy tissues.12
Although many clinicians recommend
orthodontics to realign occlusion and establish a healthy foundation after severe tooth
wear, many younger patients desire a less
expensive and quicker alternative. These
include minimally invasive treatments (e.g.,
minor occlusal adjustments) and protection
with nighttime appliances to ensure a high
probability of long-term success.
Addressing posterior teeth deflections
121
feature
Fig. 1
Initial presentation of a 29-year-old male with a diastema, occlusal complications, and tooth wear.
Fig. 2
Preoperative smile photograph demonstrating wear and

a diastema.
Fig. 3
Initial retracted view, indicating lower incisor wear and lateral

long axis angulation of the maxillary central incisors.
Fig. 4
Initial lateral view indicating lower incisor wear and mesial

rotations of the maxillary central incisors.
Fig. 6
The areas out of arch form on the facial and palatal surfaces were reduced on the diagnostic wax-up.
Fig. 7
The completed additive-reductive wax-up indicated

where reduction and addition were necessary.
Fig. 8
A green stent was fitted to the preoperative model to

indicate where initial reduction should be completed.
Fig. 9
The green stent was placed in the mouth prior to preparation to show precisely where initial reduction was necessary.
Fig. 10
Fig. 5
A diagnostic wax-up was created using an additive-reductive technique.
122
The preparations were completed with the distal contact

of the central broken in order to add to the mesial of the
lateral.
feature
that may create occlusal avoidanceleading to chipping and excessive wearprior

to restoring the anterior teeth will also help
stabilize occlusion.13 Additionally, newer,
stronger, and highly esthetic materials such
as lithium disilicate can be used for those
patients who want conservative dentistry
and an alternative to orthodontics.
Thus, the success of restorative treatment of severe tooth wear, once proper
occlusion is achieved, is predicated on
appropriate material choice, proper adhesive bonding, and predictable fabrication
techniques that yield durable and esthetic
restorations. Lithium disilicate allows for
very thin and conservative fabrication and
natural-like esthetics. Pressing to investment during fabrication ensures that the
very thin, waxed restorations do not break
during investment or transport.
Restorations bonded to enamel, as
opposed to dentin, protect the composite
restoration against cavo-surface discoloration and deterioration in marginal adaptation.14 As a gold-standard in adhesives,
using a 4th generation total-etch predictably
achieves stable bonds, although universal
adhesives have demonstrated improved
clinical success.
Case presentation
A 29-year-old male presented with the
chief complaints of chipped upper incisors, worn lower incisors, and a diastema
between the central incisors, which were
larger in size and rotated (Figs. 1 & 2). The
lower incisors presented with severe incisal
wear compared to the patients age, indicating an occlusal abnormality (i.e., posterior
interferences to closure) and habitual issues
(i.e., bruxing and/or nail biting) (Figs. 3
& 4). The patient requested esthetic treatment, but function and occlusion also
needed to be addressed.
The patients young age made it
important to treat the substantial wear
responsibly, as well as idealize function for
the case. After a comprehensive evaluation,

the patient was diagnosed with functional
anterior wear and esthetic flaws.
Continued anterior wear could lead
to posterior issues (i.e., lesions, malocclusion, etc.) and persistent patient insecurity
about the esthetics of his smile. Recommended clinical treatment included
occlusal equilibration, porcelain veneers,
The patients young age made it important to

treat the substantial wear responsibly, as well
as idealize function for the case.
and/or composite veneers/bonding.

Orthodontics could also be performed,
along with reshaping the lower incisors
and limited composite bonding.
The patient, however, declined orthodontics and requested a conservative yet
quicker solution. The proposed treatment
plan included occlusal equilibration,
maxillary anterior porcelain veneers,
and mandibular cosmetic and functional
bonding, followed by wearing a nighttime
bruxing appliance.
At the first appointment, diagnostic
photographs, a comprehensive evaluation
(i.e., occlusal analysis, TMJ evaluation,
periodontal charting, oral-cancer screening,
and evaluation of existing dentistry), radiographs, and impressions were completed.
The diagnostic impressions were used for
an additive-reductive wax-up (Figs. 5-8) and
reduction stent fabrication. The occlusal
equilibration was completed using a deprogramming period involving a leaf gauge and
a combination of diamond burs.
123
feature
Fig. 11
Retracted view of the provisional maxillary veneers and

lower completed composite restorations.
Fig. 12
Full-smile view of the provisional restorations.
Fig. 16
The completed veneers were as thin as 0.3mm on the

facial surface.
Fig. 17
After the veneers were completed in the laboratory, they

were returned for final placement.
Fig. 13
Fig. 18
The provisional restorations were checked for occlusion,

function, and esthetics.
Fig. 14
The restorations were pressed to investment and then cut

back and layered.
The final restorations were placed, closing the diastema and

improving the tooth proportions and alignment.
Fig. 19
The lateral retracted view reveals the tissue harmony of the

maxillary veneers and the completed lower teeth.
Fig. 20
Fig. 15
The laboratory completed the layering and surface texture

for lifelike esthetics.
124
The completed smile view. The patient was very pleased

with the results.
feature
Using green stents and great laboratory

communication through the diagnostic
wax-up, preparations were completed precisely. For the porcelain veneers, initial facial
reduction of any tooth structure protruding
from the arch form was completed using
the green stent as a guide (Fig. 9, see p.
122). The teeth were further prepared with
diamond burs, and the preparations were
polished with polishing discs (Fig. 10, see
p. 122). Veneer temporaries were fabricated
using temporization material in shade A1.
The mandibular incisors (teeth #2326) were lightly prepared where dentin was
visible and unsupported or sharp enamel
was present. The teeth were cleaned with
chlorhexidine pumice, and a total etch
technique was used. Etchant, desensitizer,
and dental adhesive were applied to the
teeth prior to placing A1 body and enamel
shades of composite. A glycerin-based gel
was applied prior to the final cure (Figs. 11
& 12), after which the completed composite restorations were polished.
One week later, the provisional maxillary veneers were evaluated and approved
(Fig. 13). The final porcelain veneers were
pressed to investment material to allow
for very thin facial surfacesas thin as
0.3mm. These veneers were cut back and
layered to a final shade in the B1/040 range
(Figs. 14-17).
The final restorations were seated after

removing the provisionals and checking the
veneers for fit and color accuracy using a
try-in gel. A total-etch technique was completed using the same materials as the composite bonding, with the exception of treating
the intaglio of the veneers with silane (Figs.
18-20). At the same visit, an impression was
made for a mini-deprogrammer-type bruxing
appliance for nighttime use.
Three weeks later, the restorations and
occlusion were evaluated and photographs
were taken. The appliance was delivered,
and the patient was instructed to use the
mini-deprogrammer at night to avoid
damaging the final restorations.
Conclusion
Although tooth wear is prevalent
among American adults today, severe tooth
wear can cause patient discomfort, poor
esthetics, and damage to existing dentition
and function. Esthetic, functional, and
affordable solutions are available to restore
the functionality and esthetics of worn
dentition, and are especially appropriate
with younger patients. Patients with severe
tooth wear must be offered a conservative
and esthetic treatment option instead of
more aggressive and invasive procedures,
and when conservative orthodontic treatment is declined. Understanding function,
natural-like esthetics, and appropriate

materials will prove beneficial for clinicians
performing this type of treatment.
References
1. Okunseri C, Wong MC, Yau DT, et al. The relationship
between consumption of beverages and tooth wear among adults
in the United States. J Public Health Dent. 2015 Apr 28. Doi:
10.1111/jphd.12096. [Epub ahead of print].
2. Vant Spijker A, Rodriguez JM, Kreulen CM, et al.
Prevalence of tooth wear in adults. Int J Prosthodont.
2009;22(1):35-42.
3. Mehta SB, Banerji S, Millar BJ, et al. Current concepts on
the management of tooth wear: part 1. Assessment, treatment
planning and strategies for the prevention and the passive management of tooth wear. Br Dent J. 2012;212(1):17-27.
4. Addy M, Shellis RP. Interaction between attrition, abrasion
and erosion in tooth wear. Monogr Oral Sci. 2006;20:17-31.
5. Zeighami S, Siadat H, Nikzad S. Full mouth reconstruction of
a bruxer with severely worn dentition: a clinical report. Case
Rep Dent. 2015;2015:531618.
6. Turner KA, Missirlian DM. Restoration of the extremely worn
dentition. J Prosthet Dent. 1984;52(4):467-74.
7. Patel RM, Baker P. Functional brown lengthening surgery in
the aesthetic zone; periodontic and prosthodontic considerations.
Dent Update. 2015;42(1):36-8, 41-2.
8. Abdel-Azim T, Zandinejad A, Metz M, et al. Maxillary
and mandibular rehabilitation in the esthetic zone using
a digital impression technique and CAD/CAM-fabricated
prostheses: a multidisciplinary clinical report. Oper Dent.
2015;40(4):350-6.
9. Vant Spijker A, Kreulen CM, Creugers NH. Attrition, occlusion, (dys)function, and intervention: a systematic review. Clin
Oral Implants Res. 2007;18 Suppl 3:117-26.
10. Padmanabhan S, Reddy VA. Inter-disciplinary management of
a patient with severely attrited teeth. J Indian Soc Periodontol.
2010;14(3):190-4.
11. Muts EJ, van Pelt H, Edelhoff D, et al. Tooth wear: a
systematic review of treatment options. J Prosthet Dent.
2014;112(4):752-9.
12. Pontons-Melo JC, Pizzatto E, Furuse AY, et al. A conservative
approach for restoring anterior guidance: a case report. J Esthet
Restor Dent. 2012;24(3):171-82.
13. Ruiz JL. The three golden rules of occlusion. Dent Today.
2010;29(10):92-3.
14. Berry TG, Osborne JW. Dentin bonding vs. enamel bonding
of composite restorations: a clinical evaluation. Dent Mater.
1989;5(2):90-2.
Want more CE? Choose from hundreds of courses at Dentaltown.com/OnlineCE.
Author Bio
Dr. Brent Engelberg graduated from the Indiana University School of Dentistry before establishing his current practice in Arlington Heights,
Illinois. Dr. Engelberg not only seeks out educational opportunities for himself but also strives to educate other dentists. He co-directs his
multidisciplinary dental study club in the Chicago suburbs, which attracts many local and national speakers. He is widely published in professional dental journals on the subject of esthetics and cosmetic dentistry and teaches other dentists cosmetic procedures through his courses.
Dr. Engelberg lives a happy life in Lake Forest, Illinois, with his wife and three children. He extends a special thank you to Dane Barlow for his
outstanding ceramic work in this case.
125
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the View All Courses button. Please note: If you are not already registered on www.dentaltown.com, you
will be prompted to do so. Registration is fast, easy and of course, free.
1.
According to a 2003-2004 national survey, how many adults in the

United States exhibit tooth wear?
a. 50 percent
b. 60 percent
c. 70 percent
d. 80 percent
2.
It is considered severe tooth wear when which of the

following occurs?
a. The dental patient expresses function or esthetic concerns
b. Wear is disproportionate to the patients age
c. The rate of tooth wear is deemed to be severe by the patients
dental professional
d. All of the above
3.
Attrition results from:

a. The interaction between teeth and other materials
b. Improper tooth-to-tooth contact
c. The dissolution of hard tissue by acidic substances
d. None of the above
4.
Treatment options for severe tooth wear do not include:

a. Diagnostic waxing
b. Occlusal positioning
c. Extraction
d. Vertical dimension increase
5.
Parafunctional habits lead to what kind of tooth-wear process?

a. Attrition
b. Abrasion
c. Erosion
d. Dissolution
6.
Early intervention of anterior tooth wear may lead to:

a. Posterior complications
b. Damage to healthy tissues
c. Loss of vertical dimension of occlusion
d. Further attrition
7.
This type of treatment for tooth wear provides good predictability,

load resistance, longevity, and preservation of healthy tissues.
a. Diagnostic waxing
b. Occlusal positioning
c. Restoration
d. Orthodontics
8.
Younger patients typically desire treatments that are:

a. Conservative
b. Esthetic
c. Cost-effective
d. All of the above
9.
Which of the following steps were not used in this case presentation
to restore the patients dentition?
a. Diagnostic wax-up
b. Green stent for preparation
c. Increase in vertical dimension of occlusion
d. Porcelain veneers
10. The lithium disilicate veneers were as thin as ____ on the facial.
a. 0.3mm
b. 0.4mm
c. 0.5mm
d. 0.7mm
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Apply Composite
Adapt Fibers
Finished Splint
Single-Visit Bridges
5. Its
in Las Vegas! It is common knowledge that what

happens in Vegas, stays in Vegas. And at the Townie Meeting, a
lot can happen. Dont be the dentist left in the dark.
And in case you need a few more reasons, here is what

Townies on the Dentaltown message boards have to say
You can learn more about dentistry just sitting around the lunch
table with Brad Smith, Corey, Tim Lott and Howard Farran, than you
did in four years of dental school. ~ tiger cub
Now I have to explain to my kids that it is OK for Dad to meet people
in person that he meets online, but its not OK for them. ~ drpeteg
I have attended Townie Meeting for the last 10-plus years and
it is the best meeting ever. Every year I come away with useful
information that can improve my practice, allowing me to provide
better and more dentistry to my patients. ~ paulcaselle
Last year when I walked into the reception, it was like walking into
a family reunion. Howard came up and gave me a big hug like he
had known me for years! ~ Dr. Chad
You can walk from the pool with a drink in your hand and sit in on
a lecture. ~ ELATED Buckeye
Before
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Videos and more at www.ribbond.com

128
Are you juggling with

MULTIPLE BONDS?
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ceramic without any extra primers
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evaporation problem that is a known problem with bottle systems
this ensures reliable high bond strength with each application.
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Dentaltown 2015october

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The Benefits of Mini Dental Implants by Dr.

Eric Hanson page 70

The Benefits of Mini Dental Implants

Surgical Crown Lengthening

CE: Treatment Planning for

real dentistry for real dentists www.dentaltown.com

with Michigan Endodontist

FREE FACTS, circle 33 on card

FREE FACTS, circle 36 on card

Increase yours with Dentaltown.coms online CE.

Surgical Crown Lengthening

And Sealants for All

You Should Know:

Great Patient Relationships? F.U.!

en utler gi es you tools so you an a oid

BRING THE INSIDE FRONT COVER

OCTOBER 2015 // dentaltown.com

FREE FACTS, circle 19 on card

In Focus: Microphotography using the

The Benets of Mini Dental Implants

How to Track True

Frustrated with trying to get great photos

Dr. Eric Hanson shows you how to use

Kirk Sweigard helps dentists nd out why

Denture Stabilization with SmallDiameter Implants

113 | GENERAL PRACTICE

Increase the comfort of your edentulous

Dentaltown Magazine talks with Dr.

Jay Geier chats with Dentaltown

Are You Providing Five-Star Service?

What happens after the braces come off?

Human Herpesvirus Infections and

OCTOBER 2015 // dentaltown.com

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EDI TORIAL ADVISORY BOARD

OCTOBER 2015 // dentaltown.com

Lee Ann Brady, DMD

Cari Callaway-Nelson, DDS

Doug Carlsen, DDS

Howard M. Chasolen, DMD

Linda Douglas, RDH

Joshua Halderman, DDS

Glenn Hanf, DMD, FAGD, PC

William Kisker, DMD, FAGD, MaCCS

John Nosti, DMD, FAGD, FACE

Jay Reznick, DMD, MD

Elizabeth Fleming, DDS

Donald Roman, DMD, AFAAID

Seth Gibree, DMD, FAGD

Timothy Tishler, DDS

Stephen Glass, DDS, FAGD

Brian Gurinsky, DDS, MS

Eyad Haidar, DMD

Glenn Van As, BSc, DMD

Fayette Williams, DDS

Josh Wren, DMD

19992015 Dentaltown.com, LLC. All rights reserved. Printed in the USA.

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