Dr. Lou Graham

 In this series from Lou Graham, DDS, learners will discover what the Selective Caries Approach is, and how to best apply that to their practice. [1 Credit]

In a 4-part video series, learners will be ably to identify what the Selective caries approach is and how to implement it successfully in practice. 

 https://www.catapulteducation.com/course/ce-6-6-24

 For the past 35+ years, Dr Graham has practiced dentistry in Chicago, Illinois. As dentistry evolved throughout his career, he remained at the cutting edge and incorporated many of these changes into both his multi-group specialty practice and his clinical courses. Dr. Graham’s course offerings incorporate the latest diagnostic technologies into everyday treatment planning and clinical care to ensure the best options and treatments are presented to each and every patient.

Throughout his career, his goal has always been to get teeth to their 75th birthday. With such, Dr Graham’s emphasis has always been based on trust with the patient and conservative dentistry. His courses highlight many of the restorative options in dentistry today along with an emphasis on customized approaches to periodontal care, implants, laser dentistry and treatment for the ever-expanding geriatric population.

Dr Graham is the founder of Catapult Education, now composed of 30+ speakers including clinical evaluators of the latest dental products and technologies with over 35,000 education subscribers.

Dr Graham is a published author and is the former Dental Director of the University of Chicago’s Department of Dentistry.

 Catapult Education, LLC designates this activity for 1 continuing education credit.

Catapult Education, LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at CCEPR.ADA.org.

This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Catapult Education, LLC and MJH Life Sciences.

Catapult Education, LLC. Nationally Approved PACE Program Provider for FAGD/MAGD Credit.
Approval does not imply acceptance by any regulatory authority, or AGD endorsement.
6/1/24 to 5/31/28. Provider ID# 306446.

This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of Catapult Education, LLC and MJH Life Sciences.

Catapult Education received commercial support from MJH Life Sciences for this presentation. Dr Lou Graham received an honorarium from MJH Life Sciences for the time involved in preparing and delivering this presentation.

Check with your state licensing board to determine if the course meets your state requirements.

Catapult Education delivers clinically relevant continuing dental education programs which address the needs and preferences of our audience and provides them with the knowledge and confidence to integrate new techniques, practice management and treatment options into their respective practices. Catapult Education is committed to ensuring the content quality, objectivity and scientific integrity of all continuing education courses. Instructors are advised to support clinical recommendations with scientific research-supported data whenever possible and to disclose any conflict of interest between them and any corporate organization offering financial support or grant monies for this CE activity. Instructors are advised, where appropriate and if relevant to the subject matter of the presentation, to mention a variety of different product choices so as to present a balanced view of all therapeutic options available and promote improvements in oral healthcare free from commercial bias.

[Earn 0.25 credits] In this video learn what the Selective Caries Approach is. 

Part 1

[Earn 0.25 credits] In this video learn how to begin implementing the Selective Caries Approach.

Part 2

[Earn 0.25 credits] In this video learn about the cleansing process and the variety of different materials used in this approach. 

Part 3

[Earn 0.25 credits] In this video learn the importance of digital imaging in this approach.

Part 4 The Selective Caries Approach

Articles

[Earn 1 credit via Catapult Education] Join Founder of Catapult Education Lou Graham, DDS, as he explores the Selective Caries Approach and how it can best serve patients. 

The Selective Caries Approach with Lou Graham, DDS

As a general dentist in practice for 40 years, I can say without hesitation that most patients do not floss daily. You can have the best hygienists and the finest education on flossing, yet far too many patients still do not consistently floss. Many floss the day before they see the hygienist, or a few days after, but—much like a resolution for the new year—sticking to this daily commitment is easier said than done.

Various studies provide differing statistics on the percentage of Americans who floss, but none present positive findings. This begs the questions, “Are patients flossing correctly?” and “What is holding them back from making it a daily practice?” With the current techniques and options for flossing, it is no wonder why many choose to simply brush and rinse.

Enter SLATE, a game changer in the flossing world. How, might you ask?

It was designed by Danny Snyder, DDS, whose intent was to revolutionize flossing and make it more enjoyable for everyone. He invented a powerful flossing device with 12,000 sonic vibrations/min, making flossing far easier and more likely to become a daily habit. With its slim design, SLATE goes beyond merely guiding users to floss correctly.

The SLATE Electric Flosser utilizes its Gum Sweeps—strategically placed bristles and ribs that are meant to emulate the shape of the teeth and gums. The Gum Sweeps remove plaque that would otherwise be untouched by normal brushing. It has 3 rows of rubber bristles designed to clean while still maintaining a comfortable experience. The flosser also features a tongue scraper that can be used to clean bacteria off the tongue. Floss heads can be exchanged, cleaned, and removed as needed, touting a greener and more sustainable way to floss. It is recommended for replacement every week.

Its design includes built-in silicon bristles, known as gum sweepers, for proximal gum stimulation. Additionally, on the backside of the flosser is a tongue scraper that helps remove bacteria, food debris, and dead cells. For orthodontic patients in brackets, SLATE has created a specific insert, making it simple for those patients to properly floss—an orthodontist’s dream come true.

As for my experience with SLATE, I found that inserting the disposable heads is straightforward and easy. Each insert can last up to 2 weeks with a full dentition (the company recommends 1 per week), so 1 insert may last far longer with patients having fewer teeth. The technique is easy: Insert the floss head between 2 teeth, move vertically on each proximal surface, and then proceed in a buccal-to-lingual direction to allow the gum sweeps to stimulate your proximal tissues (my favorite). Then simply flip the handle over, scrap the dorsal surface of the tongue and rinse away the gunk. The total time is often less than a minute.

You might be wondering whether I have always been a daily flosser, and the answer is no. Since discovering SLATE, I now incorporate flossing into my daily routine because it is so simple and straightforward, providing me with a much-improved overall experience compared with traditional flossing. In our practice, the doctors loved SLATE, as did the majority of Catapult reviewers. It was interesting to learn that some of the hygienists who reviewed the product felt it was a superior product overall but still liked the traditional method. 

On the other hand, patients, including my friends and family, found that they were all flossing and tongue scraping more often with the SLATE Electric Flosser (

SLATE’s beta testers found that many patients had improved probings with less bleeding on probing, and this would be attributed to 3 factors: daily usage, utilizing the correct flossing technique, and the gum stimulators (which allow you not only to massage the gingiva but to create an additional path to remove plaque and debris). These same beta testers found that patients with dexterity issues improved their home care by implementing SLATE into their normal daily oral hygiene routine. This is a key point, especially for geriatric patients. As we all have witnessed in our practices, the need for superior home care and prevention increases with this aging population. The SLATE Electric Flosser, like water flossers, should become routine as recommendations from our hygiene teams.

Here are some key metrics from our Catapult evaluation:

Two-thirds of the evaluators gave this electric flosser the highest approval rating, with many commenting that they have already shifted to SLATE (including myself, my kids, and my siblings).

More than half of the evaluators noted SLATE cleaned better interproximally than traditional floss (you feel far more control and have a different tactile sense).

The group overall felt the retail pricing was appropriate at $79 (with 4 floss heads included).

The group felt the refill pricing at $25 for 20 floss heads was very value oriented.

) did not last as long as the company states, 7 to 10 days (I have found them to last 2 weeks).

Figure 3. Inserting the disposable heads is straightforward and easy.

“I feel that it is doing a fantastic job cleaning interproximally.”

“The way it stimulates the gums…and it’s easy to use.”

“I love both the flosser and stimulator.”

“This is such a winner for those that have trouble (which is a lot) manipulating floss.”

The SLATE Electric Flosser is powered by 2 AA batteries (lasting around 6 months) and the company’s team has plans for a rechargeable unit along with potentially offering a future model with multiple vibration settings. From using my own SLATE device, I have found that the floss begins to break down after about 7 to 10 uses. The floss is woven by hundreds of strands and this construction works to remove plaque. Additionally, the floss has no wax, no toxins, no Teflon, and no polytetrafluoroethylene or polyfluoroalkyl substances.

You might ask, what about cleaning beyond just rinsing? There are many cleansing products for aligners and nighttime appliances, and these can be used in the same manner if you so desire.

SLATE is a game changer in the world of flossing and oral care, and we are thrilled to have evaluated this product and give it the Catapult Vote of Confidence™.

The SLATE Electric Flosser is a powerful device that has impressed evaluators and earned the Catapult Vote of Confidence.

A New, Easy, Effective Way to Implement Flossing Into Your Daily Routine

Preventing Chronic Implant Disease

Lou Graham, DDS, Founder of Catapult Education, takes a look ahead at the New Year.

Dollars and Cents

A Game-Changing Group of Restorative Materials

SICAT President Craig Hennings talks AI, 3D printing, and RAPID DIGITALGUIDE

SICAT Offerings Allow Clinicians to Be Smart, Treat Smart, Pay Smart

2023 Promises to Be Another Exciting Year for Digital Dentistry and 3D Printing

Tokuyama Dental Continues to Provide Shade-Matching Restorative Options

Ivoclar Kicks Off 2023 With Centennial Celebration

Education, Digital Workflow Integration Are Critical

Striving for the Holy Grail of Endodontic Irrigation

Making Dentistry Easier and More Enjoyable for Everyone

Digital Workflows, Open-Architecture Systems Continue to Play Bigger Role

Bruxism on the Rise? We’ve Got This

Zirconia Workflows Improve Along With Material Advances

Innovation, Unlimited Potential Ahead for Dental Industry — 2023

Dental industry leaders, including clinicians, manufacturers, and educators, share what they see ahead for the industry in the coming year.

Innovation, Unlimited Potential Ahead for Dental Industry in 2023

Preservation of the ridge is the go-to philosophy in dental extractions today. Extractions done for preimplant placement and preservations for fixed and/or removable prosthodontics are indications for modern-day socket grafting. Because this procedure is so popular, manufacturers continue to modify grafting materials. Let’s examine BioHorizon’s latest addition to their portfolio of grafting offerings, MinerOss® X Plug.

Traditionally, socket grafting involved mixing a saline solution with specific particulate to create a slurry of material that was then placed into the socket and followed by placement of collagen barrier and final suturing. Now fast forward to MinerOss® X Plug, a cylindrical plug that comes in 2 shapes, straight or tapered. The plugs are easily trimmed and inserted directly into the socket without the need for rehydration. Yes, gone is the mixing of particulate into a slurry, gone is suctioning the loose particles from the area, and gone is the collagen barrier.

The plugs are 80% bovine cancellous particulate and 20% bovine type 1 collagen. The collagen material allows for rapid blood absorption and delivery of the particulate. The bovine cancellous matrix supports new bone growth in the socket area. Costs per plug are lower than the total costs of particulate, collagen barrier, and saline solution. Inventory is far simpler than ordering the multitude of products for previous socket grafting. The plugs come in only 2 shapes and sizes (tapered, 9 × 15 mm; straight, 10 × 20 mm) and that is primarily all you need for your socket grafting procedures.

MinerOss X Plugs are designed to simplify and streamline the grafting process with 2 size options shaped for a variety of graft sites. The plugs are composed of 80% bovine cancellous particulate and 20% bovine type I collagen. They offer optimal clinical handling, are easily trimmed and shaped to fit the morphology of a socket defect, and do not require rehydration before implantation. MinerOss X Plugs also feature dependable delivery. Particulate embedded in the collagen may prevent particulate migration and the collagen allows for blood absorption and delivery to the particulate.

This product was evaluated by Catapult Education. Here are the evaluators’ findings:

The evaluators utilized both shapes and their final choice was split among the group, but all felt these 2 sizes were adequate.

One-third of the group hydrated the plugs prior to placement (instructions say not required). The ones who did found the material very easy to hydrate.

One-third of the group used membranes in conjunction with placement of this product.

All of the evaluators loved the handling.

All of the evaluators said they would buy and use this material for socket grafting.

The majority of the evaluators said they would use this product with other procedures that include filling of infra-bony periodontal defects, filling of defects after an apicoectomy, root resection, peri-implant defects, and elevation of maxillary floor.

Now let’s take a look at a specific case and see how unique this product is.

A 72-year-old patient presented with chewing sensitivity on her upper first molar. Upon examination, there was a parulis (on the buccal) above the mesial root, no mobility, tenderness to percussion, and probing showed a small exudate on the mesial buccal root. One periapical (

) was taken followed by cone-beam computed tomography that showed a large periapical lesion proximate to the sinus with the bone loss extending up into the furcation, which was potentially indicative of a fractured root. The decision was to extract the tooth and graft the area and then do an implant treatment later in the year.

After the patient received an injection of 1.5 carpules of Septocaine 4% 1:100,000, the procedure began with retraction of the soft tissue and the beginning of minor elevation. During this initial elevation, the crown immediately dislodged and exposed the previously placed post and core (

With further elevation, the post was dislodged and all 3 of the roots and the vertical fracture of the mesial root were clearly evident. The remaining roots were sectioned using an NSK surgical electric handpiece, and each subsequently was removed via routine elevating techniques (

Careful apical debridement and irrigation was completed. A tapered 9 × 15 mm MinerOss® X Plug then was removed from its packaging (

) with the majority of the grafting material placed (nonhydrated) into the palatal and distal sockets (

). The technique involved only mild condensing into the socket.

Final suturing was a figure-8 technique with a standard 4-0 gut suture (

As seen in Figure 11, the area is free from the usual free-floating particles. An additional advantage to this material was not having the risk of slurry of particles so close to the sinus. Healing 1 week later looked well within the norm. At the 4 weeks postoperative appointment, the area was well healed with primary closure.

We are always looking at the more cost-efficient techniques and products that ultimately create an equal to or more superior outcome. Over the past 12 months and many socket grafting procedures with this product, we continue to see excellent postoperative results and view this product as a significant shift in our clinical socket grafting protocols. Catapult Education gives MinerOss® X Plug the Catapult Vote of Confidence.

MinerOss® X Plug receives the Catapult Vote of Confidence for its ease of use, excellent results, and cost savings.

A Shift in Clinical Socket Grafting Protocols

Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated and what we deliver are truthful, independent answers from surveys that we develop with them. We have had many products that have either had to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product, or simply a product that needs refinement. Lastly our clients are omnipresent in the industry, small to large, no favoritism, simply reviewing the latest products in our practices

Routine restorative dentistry can often be viewed as very subjective. There you are, after removing an old alloy or old composite, or in this case dealing with decay under an old crown, and it’s time to remove the decay. Once again, you ask yourself the most subjective question: When do you stop drilling?

Over the past 50 years, many studies have demonstrated the advantages of selective caries removal, beginning with Mertz-Fairhurst in 1962. The selective caries removal model has shown great success in maintaining pulpal health. This multistep process completely removes the peripheral decay to solid dentin (to create a sealed restoration) while the pulpal wall is excavated until a somewhat firm or soft dentin is reached. There are multiple approaches and tech-niques to selective caries removal, but often some caries or cariogenic bacteria remain.

The question then arises of how best to seal this area and provide the best pulp protection. This is where liners truly have their utility. Traditionally, liners have been used for multiple reasons: their antibacterial properties along with their ability to seal the dentinal tubules against the ingress of microorgan-isms, remineralization of the dentin, and protection of the pulp from potential negative effects of restor-ative materials. An array of liners exhibit these properties, such as the Ceramir

 Protect LC Syringe, which is a light-cured, resin-modified bio-ceramic pulp protectant for direct and indirect pulp capping.

A light-cured, resin-modified Bioceramic pulp protectant suitable for direct and indirect pulp capping, it is designed as a moisture-tolerant, insoluble solution, and can be applied in cavity preparations. It has a high alkaline pH level to create a hostile environment for bacteria for the best healing capabilities. Ceramir Protect LC Syringe is able to be used with just a single component material. 

Back in the day, Dycal was the calcium hydroxide liner that set the stage for the usage of liners. The indication for Dycal was to place it in small increments to protect the pulp and especially when caries removal approached within 0.5 mm of the pulpal tissue. In regard to the calcium hydroxide’s antibacterial properties, these become evident as the calcium hydroxide disassociates. Calcium and hydroxyl ions are then created, and these hydroxyl ions create an alkaline pH that is antimicrobial. Ultimately, this affects the remaining bacteria directly by altering their metabolism and overall growth.

However, issues with calcium hydroxide included solubility, low compressive strengths, low elastic modulus, and decreasing antibacterial activity over time. To compensate, resin-modified glass-ionomer (RMGI) liners were recommended to be placed over the calcium hydroxide and allow for the sequence of etching and bonding for composites. Gaps were then found between the liners and thus emerged the latest era of bioceramic liners.

Ceramir Protect LC was launched into the marketplace as the latest entry in this bioceramic liner category. The single-component system delivers a liner that is insoluble and radiopaque and has the properties of both an alkaline pH and calcium release. Results have demonstrated twice the calcium release, which equates to more availability to stimulate the deposition of tertiary dentin and remineralization.

Catapult Education’s review of Ceramir Protect LC showed the following:

Ninety percent of reviewers cur-rently use liners. 

Ninety-five percent of reviewers found the handling and narrow syringe tips ideal. 

Ninety-two percent of review-ers would use this product as a liner in their practice

Catapult Education gave this liner stellar reviews and presented Doxa Dental with the Catapult Vote of Confidence for its Ceramir Protect LC Syringe.

The following patient presented holding his 25-year-old crown in his hand. Extensive decay was noted with no symptoms. The tooth was tested for vitality, and it tested positive.

Ceramir Protect LC Case

The Ceramir Protect LC Syringe is a bioceramic pulp protectant that eliminates room for error and maintains twice the calcium release.

A Pulp Protectant  Designed for Best Restorative Outcomes

Aligner therapy has quickly become one of the most popular components of dentistry, and for good reason. Aligners are a convenient, esthetic, and efficient way to achieve a gorgeous smile. And it isn’t only aligners–whether it’s sleep apnea devices, night guards, or protective mouthpieces for sports, removable dental appliances represent a vast majority of the professional dental product market. No matter the apparatus, though, all are susceptible to a buildup of bacteria, yeast, and mold. Without proper care, patient adherence drastically decreases across the spectrum of removable appliance therapy, and the likelihood of sickness from harmful debris increases. Given the proliferation of aligners and other removable dental appliances within the dental space, an effective cleaning solution has become a vital part of every patient’s oral care routine.

Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated and what we deliver are truthful, independent answers from surveys that we develop with them. We have had many products that have either had to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product, or simply a product that needs refinement. Lastly our clients are omnipresent in the industry, small to large, no favoritism, simply reviewing the latest products in our practices.

In spring 2021, members of Catapult Education were asked to evaluate Steraligner by Hier Labs. Steraligner is a dental appliance sanitizing solution that removes 99% of bacteria by leveraging a blend of oxygen-based cleaners to neutralize stains, odor, and adverse taste from accumulated biofilms on the surface and within the grooves of the appliance. Seventeen members of the evaluation team tested Steraligner in their practices for 8 to 12 weeks. During that time, they saw, gave a diagnosis to, and treated more than 200 dental patients, with each evaluator leveraging Steraligner in some form. In fact, 100% of our doctors said that within their practice they all use a variety of removable appliances, including partials, full dentures, sleep appliances, aligners, night guards, fluoride trays, and periodontal carriers.

The Catapult Education members were asked to evaluate the necessity of a product like Steraligner as well as its efficacy with patient therapy. They were also asked about the economics of using the product in their practices. Regarding the cleanliness of the appliances, 88% of members said that patients had concerns, with 1 reviewer noting that patients often comment on “how gross the appliances become.”

Independent laboratory testing shows that Steraligner removes the 17 most common types of bacteria, yeast, and mold. Conversely, traditional tablets clean only 4 to 6 strains of common odor-causing bacteria, which is an insufficient sanitizing standard in a post–COVID-19 world. Unlike tablets, which can take up to 45 minutes to clean, Steraligner cleans in just 3 minutes while a patient brushes their teeth. When our educators asked whether or not patients would like an easy 3- to 5-minute system to clean removable appliances, the answer was a resounding yes, with 100% of patients responding in the affirmative.

This aligner cleaning solution was specifically designed to eliminate bacteria and sanitize any dental appliance. From sleep apnea devices, to night guards, to mouth pieces, Steraligner is suitable for any dental appliance. It is said to utilize oxygen-based cleaners to eliminate stains, odor, and bad taste from the surface and grooves of the appliance. Daily application is all that is necessary for peace of mind for dental appliances.

Catapult Education also asked its members whether or not they were excited by an opportunity to make supplemental income in their practice by selling Steraligner. Eighty-two percent of respondents confirmed their interest in offering Steraligner to their patients to make additional revenue every year.

Our educators found that patients were thrilled with Steraligner when comparing it with traditional cleaning solutions: eighty percent of respondents were spending more time cleaning their appliances versus using Steraligner. Seventy-five percent of patients said their appliances had a funny smell and/or were sticky despite frequent brushing and rinsing, and 88% were concerned about bacterial buildup on appliances despite 77% of them cleaning their appliances daily. Eighty-eight percent said their appliances smelled better, had a fresher feel, and felt cleaner overall when using Steraligner. Ninety-four percent of respondents said they would likely purchase Steraligner versus tablets and alternative cleaning processes.

The Steraligner cleaning solution was created by Sam Daher, DDS, a Vancouver Canada-based orthodontist and a top Invisalign provider in North America, to meet the daily cleaning needs of clear aligner patients.

“Aligners can accumulate plaque buildup after long periods of wear, depending on the interaction of naturally occurring oral bacteria with saliva and other factors in some patients,” said Dr Daher. “I wanted to go beyond simple cleaning to develop the most effective cleaning approach possible to help my patients maintain great hygiene and get that new aligner look and feel every day. After numerous rounds of development and laboratory testing, we achieved that with the Steraligner cleaning solution, and I’m thrilled to make it available to Invisalign providers and their patients through Invisalign resource sites.”

It is clear that Steraligner was seen as a superior product by both doctors and patients. Notably, a 3- to 5-minute daily application of this product was well received. Of the doctors who participated in this evaluation, 94% want more information on this product line as they saw the benefits for long-term maintenance on removable oral appliances. Based on our team’s clinical evaluation, Steraligner was given the “Catapult Vote of Confidence.”

With the rise of popularity in aligner and other dental appliance therapy, keeping things sanitized and clean is increasingly important. 

A Sanitizing Solution for Dental Appliances

	With the ever-expanding role of diagnostics today in our practices, members of Catapult Education were excited to be asked to evaluate Prexion’s latest CBCT innovation, the Excelsior Pro. As a company that is based out of Japan, it has a strong history in medical and dental imaging. This latest addition to their portfolio was very positively reviewed by our evaluators.

There is no doubt that CBCT is becoming the standard of care in many of the specialties within our profession. From precise implant treatment planning to evaluating endodontic lesions, CBCT machines have led the way into our daily lives. With advancements in sleep diagnostics and TMJ evaluations, along with various dosing imaging as wonderful adjuncts, we are just beginning to understand the scope of CBCT. All four of our reviewers had previous cone beam experiences in their own offices and their overall comment was that the Excelsior Pro produced amazing images.
	Images can be acquired via adjusted voxels and focal spots, but as a dentist, that is beyond my scope of knowledge. What we all want are great images, low radiation, fast processing, and software that we can use and not be intimidated by.

	The primary reasons for evaluating this new CBCT machine were to see if this improved system could acquire more clear, concise images and allow better details for diagnostics and treatment planning.

	The evaluators found this machine to be better or much better than those of other manufacturers. There is no evaluator who has tested the entire spectrum of competitor CBCTs, but all had previous experience with some CBCTs, with the average experience in practice by the reviewers being more than 25 years. All of the evaluators said they would purchase this CBCT and recommend it to a colleague.

	The question remained if there were additional features the evaluators liked beyond the outstanding images.

	Qualities appreciated by the group included:

		Anatomical accuracy and ability to aid in treatment planning. This was rated as excellent by three of the four evaluators; the fourth rated it as very good.

		Increased case acceptance and customer support. This was rated as either excellent or very good by the reviewers.

	The question to the group then was which areas could be improved, and the answer was related to the complexity of the software. As with most CBCTs, the software can be overwhelming and the group felt additional training beyond the initial training was essential. They mentioned online training and overall asked if there could be ways to simplify the experience. I think this is a key way for Prexion to advance into the profession; education must be first and foremost.

	Additional improvements requested included:

		Panoramic images must be nothing less than exceptional as there are still requirements for these images. As an aside, it would be a great internal question among your board as to when Panorex images are required versus low-dose CBCT images.

		Large field of view (which we believe has already been addressed).

	It is without hesitation that the evaluators give a ‘Catapult Vote of Confidence’ to Prexion’s Excelsior Pro.

Why Catapult reviewers say they prefer using this CBCT machine from PreXion over others. 

How to acquire clear, concise images with the Excelsior Pro

	2016 kicked off to a wonderful start for The Catapult Group as we were asked to evaluate GC America’s new composite material, G-ænial

 Sculpt, a light-cured, universal nano-hybrid compactable composite. It is universal because it can be used for both anterior and posterior and yet, it is compactable.

	I know what you are thinking: “Oh why another composite?” Truth be told, composites continue to advance--and they need to! If all your composites have no small voids on placement, years of great polish, no staining, no brown margins, no chipping and handle ideally then put this article down and continue what you are doing. There are significant advancements with a few composites coming into the marketplace and this article will review the raves from the group about  G-ænial

	To simplify this review, I would like to start with why it is an upgrade:

	• This composite has the Nano-Filler Technology of G-ænial

 Universal Flo (GC Nano-Filler Technology) and this is unique.
	• Versus Strontium glass in G-ænial Universal Flo, G-ænial Sculpt utilizes a barium glass, and these filler particles are 300 microns.

	OK, so what does this really mean?  Most hybrid composites have much larger particles that are not evenly dispersed and equally do not have the higher density required for long term success in regards to polish retention and wear (our reviewers found the polish of this material to be in the superior category).

	• Another key feature for our posterior restorations is that this material has low shrinkage stress properties and this is critical for our high C factor clinical situations (Class I’s and Class II’s). Its high resistance to wear and staining, and equally superb polish, make this material an ideal capping material for your posterior restorations.

	• Yes, it’s very radiopaque.
	• Additionally, there are 17 shades and some unique ones such as:
	Junior Enamel (JE) in addition to Adult Enamel (AE)
	Three opaque shades that are A01, A02 and A03 (makes Class IV’s more predictable)
	Geriatric colors that include CV
	California colors of BW and XBW

	The Catapult Group utilized 28 evaluators and their results are as follows:

	• G-ænial l Sculpt scored extremely high amongst the group in the way the material handled. Over 85 percent of the doctors felt it carved easily and more than 92 percent of the doctors liked the fact that the material resisted slumping.

	• 95 percent of the doctors really liked the way the material blended with the natural tooth structure and found it extremely chameleon-like in matching.
	• 95 percent loved the polishing and that same number felt it matched its shade guide.

	• 90 percent of the group would recommend this product to a colleague.

	The challenge: Easy to onlay, easier to crown, far more of a challenge to place a direct restoration (Fig. 1).

	In Case 1, it was a challenge to place a direct restoration.

	After bevel placement, Palident Matrix System was put in place, followed by selective etching, rinsing, suction drying and application of a universal bonding agent (must be scrubbed for 20 seconds throughout the preparation due to selective etching), appropriate air drying and light curing (Fig. 2).

	After bevel placement, Palident Matrix System in place, selective etching followed by rinsing, suction drying and application of a universal bonding agent appropriate air drying and light curing.
	 

	After placement of a bulk fill low stress flowable and again appropriate light curing, the final 2 mm of warmed A2 G-ænial Sculpt was placed in one bulk fill manner. After finishing and polishing, the above restoration truly maximizes tooth preservation (Fig. 3).

	After finish and polishing, this restoration truly maximizes tooth preservation.

	This case involved replacing a chipped Class IV on number 10 (Fig. 4).

	Case 2 involved replacing a chipped Class IV on No. 10. 

	The beauty of the G-ænial Sculpt system is that one can get a superior chameleon effect from using a core shade (A2, for example) but in the case presented, we simply layered an A2O, then an A1 and then AE (adult enamel) over the very outer layer.
	The first layer of A2O was placed on the lingual surface after etching and bonding (Fig. 5).

	The first layer of A20 is placed on the lingual surface after etching and bonding.
		 

	The key here is looking from the incisal room and leaving enough room to blend in your A1 or A2 body shade and then if you want, placement of Adult Enamel.
	After the layering was completed, a series of disks were utilized (Fig. 6) for finishing and polishing.

	After the layering has been completed, a series of disks are utilized for finishing and polishing.
	

	Fig. 7 shows the chameleon effect of G-ænial Sculpt. The great results led to congratulations going out to GC America in receiving The Catapult Vote of Confidence for G-ænial

	The chameleon effect of G-aenial Sculpt is illustrated here.

	Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated and what we deliver are truthful, independent answers from surveys that we develop with them. We have had many products that have either had to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product, or simply a product that needs refinement. Lastly our clients are omnipresent in the industry, small to large, no favoritism, simply reviewing the latest products in our practices.

	This compactable, universal composite features the same high-density, uniform dispersion nano-filler technology found in G-ænial™ Universal Flo. This is said to create a resin that is easy to shape, sculpt and polish, plus it is formulated to provide a strong, wear resistant and radiopaque finished restoration with beautiful esthetics. A self-shining effect enables simple rough finishing with a bur to bring the restoration to a beautiful luster and will continue to increase in polish over time with excellent “chameleon” shade match to enamel. This helps to provide an exceptional clinical outcome for a wide variety of clinical procedures. 

2016 kicked off to a wonderful start for The Catapult Group as we were asked to evaluate GC America’s new composite material, G-aenial Sculpt, a light-cured, universal nano-hybrid compactable composite. It is universal because it can be used for both anterior and posterior and yet, it is compactable. Dr. Lou Graham and the Catapult Group congratulates GC America in receiving The Catapult Vote of Confidence for G-aenial Sculpt.

Handling is just one of the many features delivered by this new dental composite

	Identifying reliable, efficient and comfortable local anesthetics has been a challenge for dentists since the late 19th century. It all started with injectable cocaine but the obvious issues soon developed. 

	Procaine was then launched in 1905 and this adopted the term NOVOCAINE and it’s amazing this name is still utilized by many of us today describing a shot! Since Procaine’s launch over 100 years ago, there have been many new anesthetics added into the marketplace and with each, came enhanced improvements. Yet, the injection is still all too often the most dreaded aspect of an appointment and the question poised to The Catapult Group was whether Anutra Medical’s new local anesthetic buffering system could take the “sting” out of what we all do multiple times each day. Now, of course there is more to the story, but the truth for many of us is that we would love to give a truly painless injection.

	First off, what is buffering? Buffering is the mixing of sodium-bicarbonate into the dental anesthetic, the combination immediately raises the pH of the anesthetic to neutral. So instead of injecting a solution with a pH similar to vinegar, you are now injecting a solution with a neutral pH and this is so much more comfortable. In addition, because the anesthetic is buffered, it almost immediately crosses the membrane due to lipophilic base material not requiring time to become more neutral in pH. The added CO2 microbubbles (yes you will see them in the syringe) convert the lipophilic base material back into a form that reversibly blocks the Na channels. With all this said, the anesthetic is present in larger concentrations and the action of blocking the nerve channels happens that much faster than traditional non-buffered dental anesthetics. Have I lost you yet? Stay with me!

	So, what did The Catapult Group find in regards to Anutra:

	• Saved 15-30 minutes per day of chair time (80 percent of the reviewers)

	• Achieved more profoundness versus traditional anesthetics (80 percent of the reviewers)

	• Achieved improved reliability and hence less stress (78 percent of the reviewers)

	• Speed was dramatically different for onset (100 percent of the reviewers)

	• After using Anutra, nine out of the 10 evaluators would incorporate Anutra into their practice

	• On a scale from one to five, one being no pain and five being painful, the average patient rated the injection with Anutra a 1.7 proving the increased patient comfort. 

	So the first question to answer, are the injections more comfortable? How important is that to you and your patients? Given that ‘the dreaded shot” is one of the most stressful parts of the procedure, who wouldn’t want to give a far more comfortable injection. Yes, everyone says they give the best shots but truth be told, they can be better! I have been utilizing the Anutra Local Anesthetic Delivery System for more than 4 months. The technique is similar to what you all do now, but the result is just better. I dry the tissue with air (for infiltrations) and place a few drops of the anesthetic on the tissue to leverage the “microbubble effect. I let it sit for 10-15 seconds and that is my topical. For years I have never used traditional Benzocaine as a topical and this either replaces your pharmaceutical topical or adds to it. I then enter the tissue and just pierce the tissue and deposit one drop and you see a small area just “puff”, I wait 5 seconds and then slowly over a minute give the injection. It’s that simple and as noted by The Catapult Group, many of the patients ask, “was that the shot”?

	The beauty is that after the one-minute mark, they are feeling the numbness. This is critical for the apprehensive patient (reassures them) and with maxillary teeth, you can begin your preparation. Yes, at the one-minute mark! The evaluators were beginning their work, including the drilling by the three-minute mark for either arch (I wait two minutes for lower bicuspids, one minute for lower anteriors and I base it on bone thickness). This is a key point, you DON’T get up after giving the anesthetic! Just drill away (carefully) and the patient’s stress is gone because they are numb and not waiting and waiting. My patients have often commented that waiting is so stressful, and they love when you say that’s it for the drilling. Can you not relate to hearing this? 

	In regards to blocks, when using traditional anesthetic, the variability of onset can be up to 15 minutes. How often do you walk into the room and ask, “is your lip numb” and the waiting game begins. So the question to all of, how long do you wait for mandibular block to achieve its maximum effect? With Anutra, if they are not feeling numb in two minutes you missed and it happens to all of us. Why wait five and 10 minutes anymore? The group overall found profound numbness and preparations were begun on average at the four-minute mark after the block was given. Does this make up for a missed block? Honestly, I don’t think so because blocks are based on location, location, location. If you needed to reinject, this was done at the two-minute mark. My technique with Anutra’s buffered solution is to draw back 3 cc, go to your standard area and inject 1.5 cc and then often I may go a bit posterior and higher and deposit the remaining 1.5 cc. I know we all have different techniques but the bottom line, you will know much sooner if they are numb!

The bottom line was that most of the evaluators (80 percent) found this system to add time in their day and some commented this actually changed their own workflow. For myself, I would in the past inject, go do hygiene exams, and have the patient wait. With Anutra, I inject, drill, and then say to the patient, I have to do some exams and they’re relieved that the drilling is done! This is my mind shift with the product, and for me, the additional $200 of cost per month is well worth it. When I book appointments, I routinely have shortened the procedural time by up to 15 minutes and again, what is that in terms of value adds.

	Per the reviewer group, the learning curve is very easy. The kit comes with their dispensing unit (one time purchase and I bring this room to room) and all the goodies to load up and get going for the week. The goodies include a weekly brand new cassette (

) with anesthetic and buffering agent, along with 27 or 30 gauge needles and plenty of their disposable syringes (

There are videos (along with great explanation videos from Dr. Davidian at 

 for each step of loading and priming the system) and this becomes routine by week two. Yes, it’s that easy. With a simple turning of the grey knob on the top of the dispenser, (

) the bicarbonate is precisely loaded into the 2% Lidocaine (routinely, I draw back 2.5 cc into the custom syringe). Yes, you do draw the solution into the disposable syringe, shake it about 10 seconds, visualize the microbubbles, and you are ready to go. 

	With all this said, 90 percent of the reviewer said this technology compliments their practice. The question to all of you is how does this compliment your practice? In my eyes, a more comfortable injection, with faster onset, that allows me to have a more predictable working schedule…that’s a wonderful change in my clinical day.  

Thanks for reading and if you have any questions, drop me an email at lgrahamdds@aol.com and yes, some things I am slow to change!!

	Just a few final comments. The company itself has been ideal to work with. We had initial thoughts about their needles, and they have been changed. You have to love a company that listens to us….the clinicians!

	The Anutra Local Anesthetic Delivery System is a revolutionary way to simply buffer local anesthetics. With buffering, practitioners can be more productive, efficient and profitable while providing a more comfortable experience. In addition, the Anutra Feedback Aspiration Syringe is designed for multiple doses in a single syringe.

For more information, contact Anutra Medical at 844-ANUTRA-1 or visit anutramedical.com

The Catapult Group shares its review of this breakthrough local anesthetic delivery system.

A review of Anutra LA Delivery System

	Dentists have been using a variety of core build-up materials for decades. From alloys, glass ionomers to composites, there has been a long history in this product category.

Catapult reviews this dual-curing core build-up material with Active-Connect-Technology that ensures a reliable bond with all common adhesives.