Laura Dorr is the former executive editor of DPR's Modern Dental Network and a regular contributing author.

Laura Dorr

Confidence is key when providing dental care to your patients. You need to have the knowledge to effectively diagnose and treat a variety of indications. You need to instill trust in your patients. You need to avoid second guessing yourself in the middle of procedures.

But when does confidence become overconfidence? It is important for dentists to remember that sometimes a case is just too specialized to handle in house. And knowing when to forgo the hubris and call in the experts is a critical skill.

“Case selection is immensely important with respect to endodontic care,” says Rebekah Lucier-Pryles, DMD, an endodontist in White River Junction, Vermont and cofounder of Pulp Nonfiction Endodontics. “Knowledge about the procedure, and one’s own limitations with respect to endodontic care, can facilitate good outcomes for patients and clinicians alike.”

Richard Mounce, DDS, an endodontist practicing in Pacific City, Oregon, agrees.

“General practitioners (GPs) should refer whatever is beyond their skill and equipment level and only do what is in the patient’s best interest,” says Dr Mounce, “If you wouldn't treat your mother or your spouse, you shouldn't treat the patient.”

But how exactly can GPs assess whether the procedure is in their wheelhouse or not? Luckily, when it comes to evaluating case difficulty, GPs do not have to go it alone. The American Association of Endodontists (AAE) have resources for practitioners who are concerned about the potential challenges of a case.

“The AAE has an immensely helpful (and free!) screening tool on their website to help clinicians assess case difficulty,” Dr Pryles says. “This tool can help general practitioners consider the factors related to care and whether they feel care can be confidently provided in their offices.”

The AAE’s Endodontic Case Difficulty Assessment Form helps clinicians make case selection more consistent, efficient and better documented. The form outlines levels of difficulty, potential risk factors that could potentially complicate treatment and negatively affect treatment outcome, and other considerations to help clinicians provide quality care. 

On the form, clinicians can assess how tough a case will be by answering questions about a set of criteria. Then, cases can easily be broken down and classified into minimal, moderate, or high difficulty, depending on the criteria selected in categories such as medical history, canal and root morphology, gag reflex, endodontic treatment history, or emergency status. For instance, clinicians can rate their patient’s reaction to anesthesia (with no history of anesthesia problems presenting minimal difficulty, and difficulty achieving anesthesia classified as high difficulty.)

A case that falls under minimal difficulty is a preoperative condition that will require routine complexity. These uncomplicated procedures can be successfully performed by a practitioner with limited experience. In contrast, a case classified as high difficulty would present complicated factors that would make achieving a predictable outcome challenging for even an experienced practitioner. In these cases, it’s time for GPs to turn the case over to the endodontic experts.

“If there is any doubt as to these assets (skill, equipment, time) going into the case, the case should be referred,” Dr Mounce says. “I’m a frequent expert witness [in court cases] and my desk is littered with cases where someone did not take the time to competently assess the clinical situation, carried out a flawed procedure, and ultimately had a claim made against them.”

For general practitioners looking to increase their skills to be equipped to tackle moderate or higher-difficulty level cases, there are opportunities for education. Dr Mounce has several recommendations for clinicians looking to expand their expertise:

Take every endo course you can; ignore the product claims and listen for the clinical pearls and principles.

Get to know your endodontist and go watch them work. Observe their setups; there’s no reason to reinvent the wheel, so see how their operatories are laid out, how they set up and perform procedures, and observe their file sponges. Listen to how they talk to patients about complex issues, and learn to what patient concerns and reactions to expect. Pay attention to the wording the endodontists use to explain procedures while avoiding frightening their patients.

Understand the procedures and how to explain them to patients. Make sure the patient understands what you will be doing—and why—in every case. Getting informed consent is a must for each and every procedure—but impossible to do if the patient isn’t actually informed.

In order to keep your patients informed, GPs need to have a deep understanding of the procedure and protocol, as well as the ability to perform accurate and methodical diagnosis. Identifying the problem (and the correct tooth!) is the first step towards treatment. Using a system of easily repeatable diagnostic tests can help a GP hone in on and identify diseased teeth that may not be obvious at first glance.

After you’ve done your homework, it is critical to make sure you have the right tools for the job. Purchasing the proper accessories, such as a surgical microscope, electronic apex locator, loupes, or cone-beam computed topography (CBCT) system and learning how to use effectively use them can streamline diagnosis and make procedures more accurate. Being able to magnify your field, or enhance or enlarge an image or X-ray can make identifying the trouble area much easier.

“Get these tools and learn to use them correctly,” Dr Mounce says. “It will change your life.”

Once you’ve got the tools, make sure you know where to find them and that they are easily accessible. This makes them easy to pull out in a pinch. But before you can implement these tools in the chair, you’ll need to practice. Extensive practice prepares GPs for standard cases, allowing you to create strong fundamental skills that you can build on to eventually take on more difficult cases. Additionally, building up a good understanding of tooth preparation, endo prep, and isolation will increase the success rate of cases.

“Practice extensively with your chosen system in extracted teeth,” Dr Mounce says. “Such practice includes learning to gain patency with hand files, and learning how much stress it takes to break NiTi files on the benchtop. Practice making cone fit with gutta percha.”

But even with practice and education, there are cases that should not be handled in house.And recognizing those can make all the difference to treatment success.

“Remember to slow down,” Dr Mounce says. “Sometimes the best case you ever did is the one you referred."

Articles

Best practices for general practitioners handling endodontic treatment, and how to get help with a case when you need it. 

 When to Call for Help with Your Endodontic Cases

Mitigating aerosol risks has always been critical in the field of dentistry, but 2020 brought the issue of aerosol management to the spotlight. No stranger to aerosol-generating procedures, the dental practice seemed primed for the spread of SARS-CoV-2. In fact, the Centers for Disease Control (CDC) cited healthcare settings that performed aerosol-generating procedures (i.e., the dental practice) as areas that required extra engineering controls to prevent the transmission of contagious pathogens.

But dental practitioners have been dealing with combatting aerosols and airborne contamination for years, and aerosol risk reduction was nothing new for most clinicians, including endodontists. Rebekah Lucier-Pryles, DMD, an endodontist in White River Junction, Vermont and cofounder of Pulp Nonfiction Endodontics, says that in some ways, endodontists were particularly prepared for the growing concern about airborne transmission.

“I think endodontists may have been poised for better aerosol management from the beginning,” Dr Pryles says. “Endodontics poses no unique challenges to aerosol management beyond that associated with general dentistry. But we’ve all been prepared.”

While clinicians were well-versed in aerosol reduction, the pandemic pushed its importance into high gear. While many tried-and-true tricks and tools for aerosol mitigation remained the same, there were several components that became absolutely critical for aerosol reduction.

The best way to combat aerosols is to eliminate them before they spread into the air. By using intraoral evacuation with a high-volume evacuator (HVE), clinicians can isolate hazards by containing particles at the source. HVEs with high flow rates and sufficient suction create significant aerosol reduction compared to their low-volume counterparts and capture the majority of aerosols before they escape the oral cavity. In fact, one study found that HVEs can remove 90-98 percent of aerosols directly at the operatory site.

“Reducing aerosols at the source is the best way,” stated an article from the American Association of Endodontists. “This is followed by mitigation aerosols dispersion and protecting the person from aerosol microbiota. Reducing microbial payload in aerosols at source can be achieved by using high volume evacuators, isolating the tooth or area, pre-procedural mouthwashes and reducing procedure time.”

To attain this level of efficacy, clinicians should place the high-volume suction as close as possible to the tooth and handpiece head during drilling to prevent the creation of excess aerosols. To further reduce aerosols, clinicians should use a fast handpiece without (or with reduced) water, and avoid the use of ultrasonic scalers, which are culprits in high aerosol production.

But even with high-speed evacuation, there are still oral microorganisms in play. By combining HVEs with other tools, practitioners can further reduce the risk of aerosol spread and contamination.

Utilizing rubber-dam isolation is nothing new when it comes to isolation and creating a sterile field. Utilizing rubber-dam isolation also contributes to aerosol reduction. The CDC recommends the use of a rubber dam to reduce aerosols generated during rotary dental procedures,

 and it is the standard of care in most endodontic dental settings.

“One of the myriad ways aerosols can be managed is with dental dam isolation,” Dr Pryles says. “Dental dam isolation is the standard of care in endodontics, meaning our exposure to oral aerosols may have been minimal.”

And there is plenty of research to back it up. One study found that rubber-dam isolation had been shown to eliminate microorganisms by up to 98 percent when preparing teeth for procedures.

 Several additional studies also concluded that rubber dams create a significant reduction in bacterial atmospheric contamination.

“All things being equal, endodontics was minimizing aerosols well before the pandemic through the use of the rubber dam,” says Richard Mounce, DDS, an endodontist practicing in Pacific City, Oregon. “It’s nothing new.”

However, there have been some additional precautions added in the wake of the pandemic.

“In addition to dental dams, however, we've made several changes to our practice,” Dr Pryles says. “These include HVAC updates needed to reflect current CDC and OSHA guidance.”

The field of endodontics faces many of the same aerosol challenges that all dental practitioners deal with on a daily basis. Combined with other preventative measures, such as the HVAC and ventilation updates undertaken in Dr Pryles’ practice, as well as enhanced personal protective equipment and antimicrobial rinses, aerosol reduction can greatly contribute to the safety of both clinicians and patients and mitigate risks.

“Ultimately, I don’t believe endodontics presents any unique challenges in aerosol management,” Dr Mounce says. “In addition to aerosol reduction, I’m a fan of pre-op rinses and all the standard precautions.”

The use of preprocedural mouth rinses (PPMRs) was recommended for dental practices from the CDC at the beginning of the SARS-CoV-2 outbreak. Although PPMRs were not relevant to reducing aerosols, studies showed they were a good option for reducing levels of oral microorganisms within the oral environment.

 While research on the efficacy of these antimicrobial rinses in combatting COVID-19 is still preliminary, the CDC believed that PPMRs with antimicrobial properties (such as chlorhexidine gluconate, povidone-iodine or cetylpyrinium chloride) could be effective in minimizing and reducing viral loads.

“Dental offices are inherently clean places, and I am not aware of any case where there is a documented transmission from the patient to the doctor or vice versa with COVID,” Dr Mounce says. “If a doctor is really concerned about the COVID-19 status of patients and spreading COVID-laden aerosols, they might consider having every patient rapid tested.”

1. Centers for Disease Control and Prevention. 2020. 

Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission. 

Available at:https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html. Accessed 20 June, 2021.

3. American Association of Endodontists. 

https://www.aae.org/specialty/communique/aerosols-and-coronavirus-in-dentistry/

3. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz D M. 

Guidelines for infection control in dental health-care settings.

The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment

5. Harrel SK, Barnes JB, Rivera-Hidalgo F. Reduction of aerosols produced by ultrasonic sealers. 

Determination of efficacy of pre-procedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scalers. Nitte University JHS

How to mitigate airborne and aerosolized risks while performing endo procedures.

Mitigating Aerosol Risks in Endodontic Procedures

When Anthony K. Senegal Sr, cofounder, president, and operations director of Partners Elite Dental Laboratory Services (PEDLS), decided he needed to streamline his lab’s workflow for monolithic removable dentures, he wasn’t sure where to turn. He wanted a system that simplified design while reliably producing quality dentures with little need for extra manual work. After searching, he found his solution through Ivoclar Vivadent.

The Ivotion Denture System offers a complete digital manufacturing process for the fabrication of removable monolithic dentures. The digital system comprises an integrated workflow of digital laboratory fabrication methods, simplifying the creation of dentures and reducing opportunities for human mistakes.

“It’s an extreme benefit when you are talking about reducing mistakes,” Senegal says. “There’s less human error that can take place when you’re dealing with the milling of Ivotion.”

This denture system is a digital manufacturing process that simplifies the creation of dentures. Combining 3Shape’s scanning capabilities, materials from Ivoclar, and manufacturing strategies from PrograMill, this workflow seamlessly and efficiently creates dentures.

The Ivotion Denture System workflow uses materials from Ivoclar, software and scanning technologies from 3Shape, and milling machines and manufacturing strategies from PrograMill. These combine into a seamless workflow. Senegal integrated Ivotion into his workflow at PEDLS in November 2020 and was impressed with the accuracy and quality of the system. He has found that the fast manufacturing time, quality materials, and predictable results have been a great benefit to his lab.

Richard Wilson, DDS, cofounder and chief clinical consultant and director at Partners Elite Dental Laboratory Services, LLC, stands with a patient who has received Ivotion's upper denture esthetics. 

“If you ever want to make a technician go from a smile to a frown, just say the word 

,” Senegal says, laughing. “That’ll make them frown really quickly. But we haven’t had a single remake since we started using Ivotion. You’re guaranteed you’ll get a quality denture, with few to no mistakes.”

With the slogan “1 disc, 1 milling process, 1 denture,” Ivotion has an uninterrupted milling process that machines monolithic complete or individual complete dentures, immediate complete dentures, and overdentures on 2 attachments from 1 disc, reducing the need for manual work. Although he has had a few patients with larger arches who required the 2-step method, for most patients, 1 puck fits the bill.

He has found that Ivotion’s Shell Geometry technology has been beneficial for design quality and esthetics, streamlining the process more. Located within the Ivotion disc, the Shell Geometry is a 3D tooth and dental-arch structure designed for the fabrication of mandibular and maxillary dentures and allows technicians to mill accurate complete dentures—which rarely require more than polishing after production—in 1 operation.

“You design it, then you send it to manufacturing, and the machine does the work for you,” Senegal says. “So you’re guaranteed to get a quality denture with no mistakes. And that’s a huge benefit, to the lab, the clinician, and patient satisfaction.”

Although Senegal says the initial investment in Ivotion can be high, he has found his investment has paid off. Between the high-quality polymethyl methacrylate tooth and denture base materials and reduced manual steps due to milling accuracy, he has cut down on case time and been able to increase his case load.

“If you get the fit right, there are fewer patient visits after you deliver that denture,” Senegal says. “The likelihood of a patient coming back is minimal. That’s huge when you think about the time you spend on a particular case, when you could be focused on another one. You can save time to do other things and work on other accounts—and still be able to deliver a quality denture.”

Senegal has deemed the investment so worthwhile that he and his business partner, Richard “Al” Wilson, DDS, cofounder and chief clinical consultant and director at PEDLS, are in construction to build a full-service digital commercial lab and are planning to add 3 more PrograMill units, or, as they call them, Ivotion machines.

“When we first looked into this milling system, I quickly said, ‘That’s it, we’re all in, we need to offer this accuracy of milling to our patients,’” Senegal says. “That’s how much we believe in this system and how much benefit we feel that we can get.”

This system offers a total digital manufacturing process to simplify the creation of dentures.

Ivotion Denture System Streamlines Workflow

At one point, the microscope was considered a cutting-edge tool. Motorized dental drills were novel and unique. Digital x-rays were the next best thing. Now, we don’t think twice about them. A new generation of technology has taken the place as the latest and greatest—and it’s evolving every day.

But how have these technologies shaped dentistry, and endodontics in particular? Endodontically diseased teeth that would have been deemed unsavable are now being saved and restored, thanks to new technologies, treatments, and approaches. As the arsenal of tools has grown, so, too, has endodontic predictability. From lasers and 3D imaging to microsurgery and dynamic navigation, there have been developments in tools and techniques.

Advances in minimally invasive treatment have perhaps been what has shaped endodontics the most in recent years. Departing from manual files and other tools, many clinicians are exploring lasers and acoustic energy as alternatives, for quicker and more effective treatment as well as faster healing times. And Dr Richard Mounce, an endodontist practicing in Pacific City, Oregon, sees many areas of new innovation.

“Some of the big trends in endo today include minimally invasive shaping philosophy, improvements in activated irrigation, improved bioceramic sealers, the use of come beam computed tomography (CBCT) in targeted endodontic microsurgery and canal location, and reciprocated endodontics, to name a few,” he says. “While there are several partisan camps in endodontics; one camp advocates minimally invasive approaches using the Sonendo GentleWave System for canal cleaning. It could be argued that GentleWave is changing the specialty.”

The GentleWave procedure provides standard root canal treatment, but with a minimally invasive process that is reported to preserve tooth structure and promote rapid healing.

By utilizing fluid dynamics and broad-spectrum acoustic energy, the GentleWave minimizes—and even replaces—much of the need for manual instrumentation in root canal procedures, preventing the removal of extra tooth structure while providing effective cleaning through its fluid-delivery system, which distributes fluid throughout the canal system. Reportedly, this procedure is, in most cases, a single-visit treatment option.

Other advances in canal cleaning and disinfection include nanotechnology, which Dr Mounce thinks is a noteworthy area of study in endodontics. He predicts that commercial products and clinical techniques are likely to soon emerge using these particles.

In addition to this technology, other options have become attractive, made possible largely by the development of CBCT. Many clinicians, including Dr Mounce and Dr Rebekah Lucier-Pryles, agree that CBCT has made a huge difference in endodontics in the previous decade. In fact, much of the advancement in endodontic treatment and technologies stems from CBCT’s capabilities, particularly for dynamic navigation and targeted endodontic surgery.

“CBCT-guided surgery and non-surgical root-canal therapy are at the forefront of endodontic care,” Dr Lucier-Pryles, an endodontist in White River Junction, Vermont, and cofounder of Pulp Nonfiction Endodontics, says, noting that non-surgical therapies are attractive to patients who balk at the idea of surgery. Even when surgery is the only option, however, Dr Lucier-Pryles finds advances that have made the process easier.

“Technologies associated with CBCT-guided nonsurgical and surgical root canal therapy are now available and facilitating the delivery of endodontic care thought impossible years ago,” she says.“For instance, palatal apical surgery can be readily performed with the aid of CBCT-developed surgical stents. Additional surgical innovation beyond CBCT guidance now includes the use of piezoelectric devices to remove bony windows prior to accessing root apices. This approach offers more predictable postoperative healing than older techniques.”

Dr Mounce agrees. With these technologies, and the development of targeted endodontic microsurgery, guided dynamic navigation, and lasers with multiple applications, he believes the field has been pushed forward immensely.

“We now have techniques that are advancing our clinical capabilities well beyond previous limits by allowing treatment of previously untreatable clinical scenarios,” he summarizes. “Lasers have provided excellent results, and GentleWave partisans would likely argue that their technology is the most cutting-edge the industry has seen.”

The technology gains of the past few years have been impressive, but there’s more to come down the road. As innovative companies continue to do their research and develop cutting-edge products, treatment will be further simplified and care will be improved. Trends look to continue toward medical treatment over surgical, and future regenerative endodontic materials will change how we think about growth factors and material matrix designs—all benefiting patients and the field of endodontics. As these developments progress, Dr Mounce hopes to see these technologies become more accessible and affordable to clinicians.

“At some point, the technology is priced out of the range of the general dentists (and possibly some endodontists), even in the most advanced economy,” he says. “Every clinician must decide for themselves if the clinical result obtained is superior and/or justifies the expense based on the literature. The same cost, risk and benefit analysis should be made for all technology decisions. Right now, prohibitive costs mean treatment hasn’t been simplified for many clinicians; but has the technology improved endo care? Most probably, yes.”

But while some advances are currently cost-prohibitive, the growth continues (hopefully becoming more affordable in the future, Dr Mounce says), and opportunities for development continue to present themselves across the board.

“I see room for continued advancement in CBCT-guided technologies, in disinfection, and in restorative care following endodontic therapy,” Dr Lucier-Pryles summarizes. “As technology improves, our treatment strategies become more appropriate.”

Dr Mounce agrees that big things are just around the corner.

“While I don’t have any inside information, I suspect that we will see a GentleWave-like handpiece that facilitates obturation of the canal using some form of sonic or ultrasonic vibrational waves,” he says. “I’m confident that this concept--putting a handpiece over the access, cleaning and obturating all the clinical anatomy, and placement of a coronal seal via a robotic console--is being developed now.

“It's the Holy Grail of endodontic treatment,” he continues, “and would, for practical purposes, make endodontics as we know it obsolete.”

Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave System. 

. 2015;41(10):1701-1705. doi:10.1016/j.joen.2015.06.018

Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. 

. 2016;42(7):1040-1048. doi:10.1016/j.joen.2016.04.017

Technology in endodontics is evolving every day to provide better tools and techniques in dentistry.

What's Cutting Edge in Endodontic Technology Today

Although a map proves useful in getting you where you want to go, it pales in comparison to a globe for determining the relative location of different places or destinations. A map may be better than nothing, but when it comes down to it, a 2D representation of a 3D structure cannot provide an accurate depiction. 

As well as applying to our mental image of latitude and longitude, this geometric configuration can skew our interpretation of images of complex anatomy. For a long time, endodontic radiographic assessments were limited to panoramic or intraoral x-rays, which, due to a lack of 3D precision, often make it hard to accurately visualize dentition. For example, a periapical radiograph can be distorted due to superimposed anatomical structures (including the zygomatic arch, maxillary sinus, and roots), making it difficult to get a clear view of root canal anatomy. And, for precision procedures such as the treatment of root canal systems, this lack of clarity can lead to treatment failure. However, newer imaging technology has provided a solution.

According to a joint statement from the American Association of Endodontists (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) in 2015, cone beam computed tomography (CBCT) has presented a groundbreaking advancement for endodontics. This is due to its ability to visualize the dentition and the relationship of anatomical structures.

“CBCT has been hugely beneficial to endodontics,” says Dr Richard Mounce, an endodontist practicing in Pacific City, Oregon. “Much of the guesswork about canal location, numbers, curvature, optimal access location, bone levels, pathology, possible nonendodontic lesions, etc, has been eliminated or aided through application of CBCT. In my view, having access to CBCT is the standard of practice, and in certain clinical situations it is the legal standard of care.”

The AAE-AAOMR statement reiterates that small field-of-view (FOV) CBCT images are the image of choice if unusual canal morphology is suspected. These images can be invaluable to diagnosis as they allow clinicians to assess the relationship of teeth to other vital structures, assess traumatic dental injuries such as fracture or resorptive lesions and pathology, and aid in treatment planning for nonsurgical retreatment or surgical endodontics. CBCT is particularly ideal in areas subject to anatomic noise or in cases with symptoms that are difficult to localize, as it can better pinpoint the side of the endodontic issue.

“CBCT imaging has become an essential part of the endodontic world,” says Dr Rebekah Lucier-Pryles, an endodontist in White River Junction, Vermont, and cofounder of Pulp Nonfiction Endodontics. “2D images, like periapical or bitewing radiographs, are limited in their detection ability due to structural overlap (referred to as anatomic noise). 3D imaging removes this overlap and allows clinicians to visualize all areas of the tooth independently.”

These CBCT images are also valuable in retreatment cases, and the AAE and AAOMR believe that previously endodontically treated teeth warrant CBCT scans. According to the organizations, limited FOV CBCT is the imaging modality of choice when examining issues of nonhealing in previous endodontic cases or when assessing endodontic treatment complications, as it can determine what follow-up treatment should occur.

CBCT has myriad benefits, but like any technology it also has limitations. This makes it critical that clinicians understand when its use is appropriate.

“Opinions differ,” explains Dr Mounce. “Some endodontists take a CBCT on every patient, others when they feel it’s needed for complex anatomy, surgery, retreatment, or resorption cases, etc. I have no hesitations about taking scans, but I personally don’t take a scan on every case. That said, I don’t have any [problems] with clinicians who do.”

The primary concern with CBCT imaging is a possible higher radiation dose for the patient. The AAE and AAOMR recommend that CBCT should not be used routinely for endodontic diagnosis or screening purposes if there are no clinical signs or symptoms that indicate a necessity. Likewise, the organizations state that CBCT imaging should only be used when the imaging needs cannot be met by lower-dose 2D radiography.

“CBCT should be used only when the patient’s history and a clinical examination demonstrate that the benefits to the patient outweigh the potential risks,” the associations state. “The use of limited FOV CBCT should be considered on a case-by-case basis, with due consideration given to the risks and benefits of exposing the patient to ionizing radiation, the patient’s history, clinical findings, and preexisting radiographs so that superior treatment can be provided to the general public in need of endodontic care.”

In addition to the risk of higher radiation doses, CBCT has other limitations. High levels of noise and scatter and the potential for artifact generation can throw off a clinician who isn’t accustomed to reading CBCT images.

For clinicians who aren’t comfortable using CBCT, Dr Mounce recommends substituting a surgical microscope. He believes that the lack of both CBCT and a microscope can be of great detriment to the clinician.

“The surgical microscope is a critical piece of equipment and vastly superior to loupes,” he says. “If you don’t have a CBCT and don’t have a microscope, it is exceedingly difficult to envision that a dentist can practice at the same level as a specialist without the microscope. Without a microscope, you simply don’t have visual and tactile control. The double whammy of not having CBCT and/or a microscope is the harbinger of problems.”

Although CBCT presents some challenges that may sway a doctor’s decision to forgo the technology, its increasing availability and expanded applications are making the tool more valuable, despite its current drawbacks. Findings from recent research show that after reviewing CBCT images, many clinicians often change their previously proposed treatment plans because the images so effectively eliminate the concerns over distortion that accompany conventional 2D radiography.

 And, when used as indicated, this 3D imaging can provide clinicians with critical information that allows them to treat cases that may have previously been deemed untreatable.

“CBCT imaging has changed the face of endodontic care, both in its ability to diagnose obscure pathology but also in our ability to treat cases,” Dr Lucier-Pryles says. “Our ability as clinicians to diagnose resorptive dental diseases and to evaluate fracture pathology with CBCT technology has significantly improved, and as a result our treatment strategies are more appropriate.”

1. AAE and AAOMR  joint position statement: use of cone beam computed tomography in endodontics–– 2015/2016 update. AAE. 2016. Accessed June 6th, 2021. https://f3f142zs0k2w1kg84k5p9i1o-wpengine.netdna-ssl.com/specialty/wp-content/uploads/sites/2/2017/06/conebeamstatement.pdf

2. Suomalainen A, Pakbaznejad Esmaeili E, Robinson S. Dentomaxillofacial imaging with panoramic views and cone beam CT. 

. 2015;6(1): 1-16. doi:10.1007/s13244-014-0379-4

3. Ee J, Fayad MI, Johnson BR. Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. 

. 2014;40(7):910-916. doi:10.1016/j.joen.2014.03.002 

3D Imaging and Endodontics – How, when, and why to use cone beam computed tomography in endo cases.

Using Cone Beam Computed Tomography in Endo Cases

Many dentists avoid integrating denture work into their practice, finding it to not be cost-effective for the amount of work, remakes and chair time that go into getting the right fit. Richard Wilson, DDS, cofounder and chief clinical consultant and director at Partners Elite Dental Laboratory Services, LLC, is not one of those dentists.

He embraces denture work in his practice, largely due to the streamlined digital manufacturing process that he employs in his operatory and in-house lab for the production of removable monolithic dentures. He’s found that a digital workflow with the Ivotion Denture System from Ivoclar Vivadent eliminates the processing mistakes (and human error) that cause delays, poor-quality dentures, and increased chair time, all while producing a superior final product.

“The No. 1 thing is minimizing delays and knowing you’re going to get a certain product at the very end with Ivotion,” he says. “You need to know you’re going to get guaranteed esthetics, and I’ve found a digital workflow ensures this more than the conventional way of making dentures.”

The digital Ivotion Denture System is an integrated workflow of digital laboratory fabrication methods that incorporates materials from Ivoclar Vivadent, scanning and software from 3Shape, and milling from Ivoclar’s PrograMill. Because the process is digital, the need to fabricate time-consuming models is eliminated, and a quick scan gathers all the necessary information. Additionally, the accurate milling greatly reduces manual adjustments after production (most dentures just require polishing after manufacturing), hastening turnaround time and eliminating repeated try-ins. Since he began using the system in November 2020, Dr Wilson has found that this accuracy has saved him chair time and phoneline time.

“You’re not going to have these hour-long adjustment chair times,” Dr Wilson says. “You’re going to have 10-minute adjustment chair times; most of the time, these dentures just drop in, and it’s done. Maybe the patient comes back once for a small adjustment, due to their personal preference, but it’s rare. It’s a world of difference.”

Made of high-quality, long-lasting polymethyl methacrylate material, the discs’ unique shell geometry (a 3-dimensional tooth and dental arch structure designed for fabricating mandibular and maxillary dentures) allows monolithic complete or individual complete dentures, immediate complete dentures, or overdentures on 2 attachments to be milled from 1 disc in a single, uninterrupted milling process. For oversize processes, 2 Ivotion discs of tooth and denture base material can be used, providing fast and easy bonding of tooth segments with high-impact strength.

Ivotion is a monolithic, single-disc milling solution for advanced digital denture workflows. Combining high-quality tooth and denture base materials in a single bicolor disc, it provides digital laboratories and clinicians with an efficient, predictable, monolithic milling solution. It features shell geometry, a data-based 3-dimensional tooth and dental arch structure suitable for the digital fabrication of removable upper and lower dentures.

“Even in oversize milling, teeth don’t break off,” he says. “Teeth breaking off is a big inconvenience for the patient—and not only for them but for the practice as well, as you have to make time to deal with these faults. And with Ivotion’s materials, you just don’t see that happening.”

Dr Wilson also believes Ivotion can help practices’ bottom lines in more ways than just saving time. Since the process is quick and easy, he says dentists can do the entire process themselves, without needing extra staff.

“If the doctor is willing to get the design in and get it to manufacturing, he or she can save a lot of money because they can do it instead of having in-house staff to handle it,” he says. “So there are a lot of benefits to the dentists and to the labs because there are fewer lab technicians out there.”

In addition to being beneficial to his workflow (and his practice’s bottom line), he has found that Ivotion dentures affect patient satisfaction.

“Patients these days are expecting a certain type of product and level of treatment,” Dr Wilson says. “I think any [dentists who offer] Ivotion will separate themselves.”

The Ivotion Denture System can eliminate processing mistakes, delays, poor-quality dentures, and increased chair time, all while producing a superior final product.


Digital Dentures Delivering Esthetics, Reduced Adjustments

Hygienists are continually looking for advances that make their lives easier, their work faster, and care more effective. Innovations in materials, fluctuating patient expectations, and an evolving view of the profession as a whole are constantly changing the landscape of hygiene, the role of the hygienist, and how patient care is approached.

Although the industry and its protocols are always changing, the past year put many adaptations into overdrive. The COVID-19 pandemic necessitated increased infection-control awareness and shifted how dental clinicians practice. Despite the challenges, many of these changes have been beneficial, pushing the industry forward and opening new doors.

“We have to make changes, and we have to evolve based on what is going on,” says Katrina Sanders, MEd, BSDH, RDH, RF, a dental educator, and speaker. “And this pandemic has, of course, done that—it’s pushed dentistry to evolve. Dentistry can be very reticent about integrating new products; newness can be a very difficult thing. But the pandemic has pushed us outside of our comfort zone because we’ve had to invest in new technologies, such as [personal protective equipment] or patient communication software. We’ve certainly seen big movement.”

The pandemic, Sanders believes, has given clinicians the unique opportunity to make changes or shift procedures they may have been uncomfortable altering in the past. Whether that’s upgrading instrumentation or utilizing new protocols, with so many changes happening, the door has opened to make a few more.

“The pandemic has cracked open this concept of, ‘Hey, if I was ever going to make changes in my practice, now’s the time,’” Sanders says. “If you wanted to shift the way that you’re diagnosing or educating patients, now’s the time to do it because patients are expecting dentistry to look and feel different. They are expecting to walk into the dental operatory and have changes come at them—in fact, they’re hoping for it in many ways.”

One of the largest and most visible changes has been the adoption of increased personal protective equipment (PPE), aerosol mitigation strategies, and high-volume evacuators.

“Right now, I think a big consideration is obviously infection control—does a product have the ability to be sterilized, and does it solve the current problems that we are facing?” says Alyssa Aberle, MBA, BSDH, RDH, the executive administrator for the Colorado Dental Hygienists’ Association. “There are lots of options for suction and aerosol reduction on the market now, and these developments are critical in keeping both hygienists and patients safe.”

Aerosol reduction in particular has taken many forms, both extra- and intraorally. From the external chairside Dental Aerosol Extractor (Dental Safety First) and The Aerosol Solution System (Aerosol Solutions) to the chair-mounted AeroSol Away, extraoral vacuums capture aerosols before they can disseminate through the air. Intraoral options such as the Mojave dry-vacuum system (Air Techniques) take aerosol reduction to the source, providing high-volume suction in the mouth. But even with the array of current options, Aberle says there is still room for further development.

“There are a couple of things I’d love to see in the future,” she says. “A Cavitron with built-in aerosol reduction would be amazing, especially in the face of [COVID-19]. Bendable or flexible HVEs [high-volume evacuators] would make the job a lot easier and more ergonomic as well.”

One of these wishes will soon be granted: Flexible HVEs like this are already hitting the market. Released this year, the finger-mounted ErgoFinger helps reduce excessive twisting of the wrist and craning of the neck. The HVE attaches to the clinician’s finger, allowing suction to be focused at the aerosol origination point and simplifying 2-handed dentistry.

In addition to aerosol reduction, products and protocols that promote minimally invasive and same-day procedures have taken center stage.

“It’s been great to see lots of products focusing on minimally invasive procedures,” Aberle says. “This is especially important with [COVID-19] and because patients are looking for [other] options to traditional drill/fill dentistry. Patients want to maintain their tooth structure as long as possible, and we have the opportunity to rethink the way we’ve always done things. This also [creates] more opportunities for hygienists to practice at the top of their scope and serve our patients in more community settings.”

Sanders agrees, adding that due to the pandemic, patients are eager to spend even less time in the dental chair than before. And with visits being more time-consuming due to temperature checks, preprocedural rinses, and the donning of many, many layers of PPE, minimally invasive and same-day procedures hold benefits for clinicians as well.

“Patients don’t want to have to come back for multiple steps,” Sanders explains. “Same-day treatment is becoming key—and if that same-day treatment is not as invasive or offers a nonsurgical approach, patients will be more attracted to that. It’s something the sales team used to say and maybe we’d brush it off, but now it means one less round of PPE if the patient isn’t coming back—it eliminates so many steps—so noninvasive has been huge.”

One step-removing innovation has been glass-ionomer sealants. In addition to releasing fluoride, these sealants don’t require the field to be entirely dry before placement. This means hygienists aren’t spending excess time trying to dry the field on emerging molars of squirmy, saliva-filled 6-year-old patients and can get the patient out of the chair sooner with reliable results.

“Glass ionomer sealant options are a game-changer,” Aberle says. “I’m looking to start using Fuji Triage from GC America since it’s able to be applied to partially erupted molars, can be done without aerosols and can be placed over SDF [silver diamine fluoride]the same day.”

Sanders concurs that sealants and placement techniques have come a long way and increase providers’ ability to provide preventative measures that require fewer steps and are incredibly effective.

“We’ve seen an evolution of whether or not something truly requires a dry field,” she says. “Can we remove some steps in the sealant placement process, or can we remove a few seconds off the cure time? We want to meet their preventative needs without creating additional problems down the road, but in an expedient manner. And we oftentimes forget that we have these accouterments in our arsenal.”

With the changes in the dental practice, patient expectations have evolved. In addition to interest in same-day treatment and minimally invasive procedures, patients are becoming more aware of and concerned about the products and ingredients being used in their mouths. This means product selection has become increasingly important.

“Before selecting new products, what’s most important to me is whether or not the product will do what the company claims it will,” says Lynne Slim, MS, RDH, a dental hygienist speaker, and consultant. “It is of utmost importance to be objective when looking at a product and to determine efficacy. You can’t just rely on internet chats with peers; it’s important to review online sources, where a lot of the bias is removed and clinical trials have been conducted. As part of the saying goes, ‘You can’t fool all of the people all of the time.’”

Organic and gluten-free options in foods have been buzzworthy for years, and patients are now extending those preferences and concerns to dental materials. Concerns about chemicals, fluoride, and allergens mean that many practices now have to stock multiple product options to meet patient needs.

“Now everybody wants to know if things are gluten-free or organic or natural,” says Tina Clarke, MEd, RDH, a dental hygiene educator and continuing education speaker, clinician, and owner of Teacher Tina RDH, a professional development resource for hygienists. “So, you need to be aware of those types of marketing labels and what products contain, which could help alleviate the patient’s concerns.”

Sanders also sees the push for natural products, noting that more patients are researching dental materials and looking for alternative options to some of the traditional treatments.

“There’s a big call for more natural products,” she says. “For a long time, it’s been all about fluoride, and because of that, we haven’t been able to connect with patients who are concerned about some of the chemicals or controlled substances. I think we need to be better about integrating products that are going to align with what our patients are asking for.”

Concerns about fluoride have become a hot-button issue that Aberle thinks could be remedied with increased product availability.

“I’d like to have more non-fluoride options for remineralization,” Aberle says. “It would help reach a lot more patients and give them options, potentially leading to greater treatment acceptance and compliance.”

Clarke agrees, adding that the role of the clinician is to serve patients to the best of their ability and the clinician's role meet patient needs while understanding the research to provide patients with educated recommendations.

“Some patients that I serve absolutely do not want fluoride but need some sort of remineralization process,” she says. “Being able to have access to that information and high-quality products is important, regardless of where one stands on the fluoride debate. I’m pro-fluoride, but if I have a patient that says they don’t want a fluoride product, I need to be able to understand and know which fluoride-free products are available that can still provide the care they need. So, for example, right now the prophy paste I use has both a fluoridated and non-fluoridated version.”

Hygienists are also seeing a growing array of all-natural, chemical-free home care products, making personal oral hygiene more accessible—but only if patients know about them. Sanders says she’s now seeing hygienists spending a lot more time focusing on oral hygiene instructions and making recommendations for different home care products like toothpastes, electric toothbrushes, water flossers, and other components.

“I believe this increased education trend is because there is a group of patients who delayed dental care during the shutdown and [feared] returning to the dental practice so home care has become their only hygiene care,” Sanders explains. “We have this challenge now where we’re trying to play catchup, so to speak, and hygienists just are spending a lot more time trying to drive home oral hygiene instruction for the patients.”

For patients neglecting oral hygiene due to concerns about products not being all-natural. Clarke has an arsenal of recommendations at the ready.

“I have patients that want a toothpaste that is vegan or gluten-free, that doesn’t have irritants in it that will affect the tissue—but it needs to get the job done as effectively as a traditional toothpaste,” Clarke says. “I want to have recommendations for them that are scientifically proven to be healthy as well natural. For example, I’ve seen that Twice Toothpaste is doing a good job of that; they’ve incorporated clean ingredients and are really bridging the gap between being natural and [having] scientific evidence to back up its efficacy. Being able to articulate all of that to a patient can be extremely beneficial.”

In addition, recommending products that patients will actually use is critical. If the taste or feel of a product isn’t good, patient compliance will plummet. Although finding home care products that are easy to use and inoffensive to taste buds may be a challenge, a growing number of options is becoming available.

“Finding products with great flavors is especially important with kids,” Aberle explains. “Tanner’s Tasty Paste is the best toothpaste I recommend for kids—good flavors, and it doesn’t contain fluoride, SLS [sodium lauryl sulfate] or xylitol.”

Taste isn’t just important for children; Slim believes it is often a deciding factor for adults too.

“I personally love the new stannous fluoride dentifrices for adults that target a specific use like dry mouth, gum detoxify, or sensitivity,” Slim says. “The packaging of these toothpastes is pleasing to the eye, and I even put it in my occlusal guard at night because I like the taste of these dentifrices so much.”

Options such as these are becoming increasingly more accessible to a wider range of patients as prices have dropped. With so many patients not prioritizing oral health care (or even viewing it as particularly necessary), they are much more likely to invest in good oral care products if they aren’t going to break the bank.

“It’s been great to see more options for affordable home care,” Aberle says. “Electric toothbrushes, toothpastes, interdental brushes—all of these are now more accessible. Electric toothbrushes are now available at a $40-to-$60 price point instead of a $250-plus price point.”

Increased convenience is further reinforcing home care. The pandemic heralded a huge increase in delivery services for products and an expansion of subscription-based deliveries.

“We’re starting to see dental companies step into that with subscription-based models for, say, toothbrush heads,” Sanders says. “It’s a really great way to not only deliver this to the patient on a routine basis but to continue to remind them, ‘Hey, your oral hygiene is important. You just got the shipment, so don’t forget to brush your teeth tonight.’”

As hygienists increasingly focus on patient education and explore new patient-friendly treatment options, the profession becomes a more valuable resource for patients. This increased awareness and evolving view of hygienists as clinicians rather than assistants is reshaping the influence hygienists can have on patients and expanding the array of services hygienists can provide.

Slim mentions that she gets really excited to see television ads that mention the hygienist as a provider because hygienists are preventative therapists trained and educated in ways that dentists are not and can provide unique, critical services to patients.

“I would like to see dental hygienists referred to as therapists,” says Slim. “I’d like to see a schedule where patients schedule the routine exam and radiographs with the dentist at another time that is separate from the appointment with the oral therapist. Valuable time is wasted when dental hygienists sit and wait for the dentist to enter the operatory.”

And perhaps with the way things are trending, this isn’t far off.

“I’m a dental hygiene educator, and I’m a clinician,” Clarke says. “Putting on my educator hat, I think that expanded education has been one of the things that have made me really happy about the pandemic—education for both patients and hygienists [allows] us to grow, learn, and advance oral hygiene. I think it speaks highly to what hygienists can do and who we are that we were able to adapt to this [past] year so quickly as a profession. And I’m sure this is just one step in continued development.”

Innovations, challenges, and changes are reshaping the industry and how hygienists practice.

Pandemic Prompts Evolution of Dental Hygiene

When it comes to education about periodontal disease, patient acceptance and adherence have been inconsistent. Perhaps the biggest challenge in treating periodontal disease is convincing patients that they have a disease. The Centers for Disease Control and Prevention (CDC) reports that 47.2% of adults have some form of periodontal disease.

 However, many of these patients do not believe they have a problem.

With so many individuals disregarding oral health—and emerging research on the links between periodontal disease and serious systemic health issues—periodontal disease is becoming a national health crisis. If only, practitioners mused, there was something that created national awareness about an asymptomatic disease that could easily enter your body without you knowing it but cause life-threatening problems. If only the breaking story of the year involved such a potentially fatal disease that could present without pain or symptoms. If only there were identified risk factors that could predict whether someone had a higher possibility of contracting the asymptomatic disease. Enter coronavirus disease 2019 (COVID-19).

The past year has thrust just such a disease into the spotlight. Although periodontal disease and COVID-19 differ immensely, the parallels can be valuable educational tools.

“This is our opportunity to utilize this as an educational piece for our patients,” says Katrina Sanders, MEd, BSDH, RDH, RF. “I’m not saying let’s lean into the fear our patients have about this disease process—that’s not it at all. But let’s draw parallels to help them understand how periodontal disease can have serious repercussions even if it doesn’t hurt.”

Education is critical because periodontal care during the pandemic presents numerous challenges. Patients who delayed dental care during shutdowns or because of concern about the virus are returning to practices and often presenting with increased calculus following the interruption in care. As a result, the risk of inflammation is elevated. Add habits instituted by pandemic life (such as increased alcohol and tobacco use or poor dietary considerations) and high levels of stress (an etiologic factor that increases cortisol and inflammatory conditions), and the perfect environment for oral health issues has been created.

“Oral hygiene status has been poor,” says Sanders. “In addition, ‘mask mouth’ dries out the mouth and makes people more prone to periodontal disease. And a lot of patients are working from home now—they wake up, hop on a Zoom call, and they aren’t going to really be seen by anyone, so maybe they skip brushing their teeth. So, we’re starting to see these patients come in and they are a challenge.”

In addition to educating patients, practitioners need to be aware of their own focus on perio treatment. As practices reopen, dentists are focused on setting up schedules and resuming business. Hygienists must spend time comforting patients who are nervous about COVID-19 risks in the practice and becoming acquainted with new personal protective equipment and tools such as high-speed evacuation systems. But dedication to perio cannot be neglected, particularly because periodontal disease could be linked to COVID-19.

A recent study found enough evidence to suggest that periodontal disease is a risk factor for COVID-19, because diseases such as diabetes, obesity, and cardiac conditions, all of which are linked to periodontal problems, are comorbidities that are common risk factors for COVID-19.2

“During the time when periodontal disease is ongoing, there is a huge inflammatory burden on the rest of the body,” says Mia Geisinger, DDS, MS, associate professor and predoctoral periodontal program director at the University of Alabama at Birmingham School of Dentistry, and a diplomate in the American Board of Periodontology (ABP). “We have a unique opportunity right now to reach our patients and to talk about the important work that we do to manage and address chronic inflammatory disease that can create similar inflammatory burden, cardiovascular disease, diabetes, and obesity.”

As a result of these comorbidities, Sanders says, evaluating, managing, and optimizing patients’ immune response is critical in the current health crisis.

“There’s so much research coming out about how if we have inflammation in our body associated with oral disease, it can elevate our risk for SARS-CoV-2,” says Sanders. “Periodontal disease is one of the only bacterial diseases in the body that we’re really leaning on to the host response to be able to fight this inflammatory condition. By rendering patients healthier, we can reduce the burden on the immune system or the amount of inflammatory condition my patient has. This could be a huge key to help control how this disease is spreading.”

Although research has linked periodontal disease to numerous conditions in addition to COVID-19 (including heart disease, cancer, respiratory disease, and osteoporosis), it was believed until recently that only bacteria were to blame. According to the ABP, however, inflammation is a critical factor. Perhaps one of the silver linings of the pandemic has been a refocusing of attention on low-grade chronic inflammatory conditions that are endemic to the adult population, such as diabetes, prediabetes, dysglycemia, obesity, and, critically, periodontal disease.

“Inflammation is the big keyword, and there’s quite a bit of inflammation when someone has periodontal disease,” says Robert Levine, DDS, a board-certified periodontist and diplomate of the ABP practicing in Philadelphia, Pennsylvania. “As a profession, we need to take very seriously that the mouth is connected to the body and the systemic links.”

How diagnostics and preventive measures are fueling periodontal treatment acceptance among patients. 