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

Laura Dorr

Preprocedural mouth rinses (PPMRs) are nothing new. Common for many years as a standard practice before root canals or implant procedures, these antimicrobial rinses reduce the bacterial load in the mouth, reducing the risk of contamination from bacteria.

With the advent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the dangers that aerosols pose for viral spread, practitioners are looking at preprocedural rinses with increased interest. Although rinses may have previously been used to protect the patient from infection, now they are being looked at as a protective measure for dentists, hygienists, and assistants. Researchers have determined that aerosols are the primary mode of transmission for SARS-CoV-2, and it has become increasingly critical to neutralize any viral components that could be transmitted through aerosolized saliva.

“The goal is to reduce the amount of bacteria or virus the patient is expelling into the air,” saysV. Kim Kutsch, DMD, a private practitioner and CEO of CariFree. “In my practice, we now use a preprocedural rinse for 30 seconds as a standard practice on every patient. It used to be standard of care for implant procedures, but we’re now doing it for all procedures.”

Research on the efficacy of PPMRs against coronavirus disease 2019 (COVID-19) is still in its infancy, but the Centers for Disease Control and Prevention (CDC) now recommends using them before dental procedures, with the objective of reducing viral loads.

“Preprocedural mouth rinses with an antimicrobial product are recommended,” the CDC states, “with the caveat that there is no published evidence regarding the effectiveness of a preprocedural mouth rinse in reducing viral load of SARS-CoV-2.”

“To rinse or not to rinse has been a controversial topic for a long time,” says Michele Lash, BA, RDH, a clinical educator for Dentsply Sirona Preventive. “While some research has indicated the use of a preprocedural mouth rinse may reduce the number of microorganisms, the scientific evidence at this time is inconclusive, simply because the clinical research on this subject is lacking. Clinicians should use their professional judgment when considering the use of a PPMR as part of their protective layering measures and stay abreast of research, as this is an area we are sure to read more about.”

Despite the lack of published evidence regarding the clinical effectiveness of PPMRs against SARS-CoV-2, the CDC states that those with antimicrobial properties may reduce the level of oral microorganisms in the aerosol splatter generated during dental procedures.

 These include povidone-iodine (PVP-I), chlorhexidine gluconate, essential oils, and cetylpyridinium chloride. However, the agency offers no further guidance on which type of PPMR is most effective. There is not enough research yet on SARS-CoV-2, but there is past and ongoing research into PPMR efficacy against other diseases that have comorbidity factors with the virus.

“According to CDC, 40% of those people who die from COVID-19 also have an incidence of either influenza A or pneumonia,” says Jim Ratcliff, chairman and CEO of Rowpar Pharmaceuticals. “So, we decided we needed to begin investigating things that are comorbidity factors for COVID-19.”

Although investigators are performing extensive research on those comorbidities and SARS-CoV-2, at present the CDC, the American Dental Association (ADA), and the World Health Organization (WHO) do not know what the best PPMR is in the fight against the pandemic virus. But that doesn’t mean rinses shouldn’t be used in dental practices. It just means practitioners have to wade through the options on the market to decide which is best for their patients.

PVP-I rinses contain a water-soluble combination of povidone and iodine, which are known to eliminate viruses, bacteria, and fungi. These ingredients are already commonly used in the medical industry to disinfect skin during surgery. WHO has listed PVP-I PPMRs as experimental therapies for SARS-CoV-2, due to the agent’s oxidizing properties. Regardless of the concentration, the iodine in the complex oxidizes viral cells that contain nucleic and amino acids and disrupts proteins. Additionally, PVP-Is were initially recommended for use during the Middle East respiratory syndrome coronavirus (MERS-CoV) epidemic, as both MERS-CoV and SARS-CoV-2 are particularly susceptible to oxidation.

New research backs up its efficacy. In a recent laboratory study, 1% PVP-I rinses and 0.45% throat spray were found to kill up to 99.99% of SARS-CoV-2 virus in 30 seconds. However, the trial did not include human subjects, so further clinical studies are needed.

Although it can’t kill all types of bacteria, chlorhexidine has long been a go-to for caries prevention, in periodontal procedures and root canal irrigation, and as an antiseptic mouthwash. Now it has been found to be effective in the short term against SARS-CoV-2.

According to new study findings, rinsing with a chlorhexidine PPMR reduced the SARS-CoV-2 viral load in saliva for around 2 hours.

 After the 2-hour mark, viral loads increased.

Although the results are promising, the study was limited, as there were few participants and a lack of control subjects. Chlorhexidine is widely effective against bacteria, but it has not been extensively studied for its efficacy against viruses. Still, the study authors were encouraged by the results, writing, “Chlorhexidine could be beneficial in controlling droplet transmission.”

Chlorhexidine remains a popular PPMR choice among clinicians. However, it has previously been found to lower the pH in saliva, thereby increasing acidity and, potentially, the risk of tooth damage.

An old standby, hydrogen peroxide is another PPMR option. Like PVP-I, hydrogen peroxide is an oxidizing agent, and the hydroxyl free radicals that hydrogen peroxide produces attack cell components such as nucleic acids and membrane lipids.

The ADA recently recommended that patients should rinse with 1.5% hydrogen peroxide before the start of procedures. Additionally, research performed in April 2020 reported that a 3% solution was effective in patients in the early stages of SARS-CoV-2 infection.

From a patient’s point of view, hydrogen peroxide is not always the most pleasant of PPMRs, as its foaming nature can feel uncomfortable in the mouth—an important consideration for adherence as it is recommended that patients rinse for a full 30 seconds.

Sodium hypochlorite, the main ingredient in household bleach, has faced some skepticism over its use as a PPMR in recent years (recommending bleach as a mouthwash to patients makes some practitioners uncertain at best), but some practitioners swear by it. A 2010 study concluded that hypochlorite mouth rinse could reduce bacteria in saliva and decrease tongue coating accumulation.8

Additionally, in a 2011 evaluation, Jorgen Slots, DDS, DMD, PhD, stated that a bleach mixture was twice as effective as typical mouthwash at killing bacteria. He reported that bleach PPMRs had the highest success rates for killing bacteria, spores, fungi, and, most relevantly today, viruses.

Dr Kutsch also believes sodium hypochlorite to be effective. He recommends products such as those of the CariFree line from Oral BioTech, which incorporate sodium hypochlorite as one of their antibacterial properties.

“COVID-19 hit so quickly, and research takes quite a bit of time,” Dr Kutsch says. “But looking at research that’s been done…earlier last year, specifically on COVID-19, whether it’s hand hygiene or on surfaces, sodium hypochlorite appears to be one of the best agents to use to inactivate COVID-19. It’s a really good antimicrobial agent. And it’s one of the ingredients in CariFree, so, for a preprocedural rinse, that’s my go-to.”

For practitioners and patients who want to go the do-it-yourself route, the general recommendation for sodium hypochlorite mixtures is 3/4 tsp sodium hypochlorite to 8 oz water. As chlorine is a gas, it loses its potency over time, so batches must be mixed fresh for each use. However, many patients complain of a harsh taste with sodium hypochlorite products, which could reduce adherence.

With the surge in popularity of all-natural products, essential oil PPMR options are rapidly expanding. Generally made up of a combination of components such as menthol, eucalyptol, methyl salicylate, and thymol in an alcohol base, these oils are believed to compromise bacterial enzymes and reduce pathogenicity.

Though more research is needed on the use of essential oils, the researchers of a 1996 study reported that essential oil PPMRs provided a 60% to 65% reduction in salivary bacteria for up to 1 hour.

 However, there is little research to prove their efficacy at reducing bacteria or viruses in aerosols.

As practitioners search for the most effective ways to protect themselves and their staff from SARS-CoV-2, they should certainly consider adding a PPMR to their workflow.

“Preprocedural rinsing has been recommended to help reduce transmission of pathogenic microorganisms,” the ADA reports. “At this time, there is no evidence for the use of any preprocedural rinse against SARS-CoV-2. However, biologic plausibility suggests hydrogen peroxide and PVP-I could be expected to be virucidal intraorally, and may reduce SARS-CoV-2 viral load in dental aerosols.”

Essentially, what do practitioners have to lose? Although more studies on SARS-CoV-2 are needed, past research has shown that there are many products that can lower other bacterial and viral rates, preventing contamination and the transmission of disease.

“There are a lot of products on the market that claim antimicrobial and antiviral activity that haven’t been tested against COVID-19,” Ratcliff says. “All these claims depend on information we just don’t have yet. What we need now is more information.”

And more information is on the way. Rowpar Pharmaceuticals, makers of the CloSYS line of products, recently announced that according to results of a laboratory study, CloSYS Ultra Sensitive Oral Rinse reduced SARS-CoV-2 by up to 98.4% within 30 seconds—without the use of hydrogen peroxide, PVP-I, or alcohol. Instead, CloSYS uses a stabilized chlorine dioxide.

“All CloSYS products contain a proprietary formula with Clorastan, the trade name for stabilized chlorine dioxide, which is a safe and effective oxidant long recognized for its antimicrobial, disinfecting, and sanitizing properties,” CloSYS reports on its website. “The CloSYS formula is naturally activated by acids in saliva. Once released, Clorastan disrupts and penetrates dental biofilm, killing the microbial pathogens living within and inhibiting their regrowth.”

Ratcliff is excited by the lab results, but says there is more work to be done.

“All the studies that have been done today have been in vitro lab studies,” he notes. “So that’s good, but what we need now are clinical studies—how well do the products really work in a person’s mouth as opposed to a laboratory study.”

CloSYS is currently a partner in a clinical study (Effect of Antiseptic Mouthwash/Gargling Solutions and Pre-procedural Rinse on SARS-CoV-2 Load [COVID-19]) that is under way at the University of California, San Francisco. The study runs through the fall of 2021.

“In the past few months, there have been additional products that have been tested and come forward that also show a reduction in viral load,” Ratcliff says. “The 2 takeaways for us have been that certain product ingredients do work well on the SARS-CoV-2 virus and certain ones don’t, and those appear to be hydrogen peroxide or chlorhexidine, at least at this point.”

Regardless of which PPMR route a practitioner chooses, it’s important to implement one in every practice, says Dr Kutsch. He doesn’t see himself going back to only using rinses for certain procedures, and will continue implementing PPMRs for every appointment.

“I can’t imagine practices will go back to not using a preprocedural rinse,” Dr Kutsch says. “Why would [they] go back on it? Because the evidence is clear that rinses can reduce pathogen loads in the mouth for [about] an hour. That’s productive whether or not COVID-19 is a risk.”

1. COVID-19. Guidance for dental settings. CDC. Accessed January 4, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

2. Kirk-Bailey J, Sunkaraneni S, Challacombe S. The use of povidone iodine nasal spray and mouthwash during the current COVID-19 pandemic may reduce cross infection and protect healthcare workers. SSRN. March 30, 2020. Updated May 19, 2020. Accessed January 5, 2021. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3563092

3. Anderson DE, Sivalingam V, Kang AEZ, et al. Povidone-iodine demonstrates rapid in vitro virucidal activity against SARS-CoV-2, the virus causing COVID-19 disease.

. 2020; 9(3):669-675. doi:10.1007/s40121-020-00316-3

4. Yoon JG, Yoon J, Song JY, et al. Clinical significance of a high SARS-CoV-2 viral load in the saliva. 

. 2020;35(20):e195. doi:10.3346/jkms.2020.35.e195

5. Bescos R, Ashworth A, Cutler C, et al. Effects of chlorhexidine mouthwash on the oral microbiome. 

. 2020;10(1):5254. doi:10.1038/s41598-020-61912-4

6. Chemical disinfectants: guideline for disinfection and sterilization in healthcare facilities (2008). CDC. Updated September 18, 2016. Accessed January 3, 2021. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html#Hydrogen

7. Caruso AA, Del Prete A, Lazzarino AI, Capaldi R, Grumetto L. Might hydrogen peroxide reduce the hospitalization rate and complications of SARS-CoV-2 infection?

. 2020;41(11):1360-1361. doi:10.1017/ice.2020.170

8. Shinada K, Ueno M, Konishi C, et al. Effects of a mouthwash with chlorine dioxide on oral malodor and salivary bacteria: a randomized placebo-controlled 7-day trial. 

. 2010;11:14. doi:10.1186/1745-6215-11-14

9. Slots J. Anti-infective agents in periodontal treatment. Medscape. September 15, 2011. Accessed January 5, 2021. https://www.medscape.com/viewarticle/749509_2

10. von Fraunhofer JA, Kelley JI, DePaola LG, Meiller TF. The effect of a mouthrinse containing essential oils on dental restorative materials. 

11. Return to work interim guidance toolkit. ADA. Updated July 23, 2020. Accessed January 5, 2021. https://success.ada.org/~/media/CPS/Files/Open%20Files/ADA_Return_to_Work_Toolkit.pdf

12. COVID-19 final report: MRIGlobal. CloSYS. Accessed January 5, 2021.https://closys.com/pages/closys-reduced-covid-19-virus

Articles

The why, what, and how of preprocedural rinses to reduce infection risks in the dental practice. 

Preprocedural Rinse Protocols

When picturing artificial intelligence (AI), something futuristic may come to mind, like Rosey the Robot of 

 serving food as you relax while watching a football game. As much as people might love never having to leave the couch to get a snack, AI seems like something that exists only in the distant future or in science fiction such as 

When artificial intelligence (AI) is mentioned, some may conjure up images of HAL 9000 from Stanley Kubrick’s sci-fi classic, 

 or HAL’s contemporary, virtual interactive kinetic intelligence (VIKI) from 

: 2 superintelligent supercomputers that turn evil to bring about the destruction of humans. Although modern AI may not be advanced enough to kill a crew of astronauts to save itself (spoiler alert), it is a lot more ubiquitous than you might think.


Today’s AI technology would put HAL 9000 to shame. Unlocking an iPhone with FaceID, using Siri and Alexa, and even picking a show to watch on Netflix—these are just a few examples of how we interact with AI in small ways every day.

AI can be divided into different categories based on the extent of an AI system’s ability to mirror human capabilities.

 A system that can perform more humanlike tasks with equal or greater aptitude would be considered more evolved, whereas AI with limited functionality would be considered less evolved.

 Therefore, AI can be classified into 2 categories

Based on AI or AI-enabled machines’ likeness to the human mind

AI’s ability to “think” or even “feel” human

Based on this classification system, there are 4 different types of AI or AI-based systems.

This is the oldest form of AI, and as such, has the most limited capabilities. Reactive machines are able to imitate the human brain’s ability to respond to different stimuli but do not have memory-based function.

 Essentially, this means that this category of AI cannot use previously gained understanding to inform their present actions—they do not have the ability to “learn.”

 A real-world example of a reactive machine is IBM’s Deep Blue, a computer that beat world chess champion, Garry Kasparov, in a 6-game match in 1997.

These machines build on the same capabilities as reactive machines but are also able to learn from historical data to make decisions.

 Most existing AI applications fall into this category. Current AI systems are trained using large volumes of training data and can make informed, improved decisions based on historical knowledge.

 Take self-driving cars, for instance. They use limited memory to collect data that help the machine make immediate decisions.

 For example, autonomous cars, such as Google’s Waymo self-driving car, use sensors to detect traffic signals, pedestrians, and terrain.

This is the next level of AI researchers are trying to unlock.

 Once they do, theory of mind AI will be able to determine needs, emotions, beliefs, and thought processes of individuals or objects it encounters.

The last type of AI is likely decades down the road, if not longer, and will always be the ultimate aim of researchers.1 In theory, this type of AI would be able to not only process emotions but would also have emotions of its own.

 Concepts such as self-preservation, fear, and ambition would be possible in a self-aware AI system.

1.Joshi N. 7 types of artificial intelligence. 

 June 19, 2019. Accessed January 19, 2021. https://www.forbes.com/sites/cognitiveworld/2019/06/19/7-types-of-artificial-intelligence/?sh=56299eb5233e

2. Deep Blue. Accessed January 20, 2021. https://www.ibm.com/ibm/history/exhibits/vintage/vintage_4506VV1001.html

3.Lateef Z. Types of artificial intelligence you should know. November 25, 2020. Accessed January 20, 2021. https://www.edureka.co/blog/types-of-artificial-intelligence/#:~:text=Self%2Ddriving%20cars%20are%20Limited,to%20make%20better%20driving%20decisions

However, AI and Rosey are already here, and they’re serving up your next meal. AI suggests what restaurant to order from in the DoorDash app and provides recommendations for your weekly Instacart delivery.

“Artificial intelligence is a term that is broadly recognized, but I don’t think it is universally understood,” says Tony McGinnis, executive vice president of internet marketing at Scorpion. “We are seeing AI and machine-learning technologies in many aspects of our lives, from fitness apps to personal finance tools to chatbots on most modern websites, and even the content that is served to us on social media profiles. In fact, we are often interacting with some form of artificial intelligence as a consumer when we don’t realize it.”

Apps such as DoorDash and Uber Eats that recommend restaurants based on users’ past preferences are using automated technology to create connections based on information. These machine-learning algorithms become more intelligent over time, providing better recommendations as they receive more input data.

Although this may be commonplace enough that it seems unimpressive, it takes large amounts of data for AI and machine learning to be effective.

“AI can do anything, really, but the quality of data matters,” says David Broom, general manager at Henry Schein One TechCentral. “If you have good, quality data, and you have enough data, then you can do predictive analysis. AI is really about having enough data to predict with a high probability of being correct.”

Now, these data are being used beyond ordering food to streamline workflows and launch dental practices into the next generation of technology. And although AI already surrounds us, there are still many advances to be made that could change the dental industry permanently.

AI has already carved out its spot in the dental industry, and although many practitioners are excited, some are still hesitant to embrace it. However, as it integrates more into every aspect of dentistry—from marketing and diagnostics to practice management and CAD/CAM—it’s becoming more critical to practice success.

“We have seen a steady increase in the number of practices that have adopted automated technology in the past decade,” says Steve Roberts, president of Vyne Dental. “It’s the way the industry is moving towards as a standard, and those practices that are not yet looking into how technology can benefit their businesses run the risk of becoming obsolete.”

Roberts says dental practices will have to adapt to keep up. This technology is helping the industry better respond to changes in customer demands, allowing for better patient care and more accurate and secure information sharing, all resulting in sustained industry growth.

“Bottom line, AI and machine learning are helping to deliver better care,” says Ed Shellard, DMD, chief dental officer at Carestream Dental. “They’re helping dentists deliver better clinical treatment and improving efficiency drastically.”

Although efficiency may be the name of the game when it comes to AI and automated technology, it’s not all about the numbers. This technology also reintroduces the human element to the dental practice.

“AI and machine learning actually free up our time to have more interactions with our patients, and more time listening to them,” says Eric Pulver, DDS, chief dental officer for Denti.AI. “In a funny way, technology is actually increasing human interaction—we think about digitalization as being a push towards being dehumanized, but really it allows us to have more time to have conversations with patients that can bring that trust factor back to the dental profession.”

Inviting AI into the clinical setting may seem futuristic and far-fetched, but automated technology has already entered the operatory with positive results, thanks to the increased efficiency, accuracy, and improved clinical care it provides. From imaging and diagnostics to patient care, AI and machine learning are changing the way dentists practice.

“AI reduces the time it takes to gather information and diagnose,” Dr Shellard explains. “For instance, when evaluating images, the application of AI into those images helps the practitioner diagnose quicker. AI can help identify key things to highlight to the practitioner to ensure that they aren’t missed when reading x-rays. Dentists have lots of things pressing on their time, and so it can be easy to miss things. So, being able to make sure that those areas are identified and highlighted to the doctor is really important to ensure you are addressing the needs of the patient.”

Dr Pulver agrees. “Machine learning and artificial intelligence can help bring us accuracy and calibration and clarity to diagnostics. We’re able to collect data on a more efficient scale,” he says. “AI can read a panoramic image and identify pathological and nonpathological findings, number teeth, and highlight areas that can lead to a discussion with the patient.”

This ability has led to increased efficiency and reliability of diagnostics. When AI reads a scan, it can identify problem areas the doctor may not have been looking for. For example, a patient may come in complaining of pain in a certain area, so logically the doctor focuses on that quadrant. But while attention is focused on that area, an issue may present in another. AI will identify that issue and bring it to the dentist’s attention.

Denti.AI in particular is adapting this technology with machine learning. Using the expertise of oral and maxillofacial pathology and radiology, the service’s machine-learning algorithms were fed thousands of dental radiographs and taught to identify areas of concern. As more data are uploaded, the algorithms become more adept and advanced. Dentists can upload a bitewing or panoramic, and within 4 seconds, Denti.AI will detect potential pathologies and indicate areas of concern on the image. To date, the continuously learning software has reportedly been twice as likely as a master facial radiologist to find early decay.

“Basically, computer vision can find things better than the human eye,” says Dr Pulver. “The machine learning keeps making it better, and the more data it has, the smarter the algorithms are. AI can make mistakes, but so do we—and when you combine AI with a doctor’s expertise, we make fewer mistakes.”

Although this technology is still being rolled out, it could have an extensive impact on the ways dental practitioners think about diagnostics in the future.

“One day, AI will be able to not only identify potential problem areas but also diagnose,” Dr Pulver says. “We have an opportunity on the industry side, the provider side, and the academic side to work together to make sure new technology enters into the oral health domain. We need to collaborate to bring things forward. If we do this, one day we won’t have a second thought about AI technology, and we will trust it implicitly.”

Machine learning has yet to reach that point, but AI provides numerous options for organic learning. Dr Shellard sees opportunities for AI to help general practitioners better evaluate clinical case needs, expanding their knowledge base and the clinical offerings they can provide to their patients. This allows the general practitioner to perform more advanced procedures and makes specialty procedures more accessible to non-specialists, he says.

“AI helps practitioners better understand a root canal, or better understand whether or not you can do an aligner case—basically, it helps triage or identify to the general practitioner which procedures they can do comfortably, or which would be better to refer out to a specialist,” Dr Shellard explains. “It helps practitioners understand where their limits are, but also allows them to treat complex procedures comfortably because they have a sense of assurance that they’re not going to get in over their head.”

Some practitioners may not yet feel comfortable with machine learning performing diagnostics or using AI for more complex procedures, but many practices are (perhaps unknowingly) already implementing AI to streamline the diagnostic workflow through digital imaging. For example, Carestream Dental is using AI technology to do automated tracing of cephalometric images for orthodonture. Gone are the days of orthodontists using tracing paper atop an x-ray to map the points. Carestream’s software automatically identifies points and landmarks and measures them for the doctor.

“The measurements are very high accuracy,” Dr Shellard says. “A little over a millimeter in accuracy with very little variance. This certainly is one of the advantages of AI for increasing practice efficiency, because it can save the doctor so much time.”

Additionally, AI is being used to position patients for 3D imaging, drastically reducing the number of retakes. Intraorally some systems are already capable of labeling and segmenting teeth and smart-shade matching through digital impression capture using an intraoral scanner.

“With the Carestream CS 3700 scanner, you can do a full arch in about 45 seconds,” Dr Shellard says. “The image doesn’t require manipulation by the [dentist] and is 92% accurate. The doctor can make any minor adjustments they need to, but the bulk of the segmentation is done automatically by the AI engine, which saves an immeasurable amount of time.”

The marketing landscape has changed with the digital revolution. Mailers and conventional advertising are no longer the only options for reaching patients. As options have increased, so has the importance of personalization and relevancy. This means marketing through a variety of channels, which can make the task of ad buys alone virtually impossible for one person to handle.

“Not every type of communication works for each patient,” says Paul Intlekofer, founder and CEO of MMG Fusion. “Blanket communication doesn’t work. For example, if you take age into consideration, millennials respond to texts and videos. Older folks like email or even mailers—whereas a younger person will just throw that in the trash. The key is to identify what resonates with a specific demographic, and to have a machine-learning system that is reading those data and interpreting them and sending out communications based on those data and responses.”

Instead of dentists guessing at the success of campaigns, or having to evaluate marketing effort efficacy annually, machine learning is constantly analyzing and adapting responses to marketing. It allows dentists to set up parameters, and then watch for the software to figure out the most effective approaches and adjust accordingly.

“At Scorpion, we spend a lot of time thinking more specifically about how artificial intelligence can help a dental practice grow its revenue and patient base,” McGinnis says. “We know that patients are more responsive to dental providers that interact with relevant communication that resonates with their specific needs. But to do this effectively in marketing communication requires the assistance of technology that is available, which is where AI and machine learning come into play.”

By leveraging machine learning, practices can automate advertising to deliver the right message to the right patient at the right time. For example, Scorpion’s technology combines and leverages data from across all clients to identify traits and attributes to inform individual campaigns automatically and make them smarter over time. The software manages ad spend across all digital channels where a potential patient might interact with a practice, and ensures dentists are getting the most optimized placement across all channels.

“Perhaps a dentist wants to specifically promote a higher-value service they offer to the right customer who can afford it,” McGinnis explains. “This is difficult to do manually, but machine learning and artificial intelligence can continuously collect data about their ideal patient and adjust paid campaigns to continue to reach the right patient with the most relevant message.”

Relevant messaging is also critical for internal marketing and reactivating existing patients who may have neglected to follow up on care. MMG Fusion’s ChairFill analyzes the practice schedule and searches records for patients with unfinished treatment or those in need of follow-up care who fit the available chair time. The automated practice growth software generates targeted campaigns with unique methods of communication for each patient, even customizing the imagery and copy for personalized marketing. It then books responding patients into the practice schedule. This automated technology helps retain patients, simplifies appointment booking, and increases revenue, leaving the dentist free to practice dentistry.

“Assuming your data are good, automated marketing technology can lead to higher conversion, lower patient no-show rates, and—if the patient experience is a positive one—lead to an increase in recurring patient visits, and overall lifetime patient value,” McGinnis says. “And when automation has the ability to become smarter over time, opportunities become even more targeted and optimized toward successful business outcomes, depending on your goals.”

Time is money in the dental practice, so efficiency is critical. This means streamlining practice management protocols by automated appointment scheduling, claims, referrals, and communication. This has become increasingly important in the past year, as the coronavirus disease 2019 (COVID-19) and lockdowns forced the world to think about digital strategies in a new way.

“I think most recently, automated technology has enabled the industry to be more resilient in uncertain times,” Roberts says. “The COVID-19 pandemic has increased the demand for technology options that allowed patients to receive care when they could not visit a practice in person. Teledentistry and remote check-in are valuable service options for many practices and patients. Automated technology solutions also allowed staff to work from home and submit claims to support critical incoming revenue. Had the industry been unable to make shifts like this, we may have seen different results from the pandemic.”

Intlekofer agrees. “Automated technology has allowed practices to essentially run remotely,” he explains. “A central dashboard creates a workflow that practically allows your office manager to do everything from home. COVID-19 has really proved that, even to practices that may be slower to adopt new technology.”

But the value of automated technology extends well past the pandemic. In addition to making it easier to run a practice remotely, AI makes it easier just to run a practice. By eliminating manual processes and ensuring data continuity, dental practices can make the management side of dentistry run much more efficiently.

There are many AI solutions to choose from. Companies such as Vyne Dental are simplifying claims through automated technology that allows electronic claims submissions, real-time end-of-business viewing, claims tracking, and claims status within 48 hours of submission. This means less time spent on claims submission and tracking, and more time to work on other projects.

“As every back-office dental practice staffer knows, the administrative work required to run a dental practice keeps increasing,” Roberts says. “There are also increasing regulations and changes that practices must keep up with. Using automated technology solutions lets practices complete important back-office tasks like claims submissions from anywhere, decreases time spent on claims status and resubmissions, and costs significantly less than traditional, less automated methods.”

Automated technology is also changing staff management. MMG Fusion’s MMG Manage software assists team members with prioritizing tasks and tracks staff performance. The system’s virtual office manager identifies what needs to be done and creates an actionable checklist for team members to complete, increasing production and lowering overhead.

“Their job actually becomes easier because they basically have a kind of a ticket system to tell them what to do,” Intlekofer explains. “They don’t have to worry about what they need to get done—it just happens right there, and they can monitor their tasks. The software is doing it for them. So that’s where the beauty of automation and machine learning comes in, when the practice is like ‘Wow, I don’t have to worry about that,’ and the software starts to allow the practice to accomplish more things, more effectively than you could in the past, and it’s cheaper.”

Although internal communication and streamlining are critical, automated solutions are also growing in the field of interoffice communication. A few years ago, Hessam (Sam) Ahani, DDS, noticed that many patients didn’t follow through on referrals to specialists and that there was no easy way for general practitioners to track which patients had gone through with specialty procedures.

“We’re always trying to improve,” Dr Ahani says. “We’re always trying to make dentistry better and bring new features. Technology is a never-ending story; there’s always something new around the corner.”

Dr Ahani decided to create a digital solution, and in 2018 founded Refera to streamline the referral process. Through the web platform, specialists receive an automated email from the referring practice informing them of the referral and passing on the patient information. The specialist’s office can then reach out to the patient to set up an appointment.

“Instead of giving the patient a piece of paper for a referral—that they will often lose or throw out—we can inform the practice of the referral and prompt them to call the patient directly,” Dr Ahani explains. “Patients are much more likely to schedule if they don’t have to take the extra step of setting it up themselves, particularly if it’s a referral for something like orthodonture, where nothing is currently hurting or bothering them. We’re seeing much better conversion rates now, 30% more, and are able to keep track of who follows through.”

In addition to streamlining claims and referrals and simplifying workflows, automated technology is being used to monitor the status of the actual hardware in a practice. Around 2 years ago, hardware-as-a-service solutions emerged in the dental field, combining all the hardware equipment (such as computers, workstations, and drives) and managed services into one offering.

This gives companies such as Henry Schein TechCentral the unique ability to use automated technology and AI to monitor drive utilization and how much memory a practice is using, as well as wear and tear on the devices. The technology analyzes these data and sends automated reports to TechCentral detailing any issues, warning of drive failures, and even identifying when a practice’s growth curve is getting to a point where system upgrades are needed. Essentially, it’s 24/7 information technology and hardware maintenance, all running behind the scenes.

“The thresholds indicate whether or not certain tasks need to be done,” Broom explains. “Either alerts go to our staff team and we will work with the client to figure it out, or the technology will automatically fix the issue in the back end. The practice doesn’t even know sometimes, because it will automatically be cleaned up and be proactively fixed before a problem even emerges.”

When it comes to designing and milling restorations, automated technology plays a big role, from the design phase to production. For CAD, machine learning, and AI make designing restorations faster, easier, and more accurate.

“The current CAD leaders have design-centric programs to sort through data sets and patient data,” says Steve Braykovich, owner of Axsys Dental Solutions. “It has to make sure that the CAD design is suitable for machining, and also that it meets the clinical specifications and fit.”

Current CAD software looks at 3D layouts and makes intelligent design suggestions and adds design features, giving practitioners a leg up in the design process. Intuitive software will learn to become more refined and make more intelligent predictions.

CAD/CAM solutions are now offering a combination of library and adaptive knowledge for implant and crown design. Most software combines a built-in tooth library with the anatomy of a particular patient and then takes measurements. Adaptive software will then mirror the measurements to apply the known parameters to that particular area. It can then assess how movement of a contact point will affect other points and automatically adjust to quickly and efficiently make up a proposal for the tooth or crown that needs to be milled. This also eliminates the risk of doctor error in defining contact points.

“This automated technology results in more accurate designs,” Dr Shellard says. “It’s a perfect example of improvement in efficiency, accuracy, and precision. It minimizes the need for the doctor or staff to make further adjustments.”

This is particularly useful for dentists who are looking to transition to chairside restorations and milling, especially those who may not be as experienced in design. AI serves as a design assistant to help guide less experienced users through the process. However, there’s still room for improvement in machine learning for CAD/CAM.

“CAD/CAM software still needs to become more intuitive and predictive,” Braykovich says. “Templates can only get you so far in design, and the more data and accuracy you get, the better the restorations will be. Software is intelligent enough to do much of restoration design, but it still needs a human touch. I think implementing more AI will be a natural progression going forward.”

AI, machine learning, and automated technology have already changed the landscape of dentistry, but there’s more to come. As technologies advance, the benefits to clinical care and practice management will grow exponentially, and perhaps in new and unexpected ways. In terms of where technology is headed, dental professionals have different expectations.

“The impact of AI and machine-learning technologies in dentistry is just beginning, but will ultimately have many important implications, including early diagnosis of dental disease and more convenient options to deliver care,” McGinnis says. “There has been a lot of talk about AI and machine learning, but in reality, these are just 2 of the many technologies that will eventually change the way dentists market and manage their practices and provide care to their patients.”

McGinnis also expects the industry will see an increase in the use of virtual reality when it comes to both employee training as well as activities to distract patients while receiving treatment. He also sees augmented reality technology being used to assist in the visualization of posttreatment results, particularly when it comes to cosmetic procedures or orthodonture.

“When it comes to the future of dentistry, it will all come down to how dental practices utilize these technologies together that will truly set them apart as a provider,” McGinnis says.

Roberts agrees and believes the industry will see growing interest in automated practice management solutions—something that the industry needs to rise to meet.

“As an automated technology provider, it’s important that we investigate how we can better serve practices in the future to support their revenue cycle success,” Roberts says. “I think we will see increased demand for integrated back-office solutions that provide a complete picture of what is happening in the practice.”

But as technology advances, will AI take over the dental industry and make dentists obsolete? That remains to be seen, but most practitioners see AI as a beneficial tool rather than a replacement for dentists.

“AI won’t replace dentists, but it will make them better,” Dr Shellard says. “It’ll help dentists deliver care more efficiently and, in a lot of cases, be able to deliver that care all under 1 roof.

“We want all practitioners to be able to provide the same level of high-quality care because the use of advanced technologies in AI and additional diagnostic aids can help them deliver consistent, reliable, and excellent outcomes, irrespective of their experience levels. It’s important to note that it won’t replace specialists, but it will help provide the information you need to perform clinical cases at the highest possible levels.”

Dr Pulver agrees that AI should be embraced, not feared. “AI should be brought to dentistry as your friend,” Dr Pulver says. “It should be brought to dentistry as a support tool. It should enhance our communication and make a difference for our patients.”

“What AI means for the bigger picture is that we will be better able to serve humanity overall,” Broom adds, “because we’ll be able to serve more patients and have more time to provide a better service.”

How artificial intelligence, machine learning, and automation technologies are being used in the dental industry.

Always On, Always Improving

Ideally, every implant would have it all: Esthetics, functionality, longevity, and durability. But different types of implants, such as screw-retained and cement-retained, come with varied associated strengths and weaknesses. If you can’t have it all, which attributes should you prioritize for a particular case?

There are many factors to take into consideration when deciding between cement- or screw-retained implants, including retrievability, esthetics, location, and even personal preference. While each implant option comes with its own set of pros and cons, studies have found that complication rates for both are nearly identical, at 3-5%.1 This means that no matter which way you go, you’ve got a high chance of success—provided you take each case’s indications into account.

So, when should you opt for the cement-retained option over screw-retained—and how do the two types measure up?

Because screw-retained implants don’t use cement to connect the implant with the abutment and the abutment with the crown, they are exempt from the potential complications due to improper cement cleanup.

While clinical performance in regards to failure rates is similar with both screw- and cement-retained implants, a recent study found that overall, screw-retained restorations had fewer biologic and technical complications.2 This is partially due to the fact that screw-retained options eliminate the risk of complications that arise due to excess residual cement. Leftover cement can provide a conducive environment for bacteria, which can lead to infection problems and implant failure down the road.

One huge advantage of screw-retained restorations is retrievability. If complications arise, problems can be more easily addressed thanks to the removable nature of the crown and or abutment. This allows for simplified removal for implant repair, cleaning, direct visualization of the implant or soft-tissue exam.

“As a tech guy, I like to, whenever possible, have a back door, some way to ‘undo’ things,” says John Flucke, DDS, who practices in Lee’s Summit, Missouri. “That is the reason I prefer screw retained. If something goes wrong somewhere down the road, you can take the case apart and start over.”

This ability to address damage or wear and tear without having to remake the restoration is one reason that screw-retained implants are high in popularity. While screws may loosen over time, retightening them is a simple fix.

What screw-retained implants offer in flexibility is tempered by their lack of esthetics. Because these implants screw into the post through the abutment, a visible screw hole is left in the prosthetic.

“The pros of screw-retained is the ability to ‘undo’ if need be, but because the screw hole needs to be filled with composite, often esthetics are not quite as good,” Dr Flucke says.

The screw access hole, even when covered with composite, can often appear noticeably uneven. This presents a big concern to patients, particularly in anterior implants where esthetics are critical. However, when the design of the case allows, the screw access hole can be placed where it cannot be easily seen without looking for it directly.

If you’re working in the esthetic zone, it goes without saying that esthetics are paramount. Cement-retained implants offer superior esthetics compared to their screw-retained counterparts. This is because there is no need for an access hole when cementing the prosthesis directly to the implant abutment. The resulting appearance is more like that of a natural tooth.

“While I generally prefer screw-retained, in cases with a high esthetic demand, cemented prosthetics are often needed,” Dr Flucke says. “Cement retained have no holes and therefore are esthetically superior in most instances.”

With advances in cements, new radiolucent cements make it even easier to achieve a natural look. However, being virtually invisible makes these cements trickier to clean up.

This difficult cement cleanup can have major repercussions for the success of the restoration. Modern cements are often difficult to see, which means it’s easier to accidentally leave behind residual cement. As mentioned before, this excess adhesive makes a great environment for bacteria, which can jeopardize osseointegration and increase the risk of cement failure or gum inflammation and infection. Poor removal of excess cement has also been linked to increased risk of peri-implantitis and peri-implant mucositis.3

Retrievability is a challenge with cemented prosthetics. A big drawback to cemented implants is that there are few options if repairs or adjustments become necessary. Because the restoration is cemented to a screw-retained abutment, there’s no way to remove the restoration it if the screw becomes loose. Generally, this results in total destruction of the restoration to access the screw.

“While cemented implants are more esthetic, if the material chips or anything goes wrong in the future, they are much more difficult to undo,” Dr Flucke explains.

Luckily, cement-retained implants do have a higher resistance to porcelain fracture than screw-retained alternatives, so theoretically the restoration could retain its esthetics and structure for longer. However, if a cemented implant crown does need repair, it often means the entire restoration will need to be recreated, leading to extra cost for the patient.

The bottom line is clinicians need to evaluate each case and its indications individually and make determinations accordingly. For cases where esthetics are prioritized, cement-retained implants are the superior choice. When esthetics are of lower priority, screw-retained restorations provide clinicians with increased flexibility and eliminate the risk of infection or implant failure due to excess cement.

Regardless of the chosen method of retention, with careful planning and execution, practitioners can create a long-lasting restoration that meets the patient’s needs.

Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A systematic review of the survival and complication rates of implant-supported fixed dental prostheses (FDPs) after a mean observation period of at least 5 years. 

. 2012;23 Suppl 6:22-38. doi:10.1111/j.1600-0501.2012.02546.x

Wittneben JG, Millen C, Brägger U. Clinical performance of screw- versus cement-retained fixed implant-supported reconstructions--a systematic review. 

. 2014;29 Suppl:84-98. doi:10.11607/jomi.2014suppl.g2.1

Wittneben, JG, Joda, T, Weber, HP,Brägger, U. Screw retained vs. cement retained implant-supported fixed dental prosthesis. 

The pros and cons of these two implant types and when each should be implemented. 

How to choose between cement-retained or screw-retained implants

While advances in materials have led to much more predictable outcomes over the years, they are no substitute for precision and accuracy. Since user error is the most common cause of restoration failure, it’s important to make sure your technique and prep design are as accurate as possible.

“Prep design is intrinsic to clinical success, says John Flucke, DDS, a private practitioner in Lee’s Summit, Missouri. “Retentive failures normally begin with some type of compromise in prep design.”

The goal of all prep design should be to ensure the most esthetic—and functional—result with minimal removal of tooth structure. This means understanding the prep requirements for each material or adhesive used in the process.

In a perfect world, every prep would be a simple undertaking, with maximum tooth structure remaining and a clean, easily accessible field. However, it’s wishful thinking.

“Unfortunately, not every case allows for a textbook prep,” Dr Flucke says. “In cases where the operator has no choice but to create a compromised prep a strong adhesive can help compensate for that.”

Before adhesive selection, the first step is the evaluate the height and taper of the prep, as this will define a prep as either retentive or non-retentive. A prep’s status as retentive or non-retentive is based on the taper of the prepared tooth’s axial wall in comparison to the longitudinal axis of the tooth. A taper greater than 8 degrees is considered to be non-retentive, as are preps under 4 mm, which are considered short preparations.

Prep design will have an impact on the need to bond to the tooth structure with a dental adhesive,” says Rolando Nuñez, DDS, manager of clinical research at BISCO. “Preparation height and taper are the most important variables.”

Dr Nuñez cites a 2014 study that found that preparation taper, height and marginal design play a big part in restoration success when it comes to dealing with occlusal loads. It found that a smaller preparation taper of 10 degrees was more effective than a 30-degree taper. The study also concluded that it’s more ideal to decrease the taper as the prep height increases to avoid increased stress, as these stresses could result in increased risk of microfracture or cement failure.

An adhesive doesn’t just need to adhere to the tooth, however; it also needs to form a strong bond with the restoration itself. This means that during prep, the intaglio surfaces have to be effectively prepared, or the restoration runs the risk of debonding.

While mechanical retention is important, many adhesives today also provide the added benefit of chemical retention, giving clinicians greater options in adhesive features to enhance bond strength and increase esthetics. Ideal retentive reps allow for both adhesive protocols and traditional cementing strategies, while shorter preps or ones with more drastic tapers usually require adhesives bonding systems.

When selecting an adhesive, clinicians must consider the prep’s retention and resistance form, as well as the ratio of dentin to enamel, margin placement, feasibility of light curing, intaglio surface prep and restorative material—as well as the adhesive features. With so many strong, esthetic materials available, it is the dentist’s responsibility to know and understand the requirements for tooth reduction for each option. This will help ensure restoration success by maximizing both strength and esthetics.

A clinician should first decide between conventional cementation and adhesive cementation. The conventional approach uses the retention/resistance form of the preparation design to lute restorations to the underlying tooth structure by forming a hard cement layer between the tooth structure and restoration. Luting forces of these cements are enough to cement retentive prep design with good mechanical retention, which means they are best indicated for retentive preps. Since conventional cements cannot chemically bond to the tooth and restorations, they are contraindicated for non-retentive preps.

Adhesive cementation produces both a chemical and micromechanical bond between the restoration and the tooth structure. These adhesives display superior chemical properties, but can be tricky to execute properly when proper isolation is difficult.

Adhesive systems come in one- and two-bottle systems, as well as universals. One-bottle systems combine the primer and bonding agent into one, which is convenient, but their acidity level isn’t high enough for etching. As such, they don’t have the strongest retention with enamel, as it requires etching. In contrast, two-bottle systems can be self-etch or etch-and-rinse, and provide a stronger bond with enamel. Universal adhesives allow the clinician more flexibility to choose which bonding method they want to pursue. However, the practitioner still needs to take into account whether a light-, dual- or self-cure cement is more appropriate.

This means that the restoration’s restorative material also plays a part in selection. Light-cure and dual-cure resin cements are contraindicated for metal or zirconia restorations since these are too thick for light to penetrate. With these materials, a self-cure cement should be used. For all-ceramic restorations, adhesive resin cements are the best choice. However, in situations where proper isolation is difficult, they can be problematic.

Advancements in materials and prep for direct restorations

How choosing the right adhesives and dental materials for each indication can result in restorative success.