Lauren Krzyzostaniak

	Most dental professionals would agree that the use of composites and adhesive materials have changed the dental practice. But as technology develops and results in new materials, futuristic possibilities arise that could change medicine. Could dental materials one day be more than a Band-Aid for the tooth? Glass ionomers release fluoride to strengthen the health of the teeth, but perhaps future materials will go far beyond, using the platelet-rich fibrin that is mostly used in implant cases to encourage regrowth for decayed teeth. One day, dental filler materials could even produce antibiotics for the oral cavity, as one professional I interviewed suggested.

	Before we get too far ahead of ourselves, let’s review where dental restorative materials have been, where they’re heading now and where they could end up in the future.

	A shift from rudimentary materials to resin composites and glass ionomers 

	Rudimentary restorative materials, such as amalgams, have been commonly used since the 1800s, although their use has been documented to go as far back as A.D. 659, when they were used during the Tang Dynasty in China.

	To the relief of dental professionals everywhere, amalgam restorations met some competition when resin composites arrived on the scene in the 1960s.

	There were a few kinks to work out in terms of looks and durability, and once microfilled composites came out around 20 years later, they were much more successful, but they were also technique sensitive. By the early 2000s, resin composites had been drastically improved and were suitable for long-term use in posterior restorations.
	Unfortunately, the first decade of the 2000s brought little improvement to the resins that hold the fillers together, says Larry Clark, director of clinical affairs and marketing at Pulpdent.

	In fact, he argues that it was only in the last eight or nine years that resins started to undergo improvements.

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	“Before the resins started to improve, it was kind of like cement,” Clark says. “The rain would come and wash away the cement, and you’d get pits and holes in your roads and sidewalks. Composites in the ’70s and early ’80s were failing like that. Now, the resins are more durable and the fillers come in all shapes, sizes and dimensions.”

	One major benefit of composite resins and glass ionomers (and the combinations in between), aside from nicer looking teeth and happier patients, is that those materials have inspired innovation in the field of restorative dentistry. Today, restorative materials have evolved to be “more esthetic and wear resistant, easy to use and place, feature superior wear resistance and more accurately match natural dentition,” says Brendan Steidle, product marketing manager at GC America. “Typically, the dentist and patient want something that matches natural dentition so as not to indicate that there were any caries or damage to the tooth. So, anything that helps the restoration look more like natural teeth is something that both the dentist and the patient are going to be interested in. That’s where the industry has been going - dentists want that combination of esthetics and strength. Resin composites are able to offer both of those and blend in with the natural dentition, so it doesn’t stand out.”

The improvements made to resins in the last decade include the ability to bond to the fillers so that they don’t come out of the tooth. “After that, it’s about controlling shrinkage and being able to have less water absorption,” Clark says.

	“In the last few years, smarter filler compositions have significantly impacted handling, the gloss properties and the wear resistance of the materials,” adds Melanie Dietrich, restorative business unit manager at COLTENE.
	The solution to the finicky restorations of the past was twofold: to improve the physical properties of the fillers and adhesives and to identify the best techniques for use, says John Fundingsland, professional services manager at 3M Oral Care.

	“Over the last decades, composites have developed immensely and are today’s material of choice in minimally invasive, direct restorative therapy,” Dietrich adds.

	While there are many factors that determine the long-term health of the restoration, they are theoretically designed to last a lifetime, according to Steidle.

	“Dental professionals really like resin composites because of that adaptability and esthetic,” he says. “Over time, resins tend to shrink, but technological advances in development of composites provides less polymerization shrinkage over time. So, you have better adaptation at placement, and then when you have a recall a year later or even five years later, these restorations often look as good as when they were placed.”

	Now that restorative materials have improved to be stronger and more esthetic than ever, the industry is experiencing what many call a trend toward simplification.

	“If you look back to the late ’90s through the early 2000s, a lot of companies were launching comprehensive shading systems in terms of composite technology,” says Danny Vezmar, director of marketing for restorative and preventive at Dentsply Sirona, pointing to systems with up to 25 or 36 shades. “But the trend we’ve seen is toward simplification in the office. We’re finding that with today’s filler and resin technologies, you can condense the number of shades that a doctor has to worry about. Now, one shade of material may cover multiple VITA shades.”

	According to Dietrich, manufacturers and general practitioners have realized that they can get quality esthetics with fewer shades, so the trend to simplify continues.

	Because most products available advertise esthetics, strength and clinical performance, there has also been a shift toward focusing on how the material handles in the dentist’s hands - its workability, as it’s often called.

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	“People would tend to have conversations like, I’ve got 3 MPa higher fracture toughness than somebody next to me,” Vezmar says. “At some point, you reach a point that it’s not clinically relevant to have those conversations anymore because everybody’s putting materials out that provide really good physical properties in terms of strength.

	So, there is a focus now on what’s important to the dentist when they’re applying the material: how it feels in the hands, if it’s sticky, and its adaptability to the tooth in terms of shading and manipulation.”

	Since dentists can now feel comfortable with the clinical performance of most of the restorative materials on the market, Vezmar says they’re looking more into which materials feel the best to work with. And that’s something that marketing teams like Vezmar’s are trying to tap into.

	“We still go through all of the physical property testing to confirm that we are where we need to be from a clinical performance perspective,” he explains. “But the conversation about the materials is shifting toward what’s important to the dentist in terms of application, how easy it is to place, if it sticks to the instrument, if it stays where it’s placed without slumping, if it can be carved easily, what the final result looks like, if it polishes nicely and maintains that polish over time, and if it avoids staining."

	When developing a new product, every company we spoke to said it considered the needs of the dentist foremost.

	“The one characteristic dentists want most often is esthetics,” Steidle says. Next on the list include ease of use, radiopacity, the abilityto match to dentition, durability and wear resistance.

	“Clinical performance is always going to be one of the No. 1 things dentists are looking for, but it’s also about how it feels when they’re placing it,” Vezmar says. He adds that the questions posed above in terms of polish, adaptability and shading are what drives the Dentsply Sirona portfolio.

	“A product also must fit into the clinician’s protocol,” Fundingsland says. “You can have the most innovative technology in the world and not have a successful product if the technique is not accepted by the clinical team.”

	If a dentist has a problem, nine times out of 10 it’s because he or she didn’t follow the specific technique advised by the manufacturer of the materials. That’s why it’s important that dentists continue to educate themselves about the materials available and the techniques required, Clark says.

	“If they would just read the instructions for use, we’d all be better off,” he says. “I’m very blunt about that in my lectures and how we train people. All the products are really good, so the problem isn’t the product, for the most part. It’s just how they’re placed. The variables that take place in the operatory dictate the success of the composite, in my opinion. And 99 percent of the variables exist with the clinician.”

	Clark admits that the whole reason variables in the procedures exist to cause problems is the fault of the manufacturers who created specific technique guidelines to overcome sensitivity. That was before they realized that having a dentist complete two or three steps before doing the bonding could negatively affect the outcome of the bond.

	On top of the variables, there are a litany of other issues that determine the success of a bond, including how the tooth is prepared and the adhesive itself.

	Clark says that the success of the restoration - in terms of what the patient should be concerned about - is often challenged by the leakage of bonding agents. Once bacteria make their way into the restoration, failure is a near certainty.

	“There has always been an assumption that because you had bonding, you had a seal,” he says. But that was not true, especially in dentin. With enamel, you get a better bond and seal. It’s the most dependable substance you can bond to in the tooth. Dentin, on the other hand, is filled with lots of water coming from inside the tooth. That water can be detrimental to the adhesive layer as much as anything else.”

	Water will cause the adhesive to break down over time. And despite the fact that the restoration will still be intact, there will be leakage underneath it.

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	“That’s what David Paschley and Franklin Tay would call ‘water trees,’” Clark explains. “As the dentinal fluids come up, they permeate into the hybrid layer and start to degrade it with their fluids, ultimately breaking it down.”

	He says that Pulpdent tries to educate dentists on these challenges to make their restorations more successful.

	“One of the things that’s made me successful was that I not only knew the materials, I knew how to use them,” he says. “I think that’s more what the industry needs: more hands-on courses and less opinion.”

	To get restoratives right from the get-go, they should offer high levels of workability.

	"Dentists don’t want to invest time to make a composite material work - the material needs to work for them,” Dietrich adds. “A successful material delivers exactly that. Despite all the filler evolution, we still see that ideal handling properties are a prerequisite for a successful composite.”

	“You must be able to handle the composite in order to place it successfully,” Fundingsland says. “That being said, composites have to meet standards of esthetics, physical properties and wear to be successful. Marginal seal is critical to preventing secondary decay.”

	The ultimate test for any material, Vezmar says, is clinical performance.

	“Materials all have unique properties, but the true test is what a material placed today will look like at a six-month recall or five years later,” he says. “How does it stand up over time? You have to consider the factors that are important to the clinician when they’re placing it - handling, polish and shade selections - but then you also have to consider the longevity.”

	“We think you can only measure success of a composite restoration by virtue of what happens with the patient, not by sales,” Clark adds. “Everybody likes to say those things, but if that’s the case, then why have we insisted on sticking with the same bonding techniques for the last 20 years? Those are the reasons failure is occurring.”

	We’ve talked about the improvements that have been made to restorative materials so far, and the future is a lot of the same: simplifying the process and getting them to be easier to work with, more durable, more esthetic and more predictable.

	“From a technical standpoint, I would anticipate continued efforts to reduce shrinkage and the resulting stress on the tooth that shrinkage causes,” Fundingsland says. “Improvement in strength could increase the indications for composites as well as their longevity. Esthetics already rival ceramics; in the future, esthetic results will be easier to attain.”

	“I think continued efforts toward simplification of the systems,” Vezmar adds. “What we’re trying to focus on is not just the composite part of the procedure, but what the procedure looks like. What solutions can we provide to make the composite placement procedure more predictable? For example, we focus on our Class II solution, which implements everything from a sectional matrix system through the finishing system on the end just so we can have a consistent conversation and help that clinician have a predictable result, time after time.”

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	Getting a seal at the margins helps prevent secondary decay, but what about materials that can interact with the tooth structure? The ideal would be to have a material that could chemically bond to the tooth to strengthen it and inhibit further decay.

	“Better bonding interfaces or discouraging the microbes responsible should help address secondary decay,” Fundingsland explains.

	Getting restorations to be better at what they already do is just half the battle. On the other side of the coin is getting them to be biofunctional - a popular topic in restorative dentistry today and one that will be highlighted at the Nordic Institute of Dental Materials meeting this summer, where Clark will be presenting his topic on bioactive materials.

	“These are researchers from all over the world and the whole focus is on the success and the future of dental materials,” Clark says. “The whole focus of this meeting is bioactivity. Bioactive materials arebecoming more of an interest in the research community as well as with manufacturers.”

	“You need to have a more hydrophilic material to allow water or ions to transfer, or diffuse,” he continues. “You can’t have biochemistry without water. In the early days, when Pulpdent came up with the first hydrophilic resin in 2002, the idea was that the resin was more moisture-friendly, so we thought that would be a good thing from a technique standpoint, that it was OK if there was a little moisture there.”

	It wasn’t easy to convince the dental community of their approach, however. Everyone was used to hydrophobic materials, which required a dry surface. Manufacturers have since realized that they can find a balance between hydrophilic and hydrophobic materials and will engineer materials to reflect that.

	“Now, we understand that we need to think of the balance, especially if we try to introduce minerals into the resins, which Pulpdent and other companies in Europe are doing,” Clark says. “We’re starting to integrate calcium and phosphate into the resins. If they’re going to have continual ion release, like the tooth, then we need to make sure water can move in and out so there is a charge and recharge of these ions.” 

	Clark says that the importance of integrating biofunctional materials in the future is because the current process is based on repairing nature with plastics. He uses a slide in his lectures of a tree that was hit with lightning and repaired with cement as a metaphor for the current restorative protocol of repairing living tissue with materials it can’t identify with.

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	“That’s the importance of bioactivity for the future,” Clark says. “We’re trying to introduce minerals that the tooth can identify with and be a part of the process of the restoration rather than being totally ignored, which is what we’re currently doing. If you put a hydrophobic composite into a tooth, the tooth has no ability to identify with it.”

	“We have to start thinking about composite materials that function more like the tooth,” he continues. “Enamel does one thing and dentin does a completely different thing, but that’s not what we’re doing. We’re restoring everything with something that’s more like enamel. When you look at composite restorations from a biofunctional standpoint, we’re not natural.”

	For Clark and the team at Pulpdent, development won’t stop at bioactive or biomimetic materials. It will extend into biofunctionality - the ability of restorative materials to respond to forces the same way the tooth does. To him, the future of restorative materials lies in their ability to flex in the tooth.

	Dentin is not just a shock-absorbing factor for the well-being of the tooth; it also knows how to give and take torsional aspects in biting forces, Clark says. “You’re never biting just up and down; you’re biting sideways. Teeth are twisting, cusps are turning. And when you put a block of hard, hydrophobic plastic in there, it becomes the tooth against the restoration. That’s where bonding agents have started to break down. It’s not just acids and bacteria and fluids that are eating away at them, it’s also the forces that are being attributed from natural mastication.”

	He says biofunctionality can mean different things. Often, it’s synonymous with bioactivity, but for Clark and his team, it means the ability to get the material to mimic the function of the tooth.

	A great example of one bioactive material with positive effects in the oral cavity is platelet-rich fibrin, or PRF. Studies on platelet-rich fibrin have shown its efficacy in revitalizing necrotic teeth. PRF is also commonly used along with freeze-dried bone in implant cases to regrow bone tissue.

	“I think the implant landscape has changed drastically over the last five or 10 years,” says Paresh Patel, DDS, who was originally interviewed for a November 2017 piece on dental implants. “We have so many new biologics that have come on board. Certainly, mineralized freeze-dried bone or demineralized freeze-dried bone or combinations of those products are everywhere. Patient-driven biologics such as PRF are very easy to produce and the cost to get those products is almost minimal at this point.”

	With those products, dentists can do guided tissue and bone regeneration to either regrow or preserve bone. This has gotten a lot of people in the industry excited about the possibilities.

	“Remineralization and tooth repair over time could be a concept that you could look at in a next-generation composite,” Steidle says. “Those are some of the things on my wish list.”

	Not everyone sees hope in bioactive restorative materials, however.

	“While we do see great use for bioactive materials in root canal sealers, we see limited potential for this technology in filling materials since releasing bioactive components might weaken the matrix of the composite, compromising its mechanical properties,” Dietrich explains.

	If researchers can discover a way for PRF to regrow tissue that was lost to decay without compromising the composite, then that would drastically change restorative dentistry.

	Composites and adhesives have already revolutionized the dental practice by offering a more durable and esthetic option to amalgam restorations. Perhaps in the future they will revolutionize oral healthcare and medicine as a whole. It’s possible that it won’t just be about applying a sort of Band-Aid to a decayed tooth. It won’t even be about the bioactivity of releasing calcium and phosphate ions to remineralize teeth. Instead, it will be about introducing a material that immediately allows for full functionality of the tooth again while potentially regrowing the tissue lost to decay. Imagine the implications of perfecting tissue regrowth in the neck and crown of the tooth, seeing all signs of previous decay erased by the first recall appointment. Dentists are already using PRF to seal root canals and regrow tissue. Why not extend it to the rest of the tooth?

Articles

Examining the past, present and future of composites. 

The evolution of dental materials

	Dentists know that one of the most important things in their day-to-day life is gaining and obtaining their patients’ trust. Patients must fully trust that the doctor and other healthcare professionals will provide their desired end result, and they must also feel secure in knowing that their health is in good hands.

	Maintaining a sanitary space in which to work is a priority for every dental practice, but it goes far beyond instrument management. While instruments must be sterilized, the surfaces clinicians work on and around must be sanitized, too.

	Hu-Friedy, a company that specializes in instrument management systems, hand hygiene products and cleaning products for every aspect of the dental office, is now coming out with a surface disinfectant that will work on practically every surface in the operatory, from plastics to stainless steel.

Trending article: 5 considerations for surface disinfectants

	“Hu-Friedy has been a key player in the infection prevention market with high-quality products,” says Senior Product Manager of IMS and Infection Prevention at Hu-Friedy Holly Way. “While we continue to expand in the infection prevention categories, adding surface disinfectants is a natural next step. It also goes hand in hand to help expand our current infection prevention offering.”

	AdvantaClear kills a broad spectrum of disease-causing microorganisms in one minute, and it is designed to be compatible with a wide range of surfaces, such as acrylic, aluminum, brass, copper, stainless steel, chrome and plastic, Way says. 

“It’s a convenient, ready-to-use, intermediate-level disinfectant designed to clean and disinfect surfaces while working fast and effectively to kill a broad spectrum of disease-causing microorganisms, including HIV-1, HBV, HCV, MRSA, tuberculosis, the influenza A virus (H1N1), salmonella enterica, ESBL, E. coli and other pathogens,” she says.

	And because it’s fragrance free, it eliminates odor-causing bacteria without masking it with another scent.

	Since it kills most bacteria, fungi and viruses within a minute, it doesn’t take any extra time to help protect your team and your patients. And its low alcohol formula comes with two major benefits: It disinfects without affixing blood and soil to surfaces, and it cleans bright plastics without the cloudy residue that high-alcohol formulas leave behind.

	“As an industry leader in infection prevention, Hu-Friedy is excited to expand our infection prevention offerings while introducing a surface disinfectant that we stand behind,” Way says.

	AdvantaClear Surface Disinfectant became available for purchase in March of this year.

How this surface disinfectant is taking infection control to the next level.

The benefits of AdvantaClear Surface Disinfectant

	It’s clear that digital Technology makes communication easier in pretty much all aspects of our lives. That’s especially true in healthcare, when sharing patient files and images with healthcare professionals and laboratory technicians is easier than ever before.

	Still, sharing an image is not quite the same as seeing things in person, when adjustments can be made to better identify the exact angles and structures that are sometimes lost in the glare of the tooth.

	That’s why professor Louis Harden designed the Smile Lite MDP, a camera attachment he hoped would revolutionize dental photography. Instead of purchasing a new professional-grade camera and learning how to take quality photos, the Smile Lite MDP (the MDP stands for mobile dental photography) is designed to attach to one’s smartphone, creating, as he calls it, a “mini photo studio.”  

	The attachment looks like a miniaturized version of a photographer’s studio, with its back lights shining at different angles and several bright white lights coming through polarizing filters.

	One could imagine that the dentist may start to feel like a professional photographer as he or she learns the ins and outs of the Smile Lite MDP’s different lighting functions. While the central LEDs produce the kind of qualities often achieved in a before-and-after shot, the polarizing filter can be used to help dental technicians see the internal structures of the teeth more clearly than is often possible with a digital SLR camera.

To find out what a dentist thinks about it, we spoke with Marcos Vargas, DDS, a professor in the department of family dentistry at the University of Iowa.

	Dr. Vargas uses the Smile Lite MDP in tandem with his digital SLR camera because there’s room for both, he says.
	“The Smile Lite is good for people who don’t want to spend a lot of time learning dental photography,” Dr. Vargas says. “For someone who really wants to learn dental photography, I think the DSLR is probably a little more versatile.”

	Dr. Vargas finds that using the Smile Lite MDP’s polarizing filters allows him to communicate with his lab more effectively.

	“When you look at a normal photo of a tooth, you’ll see a lot of glare and reflection,” he explains. “The beauty of polarized light is that you can remove any glare from the photograph, allowing you to see the internal characteristics of a tooth.

	You can see the shape of the dentin and the internal characterization.

	“When you’re communicating with the lab, you’re trying to communicate color and the shape of things. Removing the glare with polarized light allows you to communicate to your technician the internal structures that you see in the tooth. When you remove the filter and take a photo with the shade guide, you’re communicating color to the technician.”

	Improved communication means a better workflow for the dentist, as well as a better patient experience.

	“The patient and the doctor benefit by getting more information to the technician,” he says. “With the Smile Lite MDP, dentists can transmit a lot of information to their technicians when they’re doing crowns that probably allow you fewer remakes. The technician is more likely to produce a more esthetic and accurate product.”

	While it does the job well, the Smile Lite MDP is not just for lab communication, Dr. Vargas says.

	“Sometimes when I’m with students, I’ll take the Smile Lite MDP out to teach them a bit,” he says. “We work with crowns, but sometimes we also do direct dressings. When you take photographs with the Smile Lite MDP, you are able to see internal structures that you can replicate when you’re doing direct dressings. It’s good for both indirect and direct restorations.”

	Using the two cameras in his practice - his iPhone X with the Smile Lite MDP attachment and his DSLR - allows Dr. Vargas versatility. While the Smile Lite MDP helps him show his laboratory exactly what he sees in his patient’s teeth, the DSLR is capable of capturing multiple images with larger sources of light. He uses those images to prepare lectures and presentations at the university, too.

	Dr. Vargas says the beauty of the MDP is that a dentist can work with what he or she already knows and owns.

	“It’s more about the practicality of the Smile Lite MDP. You don’t have to learn all about photography to take professional-grade photos with it,” he says.

How this camera attachment can be used to streamline workflows. 

Using Smile Lite MDP to take quality photos

	Thanks to social media - particularly “Instagram models” - patients’ interest in dental procedures is rising. They’re no longer avoiding their regular dental appointments, instead trading dread with enthusiasm. They know that dentists can help them get that Instagram-worthy smile, and they’re all in.

At least, that’s what Sarah Jebreil, DDS, AAACD, says. She practices in Newport Beach, California, “where everyone wants whiter-than-white teeth,” including her 80-year-old patients, she says.

	“Because of social media, patients are very aware of what options are available to them and they know what they want to look like when the treatment is completed,” she says. “They are no longer asking what can they do to look better. They are coming in with a treatment plan that they have in mind from what they have seen and read about online.”

Trending article: Why cosmetic dentistry matters to every practice

	Because patients are often coming to dentists with a clear idea of the treatment and results they want, it’s important that dentists discuss the options available, she says.

	“We need to really understand what it is they really want and if it is in fact achievable. If it’s not, we need to guide them to a more realistic option,” she says.

	For practices trying to keep up with their patients’ demand, here are six cosmetic procedures that will help build your list of services.

	Click through the slides to view the procedures.

	Teeth whitening is the most basic cosmetic dental service and has been offered for more than 30 years. It’s often considered the foundation of cosmetic treatment. Once patients request or receive whitening, they’re more inclined to think about other steps they could take to improve their smile.

	“When patients come in to whiten their teeth, they often say, ‘They’re whiter, but what about this corner?’ Or, ‘What about this tooth that didn’t get white? What about these restorations that don’t match?’ Or, ‘I like my white teeth, but I want them straighter,’” says John F. Weston, DDS, FAACD. “That leads to conversations about things like Invisalign, orthodontics, replacing restorations, or veneering teeth. It’s an excellent way to start a dialog about cosmetic options.”

	For practices that don’t yet offer whitening services, products like Philips Zoom whitening are a good place to start, but be sure to research your options and choose the system that works for you, advises Tanya L. DeSanto, DDS, FICD.

Related reading: Creating pearly white smiles

	“If you can have somebody leave your office with whiter teeth than they walked in with, you have impacted their life in such a positive way,” she says. “It’s instantaneous and exciting for the patient and it’s such a great service.”

	Unfortunately, the American diet is saturated with acidic and sugary foods that not only damage our teeth but affect their natural brightness, she says. Red wine, soda, tea, and cigarettes are all common culprits. But Dr. DeSanto says it’s a “win” if dentists can give their patients the white color they had in their teens. And to do that in one visit is a huge benefit for your patients that won’t go unnoticed. Another part of what makes it such a great service is its affordability, especially compared to other cosmetic procedures. The greatest benefit is to the dental practice.

	“It feeds the fire,” Dr. DeSanto says. “Patients want to know what else they can do. They might want to change their fillings or straighten out some teeth that have been bothering them. There are all kinds of little things they can do that aren’t expensive.”

	She adds that people often assume that cosmetic procedures are too expensive, as insurance typically doesn’t cover anything that’s not medically necessary. But sometimes something as simple as smoothing an edge of a teeth takes under a minute, and it doesn’t have to be expensive.

	Another quick but effective option is minor recontouring, which every dentist should learn about, says Betsy Bakeman, DDS, FAACD.

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	“I think every dentist should learn how to do gingival recontouring properly so that the changes can stay put,” she says. “A lot of patients with short teeth and a gummy smile aren’t even aware gingival recontouring with periodontal plastic surgery is an option.”

	She adds that putting the tissue where it needs to be is all the enhancement that some patients need, so it’s essential that dentists interested in cosmetic dentistry learn how to do minor, predictable adjustments, from crown lengthening to gingivectomy procedures.

	A common treatment that patients often ask about is aligner therapy, especially now that Invisalign and ClearCorrect dominate the adult orthodontics scene. Therefore, it’s essential for practices to venture into this arena, says Dr. Weston. But that doesn’t mean they have to offer the treatment in-house.

	“I think every office should offer some form of tooth alignment procedures, whether referred out to an orthodontist or provided in-house,” he says. “Patients can appreciate a more modern approach that’s done without brackets and wires, so I think it’s good to offer a clear aligner therapy for straightening teeth.” 

	Dr. Jebreil believes that all dentists should offer clear aligner therapy. In fact, it’s a huge part of her practice.

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	“Often times patients come in for a cosmetic consult with beautiful, healthy teeth that are just slightly misaligned and it would be a travesty to cut down every tooth and veneer them,” she says. “My go-to treatment is Invisalign.”

	Dr. Jebreil says that orthodontics is an essential first step if the patient needs additional work.

	“If you can get the teeth in the right position, you don’t have to remove as much tooth structure,” she says. “This allows your dentistry to be much more conservative. You can even set up a veneer case with Invisalign by expanding the buccal corridors and evening out the gingival levels.”

	For Dr. Jebreil, starting small and using clear aligners helped her build the confidence needed for more intensive cosmetic procedures.

	In addition to whitening, clear aligner therapy and minor recontouring, dentists can drastically improve the health and appearance of their patients’ teeth by offering composite resins.

	“We have so many great materials now, so it’s important that dentists learn how to best use them,” Dr. Bakeman says. “We can change the shape, contours, length and color of teeth with composite resin and work so the resin blends seamlessly.”

	While direct resin bonding is a reasonably affordable and conservative procedure to Dr. Bakeman, she says that dentists need to understand tooth shapes.

Related reading: The surprising rewards of cosmetic dentistry

	“We started to hand the knowledge and mastery of tooth shapes, contours and arrangements over to the ceramists, but to excel in cosmetic dentistry, we really have to understand tooth shape and anatomy and how to design contours properly and beautifully,” she says.

	For Dr. Weston, not offering direct bonding means putting the practice at risk of losing patients.

	“In my opinion, dentists that do everything with porcelain are simply not going to be as successful,” he says. “Direct bonding in the anterior and replacing posterior amalgams are an important service to offer because some patients cannot afford indirect ceramic procedures on all teeth.”

	Fred A. Peck, DDS, AAACD, offers a few solutions to dentists looking to start offering direct bonding services. Look for the small chips on front teeth or patients who have some discolored and visible bonding.

	“We all have those in our practice, it’s just a matter of who’s going to be able to treat it well,” he says. “You have to have confidence that you can do it so that the patient accepts the treatment.”

	He also advises taking before-and-after photographs to judge your work and to show other patients what you can do.

	5. Indirect porcelain veneers and crowns

	It’s also important for dentists to offer indirect porcelain veneers and crowns. For Dr. Weston, it’s critical to have a foundation for doing the procedure correctly. It’s also essential to have the support of a good ceramist, he says.

	“When restoring terminal dentitions, we can do some amazing cosmetic transformations using implant-retained full dentures,” Dr. Weston says. “These procedures can profoundly change lives for patients.”

	Using the AACD to build a foundation of knowledge is crucial first step, he says. While the basics of implant treatment are taught in school, he says they usually involve single posterior teeth with limited exposure to full-arch implant cases. That’s why utilizing the AACD and other post-graduate training organizations is helpful. There, you can learn “how to provide ideal esthetics and tissue management for more complicated procedures,” Dr. Weston says.

More from the author: What a paperless practice really looks like

	“If you want to advance your surgical training on how to actually place implants, there are courses and residencies that teach GPs the surgical aspects of implant procedures. Typically, restorative doctors work as a team with the oral surgeon and this seems to be the more accepted approach,” he says.

	Regardless of what cosmetic procedures you want to start offering within your practice, the foundation is always knowledge and planning.

	“You have to have that knowledge ahead of time to be able to employ any of the materials properly,” says John Rowe, DDS, AAACD. “Having additional education through the AACD accreditation program makes you realize what you can do better and what challenges you might see in any case, which you might have missed prior. It does what we commonly refer to as ‘sharpening your eye.’ If you can’t recognize what’s out of place, you can’t begin to fix it.

	“If you don’t have enough education, you don’t know what you don’t know. The last thing any dentist wants to do is get into a situation where they are under-delivering based on a patient’s expectations. The higher you can elevate your personal skill, the more you will be able to meet patient expectations. AACD accreditation can give you those tools.”

	To get started and learn about the AACD 2018 session in April, visit 

More patients are demanding cosmetic dentistry treatment, so offering these procedures could help boost your patients' satisfaction and your practice's bottom line. 

6 cosmetic dentistry procedures every practice should offer

There's no better time than the present for general dentists to offer cosmetic treatment options. 

4 easy ways to get into cosmetic dentistry

	More than ever before, patients are seeking treatments focused on cosmetics, whether they’re looking to just whiten their teeth or do more substantial treatment like veneers. That’s why now is the perfect time for general dentists to get involved in cosmetic dentistry.

Read more: Why cosmetic dentistry matters to every practice

	If you’re wondering where to start if you’re a general dentist looking to expand your services and offer more cosmetic treatment options to patients, then here are four simple ways to get into cosmetic dentistry.

	Click through the slides to find out four ways to get into cosmetic dentistry.

	One obstacle to providing cosmetic services is that a lot of the treatments depend on a solid foundation of knowledge - one that isn’t offered through dental school alone. Therefore, many dentists agree that getting involved in the American Academy of Cosmetic Dentistry is the most essential first step when it comes to introducing or expanding cosmetic procedures in the dental practice.

	Start by attending the annual session and learning more about the organization and its training programs. You’ll have the opportunity to see and learn from leading cosmetic dentists who know how to teach techniques that you’ll use in everyday practice.

More from the author: 6 cosmetic dentistry procedures every practice should offer

	“It’s a really good place to learn, be inspired and network with like-minded individuals,” says Betsy Bakeman, DDS, FAACD.

	“You’ll learn more during the session than you’ll ever learn in school,” says Tanya L. DeSanto, DDS, FICD. “You have all the top-notch speakers and all the leaders in the profession from all over the world teaching cases. You can do hands-on training and take that as the impetus to learn more, and you can follow-up with courses from these instructors that you’ve learned from.”

	Dr. DeSanto says that the seeds for continuing education are planted at the AACD scientific session. 

	“The academy can teach you every single thing you want to know,” she says. “If you have the drive and the ambition, you can seek it out.”

	2. Start small with direct resin bonding

	It’s likely that the AACD session will inspire dentists who attend. But it’s also important to remember to walk before you run, says Fred H. Peck, DDS, AAACD. The best way to do that is by integrating direct resin bonding into your skillset.

	“You start with fixing small chips on teeth so that you can’t tell that anything was done to the tooth,” Dr. Peck says. “Basically, it’s an invisible restoration. Slowly increase the number of teeth and learn how to do it effectively.”

	With direct resin bonding, you can provide many solutions, says John Rowe, DDS, AAACD. You can change the shape or shade of teeth, modify a single tooth or reconstruct an entire smile.

	“The uses for composite are purely limited by the operator’s knowledge and skill,” he says.

	Another benefit is that it’s an inexpensive way to refine your skills.

	“There are no lab fees, so it’s just the cost of the composite and what you’re able to do with it,” Dr. Peck adds. “You can move into more expensive and extensive procedures after that, but that’s a great starting point.” 

	3. Don’t focus purely on the smile zone

	Dr. Bakeman says that dentists can get patients excited about cosmetic options by making things look more natural anywhere in the oral cavity, not just the smile zone.

Related article: The top 5 ways cosmetic dentistry can benefit your practice

	“Patients can be thrilled with even simple restorations - it doesn’t have to be a whole smile makeover to make a patient happy,” she says. “With both anterior and posterior restorations, we can provide strong, all-ceramic restorations that blend naturally and beautifully. The results can be very pleasing for patients and much appreciated. You can hand the patient the mirror, even if it’s a posterior tooth, and say, ‘Here’s your new crown,’ and feel the pride when they respond, ‘Wow, which tooth is it?’

	Take the time to deliver exceptional cosmetic results, even for those less noticeable restorations. Patients appreciate it and it becomes a practice builder as a result.

	4. Partner with an AACD-accredited lab tech

	A major theme so far is to take even the simplest cases seriously. Dentists can do that by having a solid foundation of knowledge, accessing the appropriate resources, and treating every case as if it were the only one by which future patients could judge you. When the work gets more complex, the relationship you have with your dental technician will be critical to your success. Dr. Peck recommends building that relationship with the right person from the very beginning.

	“When the lab is involved, it’s about partnering with a AACD-accredited lab technician who can help guide the process,” he says.

More from the author: The 5 biggest benefits of digital impressions

	It’s easy to offer whitening, composites and porcelain and call yourself a cosmetic dentist. But Dr. Peck says that there is a lot to learn if you want to do it correctly. It requires attending hands-on courses, learning the theory and science behind the materials and techniques, and integrating that knowledge and skill slowly into the practice as you move forward.

	For more resources on how to get involved in cosmetic dentistry, consider attending the AACD 2018 Scientific Session by visiting 

	Being paperless is all about eliminating the scraps of paper, handwritten notes, physical patient files and the systems they are stored in, and gathering all of your information in one place. It’s about consolidating information, streamlining practices and accessing data from anywhere. As one doctor put it, it’s about pushing a button and “having your numbers,” making a noticeable difference in efficiency and enjoyment in the practice.

	But what exactly does it mean to be paperless, and how can a regular practice, making its way through red tape, insurance and questions of ROI, get there?

	We interviewed several dentists in an effort to outline the workflow of the paperless practice, share thoughts on operatory design and the digital technologies within it, and discuss how their practices acquire, store and secure patient data. They illuminate the benefits - as well as the drawbacks - and share guidance on how to get rid of paper in the dental practice once and for all.

	For Jason Watts, DMD, being paperless means running a fully digital office. That’s apparent before the patient even steps in the door.

	“I have a portal where I can upload documents that patients can access from any device,” he says. “All of the documents they fill out are digital and they instantly upload into their software. When they come into my office, they already have their records fully loaded. If not, I hand them an iPad and they fill out their documents there.”

	In a paperless practice, no longer are patients sitting down with a clipboard in the waiting room before their appointment.

	Their personal information precedes them so that they can instead walk into the practice and relax before the appointment, or be led directly to the operatory.

	In practices where patient information isn’t gathered beforehand, patients can fill out their information on iPads or computers.

	In many offices, patient information is still gathered in the waiting room just before the appointment, although in a paperless practice, it’s done on a tablet or computer.

“There are two computers in the check-in area of our reception room,” says John Flucke, DDS, technology editor for Dental Products Report. “The front desk hits a button in Eaglesoft, their practice management software, that signals the computer to display a personal welcome message to that patient. “They’ll press a button to continue, and they put all of their information in electronically. The screens are touch screen, so they can tap through all of the information. At the end, they sign on the screen, and when they click ‘done,’ the system takes that information and puts it into the standard health history and patient demographic areas.” 

	Dr. Flucke says it’s much easier this way because the moment the patient is finished filling something out, he or she can go to the operatory.

	Mark E. Hyman, DDS, who practices in Greensboro, North Carolina, says he does it in three ways: in advance, in the reception area on a tablet or on paper. “For some patients who aren’t comfortable with it, we’ll go old school - though I’d rather not,” he says. The paper form is then scanned and imported into their software.

No one ever said that going paperless is easy (or cheap), but those who have done it say it's worth the price. 