Nicholas Hamm

	Dentistry is, by and large, all about preserving and preventing the loss of natural materials. Certainly, restorations and other attempts to recreate something as esthetic and strong as natural enamel have radically improved in recent years. But still, humans have been unable to match what nature has perfected.

	New research, however, could provide a better way - recreating the process the body uses to create and regenerate enamel.

	Researchers at Queen Mary University of London have developed a process that recreates enamel that looks and performs almost exactly like natural enamel. The secret to imitating a natural material is to first imitate how that material is built by nature. In the researcher’s case, that involved using a protein material with the ability to trigger the growth of nanocrystals, similar to how the human body creates enamel.

 “A major goal in materials science is to learn from nature to develop useful materials based on the precise control of molecular building-blocks. The key discovery has been the possibility to exploit disordered proteins to control and guide the process of mineralization at multiple scales. Through this, we have developed a technique to easily grow synthetic materials that emulate such hierarchically organized architecture over large areas and with the capacity to tune their properties.”

The enamel created by the process looks and performs very similar to natural enamel. Both the natural and artificial materials had comparable resistance to acid and saliva, for example. As a result, the researchers see this process being used for dental tissue repair applications.

	Dr. Sherif Elsharkawy, a dentist and first author of the study from Queen Mary’s School of Engineering and Materials Science, says, “This is exciting because the simplicity and versatility of the mineralization platform opens up opportunities to treat and regenerate dental tissues.” She says that this could have applications such as developing acid-resistant bandages that infiltrate and mineralize dentinal tubules to treat dentin hypersensitivity.

	In the future, the researchers also hope to take applications for this process further, creating materials that mimic other hard tissues such as dentin or bone.

, “Protein disorder–order interplay to guide the growth of hierarchical mineralized structures” was published in 

Articles

It’s the ultimate goal in materials science, and researchers may have just cracked it.

New method could create new enamel

	Oral lesions and ulcers are common, and painful, conditions. Treatments are available, but most have been ineffective. However, researchers believe they have an answer - a patch able to stick to directly to the affected area.

	Two of the most common causes of oral lesions, affecting one to two percent of the population, are 

 (RAS). Most current treatments rely on techniques that cover the entirety of the mouth, since targeted therapy is tough with the extreme conditions present in the mucous membrane.

Related article: Study confirms water fluoridation prevents tooth decay in children and teens

University of Sheffield's School of Clinical Dentistry

 explains, that whole-mouth approach is often ineffective. "Current treatments consist of using steroids in the form of mouthwashes, creams or ointments, but these are often ineffective due to inadequate drug contact times with the lesion,” 

	To combat this, researchers at Sheffield teamed up with Dermtreat A/S, a biotechnology company based in Copenhagen. Together, they have developed the 

 patch, a biodegradable, muco-adhesive patch that can be applied directly to the mucous membrane.

The patch uses special polymers that enable it to stick even in a moist environment. Once applied, it delivers a steroid, clobetasol in the current formulation, directly to the lesion or ulcer. This delivers the medication where it is most needed, eliminating the shotgun approach of other treatment methods. Additionally, the patch also creates a barrier, potentially increasing the rate of healing. "The patch acts like a plaster inside your mouth,” says Murdoch, “which means it is very effective at directly targeting the specific area as well as forming a protective barrier.”

	The patch can reportedly remain in place for up to two hours, due to its flexibility and strong adhesion. Because it provides targeted delivery of a medication, researchers also claim that it enables higher efficacy, lower dosing and lower toxicity to the non-affected parts of the oral cavity.

	Murdoch adds that “Patients who have trialed the patch found it to be very comfortable to wear and they were really pleased with the length of adhesion which makes it particularly effective and efficient."

	The patch recently began a Phase 2b trial, and Dermtreat is hopeful it will progress quickly through trials and be available for consumers. “Based on the high unmet medical need and the interest we’ve seen from leading physicians and specialists in the field, we anticipate efficient study enrollment and expect results in the first half of 2019,” says Nishan de Silva, MD, chief executive officer of Dermtreat.

Related article: Osteoporosis meds and implants are a bad combination

	Dermtreat is working with the Dental School to develop the next generation of patches, capable of delivering a variety of other medications.

Why this patch could be the future of ulcer treatment.

A better way to treat mouth ulcers

Some of the DE editor’s favorite digital techniques ever.

Our 6 favorite digital techniques

	We recently asked several leaders in the dental lab industry what they thought the biggest issues in their field is right now. One answer kept consistently coming up: digital workflow.

If you haven’t started introducing digital processes into most every part your workflow, it’s probably time to start. And even if you’re already an expert on all things digital, from case creation to fabrication, using design software and 3D printers with ease, chances are there’s still a lot out there to learn.

	The lab workflow is changing all the time, and labs are going to have to keep up - or get left behind.

	To help with that, the DE editors have selected some of our favorite techniques from over the years highlighting just what can be done with the latest technologies and a little know-how. It’s an exciting time for the lab, and we think you’ll agree with us when we say that newer techniques, materials, equipment and software are making the most beautiful (and most durable) cases ever.

	Technique: Scan a complex implant case more efficiently

	I have spent the last decade going full force into digital dentistry and mastering the most efficient and successful ways to use state of the art technology to masterfully craft the complex cases that I routinely handle.

	I recently started utilizing the Freedom HD Scanner by DOF for milling in my lab, which allows me to streamline the process of fabricating these cases. The Freedom HD Scanner is fast and compatible with our articulators and allows all-in-one milling, which combines three steps into one. Being able obtain a pre-scan, detailed scan and antagonist scan all in a single step is a remarkable, time-saving convenience for my extremely busy laboratory.

 to see how scanning can save you time and money

	Technique: Digital case management of a delayed immediate implant placement

	A 68-year-old female presented to my office with a toothache on the lower right side. She stated that the tooth had been hurting sporadically for a week and was worsening in duration and frequency. A review of her medical history showed high blood pressure controlled with medication, but otherwise no medical contraindications.

	Upon examination, it was revealed that tooth #30 had large MOD alloy that had fractured with large recurrent decay present. Tooth #29 had previous root canal treatment and a fractured crown; all that remained was the root. After diagnosing the site, I informed the patient of the following treatment options.

	How guided implant surgery can deliver better patient care

	As dentistry has moved to a digital platform, more clinicians and labs have started taking advantage of enhanced communication tools in order to provide greater patient care.

	The accuracy currently achievable with digital dentistry is unparalleled. This accuracy, along with teamwork within the surgical and restorative team, is creating workflows where the final outcome can be visualized before a case is started. Implant dentistry is no different.

 to see a digitally-planned surgery guide

	Prior to the advent of CAD/CAM dentistry, restoring implants using the analog method required PVS impressions and multiple appointments. In the first appointment, a traditional impression was taken and sent to the lab for fabrication of the implant restoration. Several weeks later, the patient presented for the seating of the restoration.

	CAD/CAM dentistry allowed dentists to image the implant digitally and eliminate PVS impressions. It also enabled us to design and fabricate the restoration, as opposed to sending it to a lab, giving the dentist the ultimate control over emergence and tissue pressure. Using this method, the final restoration can be delivered approximately two and a half hours following imaging, or in a subsequent appointment.

 to see how a CBCT scan helps create quick results

	Technique: Using digital diagnostic design to achieve great results

	Digital intraoral scanners, as well as stand-alone and complete computer-assisted design (CAD)/computer-aided manufacturing (CAM) equipment are powerful and efficient tools in today’s dental practices. They eliminate the need for traditional analog impressions and wax-ups, as well as the conventional hands-on fabrication processes associated with all-ceramic restorations.

	As a result, in one digitally centered workflow that could be implemented, impressions are taken with an intraoral scanner, not conventional materials and trays. Computer software is used to digitize, analyze and manipulate the scanned images, instead of pouring models. Restorations are designed with CAD software, not by hand-waxing models, after which they are milled through a CAM process, rather than by pressing and/or layering.

 to see how digital designs save time and effort

	Technique: Creating an immediate load denture using digital tools

	By Tra’ Chambers Owner of Express Dental Laboratory, and Dr. Steven Park

	The dental industry is currently experiencing a major revolutionary shift in the laboratory design process, slowly but surely transitioning from the traditional physical model to a new age of digital design.

	At Express Dental Laboratory, we pride ourselves on being an industry leader by utilizing many innovative new technologies available from Dentsply Sirona in order to manage our workload more efficiently and, in turn, providing our dental partners with a streamlined process of communication and superior deliverables.

 to take an in-depth look at a denture case

	What if there were a way to increase your patients’ satisfaction, separate yourself from the dozens of other dentists in your area and create a great atmosphere for patients and staff alike? And what if that that way didn’t involve any extra time or effort on your part?

	Sounds too good to be true, right? But if Judy Thomas, DDS, is correct, then the answer could really rest on one simple word: hypnosis.

	Dr. Thomas operated a highly successful practice for over 30 years before recently retiring. She attributes the success of that practice not to marketing techniques (she says that the only marketing her practice did was word-of-mouth), but says it was because she taught her partner and staff about therapeutic communication, also known as hypnotic communication.

Related article: 4 tricks to increase patient referrals

	Now, Dr. Thomas urges dentists and other health professionals to incorporate those same techniques into their practices. Why? She says that the number one thing dental professionals tell her after putting hypnotic therapy techniques into their practices is “I had no idea this would help this much.”

	This question hasn’t been fully answered yet, with various explanations for what’s happening in the brain during hypnosis. But the most basic and most common 

 is a state of highly focused attention or concentration, where one is more relaxed and open to suggestions.

	Dr. Thomas describes it simply as affecting how the mind responds to situations. “Everything comes from the brain,” she says, “It’s that whole mind-body [connection]. If you can help someone control what their brain is putting out, then you can help them do a lot.”

She stresses that all hypnosis is self-hypnosis - no one can force someone to do something they don’t want to do. Clinical hypnosis is wildly different than stage hypnosis; it’s about getting a patient to use his or her mind in a way that’s helpful, rather than harmful or for a few laughs.

	“Just about everyone has this capacity,” she says. “People walk in and out of essentially trance states all day, and it’s a natural ability. It’s [hypnosis] just helping them to really recognize it and really hone it in when they need it. That’s what hypnosis is.”

	In dental school, she says, “we didn’t really learn that much about the brain and how pain really works in the brain. When you realize that there are certain parts of the brain that can be affected by just the words that you choose and you can change it, it really makes a huge difference.”

	Many professionals dismiss the idea of hypnosis out of hand, conjuring up images from movies. This same stigma has often applied to researchers, meaning that hypnosis has not been as widely studied or accepted as other methods of therapy - but that’s quickly changing.

Related article: Do you know why patients aren't coming in?

	The first thing to know about hypnosis is that it isn’t magic or something that’s only useful on stage as entertainment. It only works for some (what’s known as “

” varies widely from person to person as all human attributes or capabilities do), and it can’t force someone to do something they find objectionable.

	For those who are willing to be hypnotized - for instance, patients in a dental office who want to rid themselves of anxiety - hypnosis can be a great help. 

 on patients with dental phobia used fMRI scans to show that hypnotism actually alters the brain, reducing activation in parts of the brain associated with the fear response.

Related article: Why smart consumers will determine the future of dentistry

 of much of the hypnosis literature available found that hypnosis is effective for a wide range of issues, some of them found in the dental office. The analysis examined 12 studies related to the use of hypnosis on anxiety and found that all acknowledged that hypnosis was effective. On the topic of pain, the largest topic studied with 37 studies examined,  the results were similar, indicating that  for both chronic and acute pain conditions patients reported that hypnosis “significantly reduces their perception of pain.”

	It’s all well and good to describe hypnosis in theory, but what does it actually look like in real life? Does it fit into the dentist’s (and patient’s) hectic schedule?

	When asked what she wished every dentist could know about hypnosis in dentistry, Dr. Thomas simply responded, “It doesn’t take any extra time.” Again, clinical hypnosis is not like the movies, where a bald-headed man in a tweed jacket swings a pocket watch back and forth for several minutes. Instead, it’s simply about choosing the right language.

	Dr. Thomas makes a distinction between being hypnotic as opposed to doing hypnosis. By being hypnotic, she means that “the majority of people walk into the dental office - even those who don’t admit to it - have a slight bit of anxiety. When they come in, the idea is to be able to recognize that they’re not in their normal state, their brain is thinking and acting differently.”

	Patients in this modified state respond more with the emotional parts of their brain, so it’s up to the clinician to recognize this and choose the right words to respond to that state - right from the moment they walk into the office. Dr. Thomas taught her entire staff hypnotic language, barring certain words and negative language, which helps to put patients at ease.

	She says it’s difficult to give an example of a typical patient, because all patients react differently. “Hypnosis is a way of getting the most out of those precious few minutes with a patient by being able to join them in their understanding of the world,” she says. So for instance, a visual learner might benefit from hearing about the esthetic advantages of a crown, or a kinesthetic learner might appreciate talking about the smoothness of it. “It’s not necessarily doing hypnosis as being hypnotic. Hypnotic communication understands the mind/body.”

Related article: 5 ways dentists can improve their customer service

	“Hypnosis,” she adds, “is understanding the patient on every level and utilizing those few minutes with them in the most efficient way possible.” She says that she has colleagues tell her that patients just sit there with a glazed look on their face, not even listening. “Yes, they are!” she says. “That is an altered state! Recognize it, understand it and be able to communicate with that part of their mind effectively. They are hearing you, they are not understanding you. Hypnotic communication is about the patient understanding you because you have the ability to meet them where they are.”

	She gives these two examples of using the right language to accomplish that. Instead of saying “Here is a prescription for pain,” try “Here is a prescription some people use to help with discomfort but I’m sure you’ll find that any sensations you feel will be those of healing and needn’t bother you.” Instead of the usual “You’ll feel a slight pinch,” try “You may feel some coolness or tingling as this anesthetic takes effect.”

	There is also the option for more formal hypnosis. Dr. Thomas performed a lot of what she calls “habit control,” which often required more focused sessions. One patient she had would bite his nails, and had for over 50 years. As a result of this, he lost #9 and was losing #8. She couldn’t figure out what the problem was, until he admitted his problem. For patients like that, she would see them during a more quiet time and take 30 minutes to an hour with them, for as many sessions as necessary to help them stop those habits.

Related article: How to deal with flirty or derogatory patients in the dental practice

	Those more formal training sessions, however, were much rarer than the general hypnotic language used on every patient. “People think of it as something more formal, and it isn’t,” she says. “It really is easy, and amazing.”

	Most patients - aside from those undergoing more formal hypnosis - were not even aware of the use of hypnotic language. Dr. Thomas describes one patient with a “high dental phobia.” This patient who would go to her periodontist for cleaning, simply because the periodontist was her neighbor and she knew him. If the periodontist saw something wrong, he would send the patient to Dr. Thomas. She would talk the patient while she worked, and “she didn’t know why she felt comfortable, but she did. And you know, she just raved about me.”

	That all changed when she sold the practice, and the new owner’s website mentioned that she did hypnosis. The patient read that, and came in and said, “don’t talk to me. I don’t want you doing that thing with me. That voodoo thing.”

	The majority of patients, she says, are very receptive to the concept of hypnosis once it’s explained. She explains that what it’s really doing is not taking away control, but is actually giving them 

 control over their own mind and body - the exact opposite of what happens with what they see in stage hypnosis. “The things they can do by just telling their mind to do it, it’s very powerful,” she says.

	At the end of the day, hypnosis in the dental practice is about empowering the patient. “If you actually empower them,” Dr. Thomas says, “and help them get over it, not only do they the one emergency thing, but then they’re looking at their teeth thinking ‘I haven’t been to the dentist in 30 years, and now I don’t like the way my teeth look’ and you’re looking at a full-mouth reconstruction. And all you did was help somebody feel better about themselves.”

	It follows that if patients are largely supportive of the practice and its results, your practice will also thrive. Dr. Thomas tells dentists, “I guarantee it makes a huge difference on your bottom line when people feel understood and you’re saying the right words.”

	She gives one example of a new oral surgeon who had taken a level one fundamentals course and was trying to open up his own practice. The problem was, his practice was in an already-saturated market where people told him that he couldn’t succeed. He needed something to set him apart from all of the other oral surgeons in the area - that something was hypnotic language. He helps them lessen their post-op pain and reduces anesthetic use. In just a couple of months of the word getting out, he was booked solid.

Related article: 4 ways cosmetic dentistry opens doors to new opportunities

	Overall, says Dr. Thomas, dentists need to know that learning therapeutic and hypnotic language is “just going to make such a big difference in their practice and their lives.”

	If you’re interested in learning more about the use of clinical hypnosis, there are a variety of resources for beginners. The 

, of which Dr. Thomas is a member, offers a series of classes and support for any licensed healthcare professionals with at least a master’s degree.

It’s not magic, but hypnosis has the ability to radically transform your dental practice.

Why hypnosis is right for your practice

	It may sound strange for problems with two very different systems, the eyes and the mouth, to be connected, but depending on who you ask, periodontal disease (PD) could have a huge impact on the development of age-related macular degeneration (AMD) - or not much of one at all.

	Certainly, there is already a mountain of evidence showing that PD can cause a slew of other problems in the body. The bacteria responsible for periodontitis have been linked to several different types of cancer - of the 

. It’s not a stretch to imagine that one other system could be affected.

Related article: Is wine a good mouthwash?

	That’s the conclusion that one American team reached in a 

 examining a link between PD and AMD. In that study, the team researched 8,208 adults from the National Health and Nutrition Examination Survey III. In that population, a total of 52.30 percent had PD, and 11.45 percent had AMD. For patients younger than 60, after taking a variety of other variables out of play, those with PD were nearly twice as likely to develop AMD.

	Seems like an open-and-shut case then, right? Not so fast. That study, along with other smaller studies performed in Poland and Finland, were performed among largely a Caucasian population. Another more recent 

 conducted in Korea had results that weren’t quite so one-sided.

In that study, examining a large population of 13,072 adults, 37.4 percent had PD while and 5.6 had AMD. The study found that, overall, there is no significant link between having PD and AMD - except in one section of the cohort. Adults between 40 and 62 with severe PD were 1.61 more likely to develop AMD than those who were older or had only mild PD.

	So what does this all mean? Clearly, there’s at least some sort of link between PD and AMD, but who exactly that link affects is up for debate. The next logical step, then, is determine what the possible cause could be.

 examining the effects of PD bacteria on retinas may have the answer. First, researchers isolated one of the primary bacteria responsible for causing PD, 

 (Pg) and infected human retinal cells with those bacteria directly. The retinal cells took up the Pg, and exhibited markers of infection. In the second part of that study, researchers injected mice with that same bacterium, and those mice that were injected showed higher levels of AMD.

Related article: How scientists are turning teeth into drugs

	Dr. Pachiappan Arjunan, assistant professor at the Department of Periodontics at the 

Dental College of Georgia, Augusta University

, says “This is the first study to demonstrate the link between oral pathobiont infection and AMD pathogenesis and that Pg can invade human retinal-pigment epithelial cells and elevate AMD-related genes which might be the target molecules for both diseases."

	More research is needed - after all, mice aren’t humans and retinal cells are the same as a living, breathing human - but there’s clearly something here. There’s no need to panic yet, but it’s just one more really good reason to keep your patients healthy.

There seems to be some sort of link between periodontal disease and macular degeneration, but just how strong is it?

Does periodontal disease cause eye problems? It’s complicated

	You’ve heard the debate about the value of digital versus traditional impressions for years now. Dentists argue passionately that one is inherently better than the other and it seems like the debate won’t ever end, but at the end of the day it really comes down to personal preference the individual case.

	Traditional impressions are still widely used (

 say the average dentist does around 380 a year), and they’re not going away anytime soon. And while impression materials seem to get better every year, they still account for one huge problem: people. No matter how good the material is, human error still plays a factor.

How many impressions do you think you’ve sent to your lab that could be described as less-than-perfect? If you’ve ever gotten a desperate call from your lab telling you that your impression-taking skills need some work, you’re not alone: a recent study found that 64.5 percent of impressions sent to labs are unacceptable.

the lab will call me if there’s a problem. It’s on them to make sure it’s right.

	But just like you, labs are a business, and they need to make money. Jason H. Goodchild, DMD, director of clinical affairs at Premier Dental Products Company, likes to tell this anecdote. At a recent visit to a lab where he was teaching a recent CE course, a technician spent some time showing him different bad impressions that had been sent in over the years.

Related article: The 10 golden rules for taking impressions

	Dr. Goodchild asked the technician, “What do you do when a dentist sends a bad impression?” to which the tech replied, “Call them.” “After the tenth time?” he asked. “We don’t call them anymore,” the tech said, “We’re game players, not game changers.” What the tech meant was that, while labs can fix some mistakes, they’re not miracle workers.

	Just like other business, labs also need to keep their customers happy. Dr. Goodchild says, “If the lab calls you every single time [there’s a problem], the dentist is going to find another lab. They don’t want to be bothered.” The lab is stuck with the conundrum of either losing the customer or creating a crown off of a bad impression, so they’ll make the crown because they don’t want to lose business.

	It’s up to you - and only you - to make sure that you aren’t part of that 64.5 percent sending bad impressions. Here are just a few of things that can go wrong and tips to help you fix them in the future.	 

	One of Dr. Goodchild’s strongest bits of advice is, “don’t be cheap.” This is especially important when it comes to material and tray usage. Many dentists, he says, make the simple mistake of not getting enough material into the tray, or using a cheap tray with bad side support. “Cheap dentists want to skimp on that stuff,” he says.

This image is good example of how not to take an impression - the likely culprit is that there isn’t enough tray material to support the wash material.

	Using less material seems like it should be an easy way to save significant amounts of money. The average impression with stock tray 

 somewhere between $18 and $35. If the dentist does 380 impressions a year, that amounts to $6840 and $13300. Certainly not your practice’s biggest expense, but a dentist looking to save some money could easily decide that skimping on impressions is a good way to cut costs.

	But is a bad impression really worth saving a small amount of money here and there? Dr. Goodchild likens impression-taking to that famous scene in The Fellowship of the Ring where the wizard Gandalf stands at a bridge and yells “

!” He says that impressions are like this - without a good impression, you can’t move forward.

	Do what you can to get it right the first time, before it gets sent to the lab and is either rejected or you end up putting something in a patient’s mouth. It will be more expensive and time-consuming if you don’t.	 

	Depending on who you ask, adding in an array of extra instruments and techniques can either be a great help or not necessary. The important thing is to use the techniques and instruments you feel comfortable with, using them for the right case and not taking any shortcuts along the way.

	John Flucke, DDS, technology editor at DPR, has found great success using a variety of instruments in his practice. He admits that these days he’s mainly switched over to digital impressions, estimating that he maybe takes one traditional impression per quarter for what he calls “oddball situations” - mainly partial dentures where a crown has to fit with a partial, which he says none of the scanner companies have quite figured out yet.

He recommends two major tools to help with impressions, diode lasers and electric handpieces. Using a low-power laser (and he emphasizes the need to keep it at low power, to avoid burning the tissue) he will remove a small amount of tissue around the tooth. This creates a small groove below the margin of the impression, which allows material to flow down into that groove.

Electric handpieces, Flucke explains, are gear driven, which means that you can run them more slowly and get good results because they don’t stall. He says that he uses it in problem areas with decay in the gumline. He begins with a small-diameter bur to get tooth structure out of the way, then he goes back with the large-diameter bur to refine it, using the smaller bur to give himself room to use the larger one.

	Dr. Goodchild approaches impressions from a different angle. Rather than recommending any specific tips and tricks, he advocates for a “back to basics approach.” He says, “All those things we learn in dental school, they’re still valuable. Pick the right material, syringe the right way, seat it correctly, transport and store it correctly.”

	He says it’s not about “any slick tips and tricks, but getting it done right the first time.” He stresses that everyone is going to find the techniques that work best for him or her, and it’s about using the techniques that will get good results, not taking any shortcuts.

	So, whether you take the more hi-tech approach or a more back-to-the basics approach, stay consistent, do what works for you and take pride in your work.	 

	Relining is another technique many dentists use to attempt to make impressions more accurate - or they just use it to save a little time and money.

	Dr. Goodchild has seen a variety of examples where relining is the cause of bad impressions, which has led him to the conclusion: Don’t reline an impression, just take another impression.

In this one example, an associate attempted to reline an impression to get more detail out of it, instead just creating something unusable.

	Labs feel the same way about relining. One lab 

 for dentists: “If you want an impression that the lab can actually use, you must completely re-do the impression. Many dentists mistakenly believe that relining will result in a more accurate impression, but this is the exact opposite of the reality.”

	They say that relining an impression makes it nearly impossible to seat the impression correctly. “The inevitable consequence is that you create a double copy of the prepared tooth inside the impression. There isn’t enough space for the impression to seat fully with new material inside of it.”

	Rather than saving time and money, relining can often lead to more waste - so make sure you have it right the first time, or just do the impression all over again. Your lab (and your patient) will thank you for it.

	Dentists work with the human mouth day in and day out, so it’s sometimes easy to forget a simple fact: 

. It’s constantly warm and damp, a perfect breeding ground for bacteria, and always open to the elements. Where else in the human body does bleeding and decay occur on such a regular basis?

Part of getting a good impression is dealing with that. No matter how hydrophilic a material, blood flow needs to be stopped or it will ruin the impression. Blood has to go somewhere, and that somewhere usually involves pushing impression materials up, creating voids and a host of other problems, not to mention the issues caused by dried blood getting into the impression material.

	Sometimes a somewhat unconventional approach works best here. A 

 by Gordon J. Christensen, DDS, MSD, PhD, recommends several simple approaches for stemming blood flow. The first is to have the patient use one of the many-available chlorhexidine gluconate mouth rinses - twice a day for six weeks, beginning two weeks before their appointment. The rinse makes the gingival tissue pink and firm, preventing blood flow.

	If that route is undesirable, the article also mentions a more technique-sensitive method for controlling bleeding. Inject medium-viscosity material around dried tooth preparations, then use a small stream of air to push the material, forcing it into the gingival sulcus. If blood emerges from the unset material, gently blow air onto the impression material in the bloody area until bloody area is no longer visible. It might take several tries, but a combination of air and viscous material will eventually stem the bleeding.

	More traditional routes include a variety of hemostatic agents or retraction cords. Use the products you feel comfortable with that are best with the situation you’re working with.

	Remember, if you’re putting something in a patient’s mouth, whether it’s a retraction cord or a cotton roll or something else, remove it before you send it to the lab! Anything in a patient’s mouth is going to filled with a variety of bacteria, and as Dr. Goodchild says, cannot be disinfected. No lab wants to deal with a cotton roll full of germs - not to mention the fact that the impression could be damaged when trying to remove it. 

	To remove a retraction cord stuck in an impression, Dr. Christensen recommends soaking the impression in a cup of water to wet the cord, then carefully pulling it out. If you can’t pull it out, take another impression, or you’ll risk an angry lab impression and a bad impression.

	Many impression mistakes are just small technique errors. While these can create big problems, they usually involve a quick fix.

One common issue Dr. Goodchild has seen is a problem with syringing technique. When syringing wash material, many practitioners will start and stop at the same location. As Dr. Goodchild explains, this creates suction as the needle is removed, which causes v-shaped voids to form in the final impression. Instead, go around twice and end at a different place than where you began.

	Dr. Goodchild says this is often the result of younger dentists having only previously worked with alginate, where that technique is correct. As with many other problems, it comes down to a matter of using the right technique for the right material.

	Another common mistake is based on the misconception that a rough surface will create a better impression than a smooth one. In fact, the opposite is true: the smoother the prep, the better.

	Finally, the last quick-fix mistakes many dentists make is not timing their impression. Dr. Goodchild recalls learning a technique in school to learn how to judge when an impression is ready to be removed: Test the impression by digging a fingernail into the impression; if it springs back, the impression is complete. As Dr. Goodchild explains, this technique is bad and should not be used.

	Instead, follow the manufacturer’s instructions for timing, and use a stopwatch to time it. Don’t create guesswork for yourself, pull out your phone or computer or pick up a dedicated stopwatch. It’s a simple fix, but one that can save you a lot of headaches (and money). If you don’t, you can end up removing the impression too early, resulting in tearing.

Many dentists still prefer analog impressions - but a lot still goes wrong.

5 ways that traditional impressions can go wrong

	Going green isn’t anything new. You’ve definitely heard about, have maybe even thought about how you can make your dental practice more green, maybe even done it.

 is right around the corner (April 22), which means that now is a good time to reevaluate just what going green could mean for your practice, and how you can do it.

For many, however, the anticipated costs and problems associated with making their offices more environmentally friendly are just too much. Won’t installing all of these energy-saving devices cost a lot of money? Won’t my patients and employees be annoyed with low-flow toilets? Disposable plastic tools are way more convenient than reusable ones!

	All of these are valid concerns, and no one should pretend that going green isn’t going to take some extra work. But if you’re committed to lowering your environmental footprint, it’s worth it. And if that doesn’t convince you, maybe this will: Going green can also save you a lot of, well, green.

	These four tips show that, while it might take some extra work or some time to get used to, making your office more environmentally friendly might just be the best thing you can do for the earth and for your practice’s budget.

	We’ve talked a lot about the benefits of transitioning to a paperless office, and have told you how 

. And while it’s tough, most practitioners feel that in the end the results speak for themselves.

	If you haven’t gone paperless, think about the amount of paper that flows through your office every day. The small sticky notes, the ever-growing patient files, the printed 

, the memos, the patient sign-in sheets, the advertising brochures you hand out at your front desk. All of these costs are small per unit, but they start to add up over time. That’s not to mention the huge footprint that much paper leaves, and the amount of ink and chemicals involved in printing X-rays is expensive and environmentally damaging.

	What about recycling you ask? Isn’t that good enough? Certainly, recycling is a good thing, and no matter how digital you get, you’ll still be using some amount of paper. But that doesn’t change the fact that only about 

 is recycled, and even of that 10 percent a fair amount of it is made up of virgin paper.

Related article: How I managed to create a paperless office

	All that paper really starts to add up in the environment. One ton (2000 pounds) of paper 

 to make, or in other terms, one tree creates 8,333 sheets of standard copier paper. That sounds like a lot, but think about your file room. How many thousands of sheets of paper have gathered in there over the years?

	X-rays are a whole different story. When you go digital, you eliminate the need for all of the various chemicals - like heavy concentrations of silver or hydroquinone, both of which are toxic - and the detrimental impacts they can have on the environment. Plus, you avoid the hassle of having to dispose of old X-rays and their related materials.

	What about the expense of going digital? Of course costs and timing will vary, but according to 

, it only takes 10.8 months to recoup the cost of switching to digital X-rays, billing and charting because of the cost savings. After that? Each year you could see savings of $8769. Your staff will spend less time organizing a mountain of paperwork, and you’ll be free to see more patients instead of chasing down that one file.

	While just shy of $9000 isn’t necessarily going to save your practice, it’s nothing to sneeze at. And if makes your practice more environmentally friendly, then why not go for it?

	A lot of focus on environmental issues deals with areas such as air or water quality. But an important part of the environment is people. Just as reducing waste can make for healthier soil or air, it can also make for healthier people.

? It’s an increasingly common phenomenon where office workers report feeling ill just from being in an office building. Symptoms include everything from headache, dizziness and nausea to personality changes.

	No one knows the exact cause, but several culprits are suspected. Chemical contaminants, like motor vehicle exhaust coming through ventilation shafts or from sources like adhesives or upholstery could be one cause; other sources could include bacteria trapped in air conditioning or in pipes or just poor ventilation.

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	Beyond these physical sources, psychological factors may play a factor. A high-stress office can be a problem. Poor communication and a bad working environment can affect the health of your employees. But there’s also the problem of bad lighting, poor ergonomics and humidity.

	A fair number of these problems can be solved by improving the health of the building. Put in more ventilation. Improve your seating for those who stay seated, and brush up on 

 for employees who are on their feet or who work with patients.

	If this sounds like a lot of work (and a lot of expense), know that it’s all worth it in the end. Consider 

 on the effect of green buildings and productivity, showing that 

 buildings tend to be healthier buildings, which create healthier and happier employees. Once you take into account the amount of sick time and the general lack of productivity in a bad building, the economics start to make sense. In real dollar amounts, the study estimates that owner-occupants can count on over $100 per square foot of building in extra value.

 shows that emphasizing environmental friendliness can actual make people happier. Why wouldn’t you do something that leads to happier employees? Consider your 

 - tell your patients that you’re doing everything you can to create a healthy environment. If it works for your employees, why wouldn’t it work for them?

	Think about the sheer number of disposable, one-use-only items in your office. Everything from disposable air/water syringe tips to bibs to towels to sponges to tray covers to needles to the paper cups next to the water cooler in your lobby - all of that really starts to add up in landfills.

	A large part of that waste isn’t disposed of properly, allowing for dangerous chemicals or biohazardous materials to leak into the ground or water supply. Since 1996, the medical community has known that the incineration of used medical supplies leads to carcinogenic 

 being released, and while improvements have been made through monitoring, the 

	Dangerous chemicals aside, dental offices still produce large amounts of trash, especially from disposable plastic and paper products. Consider making the switch to reusable items wherever possible. Switch items like chair barriers or towels to cloth towels. Replacing disposable items with cloth ones can 

Being environmentally friendly doesn’t necessarily mean losing money, sometimes it actually helps you be more profitable.