Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.

Robert Elsenpeter

The Right Cut | Image Credit: © Andriy - stock.adobe.com

Whenever they find themselves in a pickle and need help getting out of the jar, James Bond and Batman can always turn to their trusty gadgets. Whether it’s Bond’s laser watch, pen grenade, or a tricked-out Aston Martin, or Batman’s smoke pellets, Batarang, or Batmobile, there is always a gizmo.

While not a matter of life or death, dental labs are faced with a range of options when it comes to machining and tooling, given different materials and applications. Finding the best tool depends on a variety of factors that lab owners must keep in mind.

In the lab, the tools used by milling machines to carve shapes out of materials share a common form factor.

“Most of these tools are made out of tungsten carbide,” Chris Urist, president and partner at Primotec USA, notes. “That’s the best-quality raw material to use. Different machines have different sizes and dimensions of tools, but for example let’s just say the most common mill is a Roland Mill, and those have a 4-mm shank diameter where the chuck holds the tool. The first tool that the machine will grab is a roughing tool, which is the biggest tool, and removes the most material the fastest.”

The machines that do the heavy lifting of CAM work are the mills themselves.

“First and foremost, you need the mill,” Lisa Aguirre, dental marketing manager at Roland DGA, says. “It’s like if you want to print something at home, you must have a file to send and a device to send it from, but you need a printer to produce the print. It works the same way for dental milling, where the mill creates the final product.”

Milling machines work in wet or dry capacities, depending on which material is used and what is being produced.

“The type of hardware you use is going to depend on the type of product that you’re looking to produce,” Aguirre says. “For example, if you’re producing zirconia or dentures—or for anything removable—you’re looking at a dry milling solution. Whereas if you’re using a glass ceramic material, a lithium disilicate, or a custom titanium abutment, things of that sort, you’re going to be looking for a wet milling solution.”

“There are a variety of mills out there that handle multiple materials,” adds Matt Viens, CAD/CAM training supervisor, Zahn Dental. “Some of the major manufacturers include Roland DGA, VHF, Amann Girrbach, Imes, and imes-icore. Each major manufacturer typically has 1 model dedicated to milling wet-milled materials only, then other models that are suitable for milling multiple materials. This includes dry-only mills or mills that can function as a wet and dry combination. For these combination mills, the best rule of thumb regarding matching the hardware to the materials is to stick to milling either wet or dry materials for as long as possible within the production workflow, before having to switch over to the other.”

While there are mills that can handle both wet and dry applications, they tend not to be very efficient.

“The process of having to clean out the mill between materials can be tedious and time-consuming,” Viens says. “Not to mention that if not done correctly, it can and will lead to premature wear and tear on the integral parts of the mill itself. With wet-only mills, it is imperative to keep up with required daily cleaning and maintenance routines to ensure that any additional buildup is not going to cause issues with the normal function of the equipment. With dry-only mills, vacuuming and minimizing the amount of debris left within the milling chamber will help to reduce the influence that the particles can have on the units being milled and on parts of the mill itself. In short, keeping up with cleaning and maintenance is key, no matter the material type.”

Labs also have the opportunity to select tools and equipment based on whether they can interoperate with other manufacturers’ products. Those pieces of hardware and equipment that work only with a single manufacturer’s products are said to be “closed architecture.” On the other hand, those that can work with other vendors’ offerings are said to be “open architecture.”

“Our solutions at Roland DGA are all open architecture,” Aguirre notes. “This allows you the freedom to choose your preferred materials, whereas a closed system would limit you to using the particular materials approved for that unit. Open architecture means that from scan to design to the actual milling of the material, it’s open, so if a new material comes out on the market tomorrow—as long as it’s FDA validated or 510(k) certified—you would be able to mill that material, whether it be wet or dry, depending on the solution you’re working with. Using a milling solution with open architecture is a good way to ensure you are getting the most bang for your buck.”

There are, naturally, pros and cons to each architectural philosophy. Supports of closed systems tout their solutions as more predictable and reliable. Open systems, on the other hand, allow for more flexibility.

“Obviously, with open architecture solutions, you’re going to have more restorative options and more possibilities as far as materials and also with tooling,” Aguirre says. “As far as materials, for example, if you’re working with a closed system, you may only have 5 or 6 materials to choose from, whereas from a laboratory standpoint, there may be a better material out there that would better suit this case, based on the patient’s function or other variables. With an open milling system, the laboratory would be able to offer that other material to the clinician as a recommendation for their patient.”

There doesn’t seem to be a strong pull, one way or the other, as far as which type of system is most prevalent.

“It’s still 50/50,” Aguirre adds. “For instance, 3D printers. They’re about 50/50 right now. You have some companies that believe if they lock you into materials, hardware and software, it’s a more controlled production environment.

“My background is clinical,” she continues. “I always talk to clinicians about avoiding becoming a cookie-cutter practice. You don’t want a consultant that’s going to come in and cookie-cutter your practice with that solution. You want to be able to make the best decisions for your patients based on their unique situation, because no 2 mouths are the same. It’s like a fingerprint, whether it be the bite, the anatomy, the function, whether they have dry saliva vs more of a wet mouth, or the foods they eat. I could go on and on, but closed architecture really narrows down your options. You’ll see it even more on the 3D printing side, because they’re basically forcing you to buy their consumable materials as well.”

Can any one machine do it all? That is, can a lab get by with just 1 mill that can handle wet and dry cases? The answer is a resounding, “It depends.”

“There are hybrid milling machines which mill both wet and dry,” Aguirre says. “At Roland DGA, we don’t presently manufacture hybrid machines, only because it requires a significant amount of maintenance when you go from wet to dry. Take zirconia milling as an example. If zirconia dust were to enter the milling chamber, because they’re milled in the same chamber, and there’s any amount of moisture left in that machine, which happens more often than you’d think, and you start milling zirconia, you’re going to have concrete in your mill. Anybody who’s ever touched zirconia dust knows what I’m talking about. It is fine. It makes a mess. So obviously, it’s not something that’s meant to be wet milled, unless it’s fully sintered, and there are not too many of those products available.”

Tools seem to be best used with a specific material.

There is no such thing as an all-purpose tool,” Viens says. “There are tools, like carbide tools, that can handle a variety of materials such as zirconia, wax, polymethyl methacrylate (PMMA), and other types of ‘soft’ materials. But due to their composition, these tools are not suited for lasting a long time and they degrade faster than specialized tools for the particular materials. Typically, carbide tools are the cheaper option among the tools available. Therefore, the versatility and advantage of such a tool is quickly overrun by the constant need for replacement. Tools are designed and produced to be effective and efficient against specific materials. Though it may cost more to run multiple sets of tools to cover the variety of materials, the cost over the long run is greatly lessened due to their durability.”

While tools may be able to handle different materials, they can wear faster if they’re not used properly.

“You can have 1 tool that does everything, but that’s one of the least efficient ways of milling, because again, if it’s just that carbide material, it’ll be fine for wax and PMMA. It’s OK for zirconia, but not great,” Urist says. “It does not last very long. And most people are milling zirconia out of their machines the majority of the time. So, with zirconia, we—and most manufacturers—recommend a diamond coating. That diamond coating will make the tools last way longer for milling zirconia; it could be up to 10 times as long as a carbide tool. So, it is more expensive, but it’s a higher-quality coating. It just really makes the surface and the sharpness of that edge last a long time. But that’s specifically for zirconia milling. If you were to go and start milling another material, like PMMA with that, it does not last quite as long.”

Labs can extend the life and the function of their tools by avoiding some common mistakes.

Using the correct tooling for the job tops Aguirre’s list.

“The No. 1 mistake, I would say, is not using the proper tooling,” Aguirre says. “Tooling is so important to the success of the milling job. I think in our industry, a lot of times we don’t put a lot of emphasis on it, but using the right tools and using quality tools are really, really important in the long run. Again, our systems are open, so they can use any appropriately sized tool—and there are a lot of them out there. We can guarantee our Roland DGA, DGSHAPE tools are authentic; they’re high quality. Sometimes users think that they’re saving money by using less expensive tools—kind of the no-name knockoffs. We see these cheaper brands in implant parts, tools, and materials. And they’re less expensive for a reason. There is value in using quality tools and making sure that you’re using the right tools for the job.

“There are actually 3 things to keep in mind when choosing your tools,” she continues. “The first one is, are you using quality tools? Because if you don’t use quality tools, you’re going to be swapping those tools out much more frequently. And that’s something that in any mill is going to require an actual technician to do. Those frequent replacements eat into your profits, reducing your [return on investment] and increasing your overhead. Typically, lower-quality tools also break more frequently, and not when they’re supposed to. Maybe the tool has this many hours and maybe it’s getting close to its estimated lifetime. Lower-quality tools can be unpredictable, which can also cost lab owners time and money.”

Tools, Aguirre adds, should be appropriate for the material being milled.

“The second question to ask yourself is, are you using the right tools for the material that you’re milling?” she says. “For example, are you trying to mill zirconia with a PMMA tool or vice versa? More often than not, when we see chipping in zirconia, for example, we’ll see users using carbide tools. Although there is an indication for using carbide tools, the best tool to mill zirconia with is a diamond-coated tool. And then same thing for PMMA. You’ll see somebody saying, ‘Oh, I don’t know why this tool keeps breaking,’ and they’re milling a PMMA puck with a diamond tool, which is not the right tool for that application.

The third consideration is paying attention to your CAM software. CAM software will always tell the user what tool slot each tool belongs in,” she continues. “Sometimes while setting up their milling session, people are so busy clicking that they may not notice that something changed, because each setup is based on the design that’s created. It’s best to always take the time to ensure that your tool setup mimics what you see on your screen and your CAM software.”

There are several variables at play when it comes to selecting the right tool for a given material and job.

“Relative to tools, the most common issue is putting the wrong tool size in the wrong slot or labeling the tool in that slot incorrectly in the CAM software,” Viens adds. “For example, placing a 1-mm bur in the placement where a 2-mm burr is meant to be or mislabeling a 1-mm bur as a 2-mm bur in the CAM software. Some mills are able to detect the type of bur and will let you know that the wrong one is in the current slot and allows for you to correct this error. But other mills or software are only as capable as the information that is input into them. So, the mill assumes that the correct bur is in the correct slot, and when it goes to mill it either breaks the bur or overmills certain areas because of the difference in size.”

“I would recommend that [dental labs] use a different tool for their different materials,” Urist adds. “Some labs will just use the carbide tools, and they’ll use it for everything that they’re milling. And again, they are the least expensive, but they won’t be the most efficient and cost-effective over the life of the tool. So, if you had one set for zirconia, a diamond coated set, and then another set for the other stuff you’re milling—PMMA and wax—it may be more up front of a cost for them, but it will help them in their tool longevity over the life span of that set of tools.”

He also advises labs to be mindful of bur coating materials.

“There are diamond coatings for zirconia, but there are other coatings as well,” Urist adds. “We make a gold coating for metal milling. Different coatings add different hardnesses to the tool, and they just help milling different materials. So, we have a Blue Line coating, which is good for PMMA and PEEK, and then a Gold Line, which is good for metals. Finding the right tool for the right material really just helps with the longevity of the tool.”

Tooling costs are, of course, important. And while it may seem that the lab will get a longer life out of a more expensive tool, Urist observes that there may be cases where it’s more efficient to buy less expensive tools and chalk up frequent replacements as more efficient for the business.

“It might go in the other direction in that labs will just want to use a set of diamond tools and they’ll end up using that for everything,” Urist says. “But in that case, it would make more sense to also buy a less expensive set of tools for the other materials that you’re milling that don’t need that coating. So, if they mill a lot of PMMA or wax, for example, then there’s no need to buy that more expensive coated tool. It just really depends on the material they’re looking to mill, because I would always recommend a diamond-coated tool for zirconia but not for other materials. But again, there are different types of diamond coating, and they can find much less expensive ones that are manufactured in China or India, but usually the coating isn’t quite as good as other coatings that are done here in the US or in Germany, for example. And that, honestly, doesn’t always depend on where it’s manufactured or what tools you’re using. A lot of it also depends on the CAM software and the strategy that they’re using. Two different labs might have the exact same milling machine and using the exact same tools, but they have one as a strategy from Company A and one strategy from Company B, but Company A’s will be much faster. They will be able to mill a crown out in, let’s say, 12 minutes, and then Company B will sell you one that takes 20 minutes. And typically, when this is the case, the lab that’s milling with Company B, the tools are lasting way longer. They’ll get hundreds of hours out of a tool, and Company A will get, let’s just say, half the amount of time out of a tool. And again, that just depends on the strategy that’s being used in basically how hard and fast that tool is working. There’s no right or wrong answer, because some labs just say, ‘I don’t care. I’d rather go through tools a lot faster and have these crowns milled out in 10, 12 minutes, because we’re a production lab and we need to pump these units out.’ And others would say ‘I’d rather have a higher-quality milled restoration and have the tools last a lot longer.’ So, there are many different variables, but really the longevity comes down to the CAM strategy and how fast you’re manufacturing your parts.”

More expensive does not always mean better.

“The most expensive tool is not always the best option,” Viens says. “You have to look at the yield of the product relative to its cost. If it is able to produce similar-quality units as cheaper burs but last a great deal longer, then it may be worth it. If it cannot match the quality but lasts longer, then it may not be the best option. As mentioned before, the carbides are going to be the cheapest to start out with, but they will not last the longest. The diamond-coated tools or similar are specifically engineered to last longer and are better suited toward all budgets, both in cost and effectiveness.”

Dental labs’ tools may not be quite as cool as James Bond’s or Batman’s, but there is always the right tool for the job.

Articles

How to find the best tools for your mill and for the materials you use in your dental lab.

The Right Cut

Dental Labs by the Decade | Image Credit: Samuel Perales - stock.adobe.com

If one really wanted to be pedantic, it could be argued that the first dental laboratories existed in Mexico, circa 2500 

. That is when the oldest set of false teeth (made from wolf molars) was dated. Although the toothless patient probably was elated to be able to chew again, thanks to a contemporary’s ingenuity, dental labs as we know them today trace their roots to the late 19th century.

Labs have always been on the forefront of technique and technology, all for the patient’s benefit. In the nearly 150 years since then, labs have continued to evolve and innovate—and there seems to be no slowing down.

“The early 20th century is when dental labs emerged,” observes Marybeth Starr, head of brand promise for Harvest Dental Products, based in Brea, California. “They were workshops where skilled artisans crafted dental prosthetics by hand, changing dentistry forever.”

According to the National Board for Certification in Dental Laboratory Technology, in the late 19th century dentistry was evolving and improving. But not every dentist was adept at every skill. Some were better at certain skills than others, creating unexpected opportunities. For instance, some were particularly skilled in fabricating prosthetic equipment. Those dentists found another revenue stream by selling the fruits of their labor to other dentists. And that is where the dental lab that we know today began.

Boston, Massachusetts, dentist William H. Stowe was particularly talented in creating prostheses. In fact, he was so talented in laboratory work that he no longer had time for treating patients. In 1883, he started focusing solely on the laboratory side of his practice, catering to a select few dentists.

But by 1887, business was so good that Dr Stowe opened a dedicated dental lab, which was later joined by his cousin, Frank F. Eddy (the lab was later known as Stowe and Eddy) and is widely regarded as the first commercial dental lab in America.

There have been many milestones in the past 150 years, but which decade has seen the greatest evolution? In the past 20 years we have seen remarkable advances, most of which convince industry leaders that was a key era in dental lab history.

“I’m going out on a limb here and not saying the 2000s; it was really the 1960s that brought about the biggest change in the dental lab industry with the introduction of CAD/CAM technology,” Starr says. “It literally revolutionized prosthetic design and production for many industries, including dentistry.”

Although dental labs have been around since the late 19th century, perhaps the biggest change has occurred in the past couple of decades—in terms of materials and equipment and the business of dental labs. “Probably there wasn’t a whole lot going on in the ’90s,” adds Conrad Rensburg, CEO and president of Absolute Dental Services, headquartered in North Carolina. “It was a lot more of the same. We had better ceramics, but the techniques still required using a lot of highly talented hands to fabricate the prosthetics. I think where things really started changing was after 2010, when we started seeing 3Shape come out, digital design came out, but I don’t think it was really until zirconia became a feasible restorative solution that things really changed in our industry.”

Analog tools are the bedrock of lab work, and it is no secret that although they are still used, the tools have become even more high tech. It is not just the gee-whiz factor of technology that makes things like CAD/CAM appealing. That technology makes the fabrication process more efficient, less expensive, and more consistent.

“Considering the evolution of analog tools over the past 30 years in the industry, I believe technology like induction-heated tools made a big impact and helped dental labs move away from the Bunsen burner,” Rensburg says. “That was one of the biggest shifts in analog tools in my time, in the early 2000s. That’s when you saw a lot of analog tool changes or improvements.”

The human touch is, of course, a valuable and essential part of lab work. However, the ability to automate and streamline processes showed CAD/CAM to be a seismic shift in lab work, having ushered in an era of faster, consistent, and more replicable work.

“Dental lab tools have evolved from traditional hand tools to high-tech CAD/CAM systems, digital scanners, and 3D printers, enabling precision and efficiency in prosthetic fabrication,” Starr says. “We still love analog and handcrafted restorations and [although] the hand tools aren’t as popular, there is still a demand for them, and they have evolved as well.”

From wolf molars to metal to zirconia, materials continue to evolve and advance. Although the current attention to materials tends to focus on CAD/CAM, Rensburg notes that earlier generations of materials and processes led to more esthetic results.

“The ’60s, ’70s, ’80s, and ’90s were all owned by layering ceramics, feldspathic materials, those kind of PFM [porcelain fused to metal] materials,” Rensburg adds. “In 2005, we started seeing zirconia, but it wasn’t really a contender probably until about 2015. And I think between 2010 and 2015, zirconia completely eradicated layering ceramics. So, surprisingly, there hasn’t been a whole lot of different materials. You had PFMs—which really ruled the world for 30 or 40 years—and now the next generation, or the current generation of materials, multilayer zirconia has eradicated layering. And the reason for this is it has a digital workflow. Layering ceramics does not have a digital workflow. You bring in a lot of analog processes and analog mistakes and human interpretation of the data, where as zirconia has eradicated that need for the ceramics to decide how far to build something.”

Materials continue to evolve. Milling and CAD/CAM are reductive processes, meaning a block or puck of material is placed into a mill and then pieces are carved away until the final prosthetic is produced. This is a wasteful, inefficient process, and Rensburg expects 3D printing to be the next phase of lab materials.

“The next revolution or evolution will be printable materials, printable polymers,” he says. “There’s a lot of new materials, like a new graphene that they launched at IDS [International Dental Show] in the spring. That was a big material. A lot of these things are still millable. It’s reductive technologies instead of additive. I’ll stick my neck out and say, within the next 5 years, you’ll start seeing the eradication of reductive technology. It’s going to be the next thing. Milling is slow and it’s dirty and expensive.”

But advances are not just in dental labs’ rearview mirrors. Technology continues to march forward. The latest advancement is artificial intelligence (AI). For example, dental AI company Overjet (

)—already used by many of the largest dental service organizations in the nation—saw growing demand from dental labs. In the laboratory setting, AI has transformed how dentistry operates by making restoration production more accurate and predictable, and Overjet has emerged as a powerful tool for dentists.

AI, like CAD/CAM, is an end-to-end solution, starting at the dental clinic before progressing to the lab, and it also provides the ability for streamlined in-office visits. Last year, Overjet launched a partnership with Glidewell to improve dental diagnoses for patients by enabling easier access to AI-powered x-ray analysis and clinical insights. Glidewell’s customers, such as dental practices, can tap Overjet’s AI technology to help dentists identify areas of concern, such as cavities, gum disease, and other dental issues. In addition, Glidewell uses Overjet’s AI to identify restorative treatment needs, enhance the patient experience, and strengthen the patient-clinician relationship.

In-Office Solution, which offers dentists everything they need to scan, design, mill, and deliver same-day restorations. The

In-Office Solution uses AI technology to create single-visit restorations made from BruxZir NOW fully sintered zirconia and other industry-leading materials. This AI-driven chairside CAD/CAM system gives clinicians full control over the restorative process and makes it simple to provide patients with high-quality, convenient treatment options while increasing practice profitability.
Ultimately, AI improves outcomes for better patient experiences. “Having a consistent and accurate clinical diagnosis is foundational to good patient care,” says Teresa Dolan, DDS, MPH, the chief dental officer at Overjet. “Crowns, bridges, and implant dentistry are more likely to be successful when the dentist accurately diagnoses the patient’s oral health status and develops a comprehensive treatment plan. Artificial intelligence can help guide that assessment and decision-making by providing quantified data. It replaces subjectivity with objectivity.”

In the lab, AI streamlines their fabrication process, making fabrication faster and more efficient. “I think we’ve already seen it with a single-crown design,” Rensburg says. “It’s made a huge difference for us. We use a lot of AI for single crowns. I think it’s going to get better with time. I do believe that AI will eradicate human digital design at some point. Not all of it, but I think at least 80% of it. So, the same as zirconia eradicated ceramics, I think AI will ease digital designers’ responsibilities.”

But, for all the talk about AI, there remains the need for a human’s eye and touch. As such, do not expect the computer to do everything—at least, not yet.

“I believe people are still needed,” Rensburg says. “Our artistry is now the final contour, the line angles, the labial anatomy; those little details are the fine-tuning that I don’t see computers replacing the human touch for probably the next 20 years. That’s very hard to tell, but I don’t see it, hopefully, in my lifetime. It’s changing so fast, but I think for the next 10 years at least, AI will make technicians’ lives easier. It’ll make us more efficient. It will reduce the amount of hand processes needed to do things, but I don’t think AI and technology will be able to replace artistry, not in the next 10 years. I think after that, it’s a free-for-all, but [for the] next 10 years, artistry is still alive.”

But for all the talk about the nuts and bolts of dental labs, it is important not to lose sight of the fact that labs are businesses, and the business of dental labs has changed in the past 150 years as well. “I think it actually became scalable,” Rensburg says. “Starting in 2010 onward—between 2010 and today—it’s become more of a business than an art form. I think before CAD design, before millable zirconia, highly esthetic zirconia, polymethyl methacrylate (PMMA), those kinds of things, everything was still pure artistry. It was very expensive. It was almost reserved [for] special technicians and the real artists [who] used ceramics as a canvas. I think after that, the playing field was leveled a little bit more, but I think the labs that still try to bring that artistry into the technology came out better on the back end. It’s more predictable, more consistent products. And I think although the artistry is not from start to finish anymore, the artistry is now applied on the back end. Before you send the case out, that’s when the artistry comes in.”

Dental lab workflows have certainly evolved, especially in the past 30 years. “When I started [in] this industry, I had to do the substructure,” Rensburg remembers. “I had to do the layering, then I had to do the contouring, and then I had to do the glazing. And that’s all done by computer now. And now the ceramacist or the contourer applies the final artistry before it gets glazed and stained and before it gets sent out. So, it’s become more of a scalable business. I think it’s more predictable and I think a little bit more of a business than the starving artist we used to be in the ’90s and 2000s.”

The dental lab industry saw a consistent, steady growth into the early 2000s. According to the US Bureau of Labor Statistics, there were 7863 laboratories and 49,597 employees that peaked in 2004. Unfortunately, since then, laboratories and employees have declined. By 2015, there were 6584 laboratories, a 16% drop from the peak in 2004. Further, the number of employees dropped by 10%. Factors contributing to that decline include globalization of the economy along with offshore laboratories, taking up to 40% of the work away from domestic labs.

Labs went from small studios (many of which still exist, of course) into larger endeavors. “In the beginning, it was small artisan studios. Dental labs have transformed into modern enterprises both large and small with a focus on customer experience, efficient workflows, and online visibility through platforms and social media, elevating the industry’s overall presence and professionalism,” Starr says.

In the grand scheme of things, dental labs are a fairly new industry. For example, Peugeot, founded in 1810, is the world’s oldest automaker. Even AT&T predates the first dental lab (only by about 10 years). Still, since its humble beginnings as a service provided to a select few Boston dentists by Dr W.H. Stowe, dental labs have experienced amazing ups and downs in terms of the equipment and materials they use, but also business. Progressing further into the 21st century, dental labs can expect even more growth, evolution, and opportunity.

What’s changed, from the workspace to the tools and everything else inside today’s dental laboratories.

Dental Labs by the Decade

Ghost of Implants Past. Image credit: © Dental Pro Content - stock.adobe.com

, Ebeneezer Scrooge is visited by 3 ghosts: the ghosts of Christmas Past, Christmas Present, and Christmas Yet to Come (technically, he’s visited by 4 ghosts, but Jacob Marley is irrelevant to this discussion).

Dental implantation—and the resulting patient care—can mirror the classic story: Learning lessons from the past can help improve future patient outcomes.

One of the most common implant problems, observes Catapult Education founder Lou Graham, DDS, is peri-mucositis.

“Peri-mucositis is inflammation in the tissue—without bone loss—around an implant,” he says. “The first identifiable problem would be bleeding on probing, bleeding on brushing around an implant. So if you know it’s a common problem, how do you avoid it? One solution to solve this issue is to place an implant with at least a minimum of 2 mm of keratinized tissue. So if a patient comes back to you and they have bleeding on probing and they do not have attached tissue, one of the immediate solutions is to have a tissue graft placed such that we can minimize the cause of lack of keratinized tissue.”

All too often, peri-mucositis can lead to peri-implantitis.

“Plaque accumulation happens faster around an implant,” Dr Graham continues. “And because it can happen faster, without proper keratinized tissue, further problems such as those described occur down the line. So in essence, they should be thinking about this before. Peri-mucositis can occur immediately, whereas peri-implantitis often becomes evident later on.”

As one might suspect, implants can be affected by other issues in the oral cavity.

“The literature for decades has shown that if other areas of the mouth have periodontal disease, then those bacteria can contribute to periodontal issues involving implants, again bringing us back to peri-mucositis as a precursor to peri-implantitis,” Dr Graham says. “Imagine you have an implant placed in the No. 19 area and you have periodontal disease in other quadrants of the mouth. That implant has a much higher chance of periodontal issues. So I think what dentists routinely do is only focus on the implant and not the overall condition of the mouth. My recommendation: Focus on the entire dentition.”

The first ghost took Scrooge back to his youth, a time when he had optimistic aspirations. That is also the case for implants. Patients and dentists have a vision for how dental implants can improve a patient’s life. Regrettably, sometimes that vision does not come into focus, especially as complications arise.

On the clinicians’ end, there are several factors that can come back to haunt a case.

“There are many, many factors that determine ‘successful’ implant placement,” Sam Shamardi, DMD, observes. Dr Shamardi is an American Board of Periodontology and Implant Surgery diplomate, faculty member at Harvard’s School of Dental Medicine Division of Periodontology, a member of Catapult Education’s speakers bureau, and the author of 

The Financial Survival Guide for Dentists

“It would be incorrect to assume 1 or 2 primary factors are all that it takes, as each case and patient situation is truly unique,” he notes. “That being said, some of the main factors for improper placement include poor initial planning, poor angulation, insufficient bone height/width, incorrect implant size/length choice, excessive heating of drills and/or using dull drills, improper site preparation, not taking radiographs during placement to confirm proper positioning and angulation, poor visibility due to poor flap management.”

The implant itself isn’t the only component that can lead to a less-than-ideal restoration. The appliance attached to it is also a factor.

“We’re talking so much about the implant itself, but there’s also the restorative component,” says Richard Lipscomb, DDS, a general dentist in Mitchellville, Maryland, and a member of Catapult’s speakers bureau. “How does the crown look or how does the bridge look? Is it in the right position? Does it look like it’s in the right position and is it functioning for the patient? Both of those things are important when it comes to an implant, as opposed to a regular crown and bridge. Because of the money and the time involved, patients’ expectations of it being a certain way are higher than anything else.”

The implant’s location can have an impact on whether the placement is negatively perceived.

“In the posterior,” Dr Lipscomb says, “the look of the restoration does not have to be perfect. In this area, we’re dealing with a larger missing tooth or missing teeth, and it’s more about function. In the anterior, it needs to be more Hollywood, because that’s what patients’ expectations are. When you’re dealing with teeth in the esthetic zone, you’re also dealing with implant placement with specific angulation requirements.”

Happily, we don’t have to wait for the future for things to improve for clinicians.

“Technology and software have come a long way, to the point of having the option for guided surgery and surgical stents that can significantly direct clinicians to place more accurately and with fewer risks,” Dr Shamardi says. “However, even then there is a chance for error—or even for poor guide fabrication—which doesn’t match up with the clinical situation. Thus, the dentist has far more chances of doing things ‘better’ now than before, but you still need a good grasp of fundamentals regardless of what experience level and technology.”

Nascent technologies and treatments improve over time and dental implants are no different.

“The hardware has gotten better and implant surfaces are far more streamlined now,” Dr Shamardi says. “However, knockoffs still exist that can be problematic. Original blade implants were a disaster and not predictable; on the flip side, the sheer number of implants placed today combined with the higher number of inexperienced clinicians placing them has created a situation where complications have also risen significantly and some studies quote 20% to 25% peri-implantitis after 2 years so despite better technology, we are struggling with more complications. Stricter standards on who can place implants would help; dentistry is an open border and there are no real guidelines or enforced rules to prevent clinicians with no surgical experience from placing however many they want.”

Dr Lipscomb observes that implants, historically, tend to be largely successful, but most problems tend to stem from overloading implants—too much load or too soon of a load.

“Implants have a high success rate,” Dr Lipscomb says. “And it’s up to the restorative doctor to manage the load placed on implants. Are we waiting 3, 4, or 6 months, a year? Are we putting on a single crown? Are we loading it up with a full-arch, fixed restoration? All those things play a part in terms of, did this implant fail because of poor placement or just overloading it? In most implant cases that fail, it’s the overloading and not so much poor placement.”

Implant restorations are improving, Dr Graham observes, because the 3 components comprising a restoration are in better harmony with each other.

“The machining of implants has gotten better, meaning the fit of the abutment, the crown and the abutment, the abutment to the implant. The machining has gotten better over decades,” he says. “There’s no question about it. So that fit is important because it minimizes bacteria. They continue to come up with different surfaces for faster integration.”

One of the best advances for dental implantation is improved imaging. Thanks to 3D imaging technology, there’s less guesswork in placement planning.

“Imaging is a big boost,” Dr Shamardi says. “Having 3D technology changes the planning and execution phase and has given rise to guided surgery and stent fabrication. Standard-of-care arguments are trickier, however. Cone beams are an expensive investment that not every office is able to invest in, and many patients still fear radiation even though CBCT [cone beam computed tomography] tech is very safe and shouldn’t be a major concern. Also, there are cases that are ‘easier’ and may not require all the extra bells and whistles, so saying it has to be used for every single case is a tougher case to make. Nevertheless, the information gathered from CT scans is invaluable and makes a noticeable improvement in overall outcomes.”

“Twenty-five years ago, we were using Panorex and radio-opaque markers to estimate bone levels and where to place an implant,” Dr Graham says. “Today, with CBCT technology, we can create ideal surgical stents for proper placement with the idea that placement is restoratively driven. In our practice, our implants are placed accordingly with surgical guides. We then know the restorative end point has already been treatment-planned into the placement, vs years ago when they were just placing implants in bone and then the dentist would have to restore it. As a result, we have far better angulation, far better placements today than we did 25 years ago. I know, many doctors feel that there are many times that guides may not be necessary, but as a restorative dentist, I can absolutely say, ideal placement is not easy without a guide.”

How Patients Live With Poorly Placed Implants

“One of the most common problems that can occur in as little as a few months is open contacts,” Dr Graham says. “Per Tarnow’s studies and others, open contacts can develop in up to 60% of implant casework. We have all seen them become bigger problems for our patients. We all have heard our patients comment about food impaction around an implant, and this often leads to gingival inflammation and/or adjacent tooth decay on the neighboring teeth. One of the solutions is to fabricate patients a retainer when you deliver your implant to minimize tooth movement. Another solution during hygiene visits is to utilize a product called Hybenx around inflamed tissue, around implants and natural teeth. We reviewed this product with our Catapult evaluators and this is a must-have in all of our practices as part of our treatment.”

Sometimes problems can be mitigated by replacing or adjusting the crown or bridge attached to the implant.

“Materials have gotten better over the years,” Dr Lipscomb says. “So now we can use a different material that could be stronger, better, and compensate for the issue with the lack of contact and trying to solve that problem.”

But in the grand scheme of things, it isn’t just the replacement where problems can arise. Patients must do their part, and it’s a good reminder for them to keep up on their at-home care.

“Patients live with horrific periodontal disease and decay far more and far longer than they do with poorly placed implants,” Dr Shamardi observes. “Management wise, there are considerably more options today than before. Too much attention is placed on the procedure itself and not on the management, which is really what makes or breaks the case over the long run. Once an infection establishes itself, it becomes a salmon-swimming-upstream situation and treatment and predictability are far less than they are with maintaining natural teeth, to the point some literature has mentioned reconsidering removing so many teeth in place of implants. That being said, we have numerous options from in-office air polishers and various biofilm-attacking gels and powders to at-home custom peroxide trays via Perio Protect, water flossers, implant-specific flosses, and mechanical brush heads. Thus, we have far more options and the key to success is managing the biofilm and doing whatever possible to prevent and/or minimize complications.”

Scrooge knew if he didn’t change his ways, bad things would happen. Happily, dentists tend to be more proactive than Ebenezer Scrooge was. Implant dentists are always on the lookout for ways to improve their care.

“The biggest difference with the implants that I do, which are small-diameter implants as opposed to traditional implants, is the size,” Dr Lipscomb says. “And when a small-diameter implant fails, we remove the implant, let everything kind of heal back in the soft tissue, in the bone. And then now we’re back to square one. Because they’re small, the space isn’t very big in the bone. It’s basically like taking out a tooth where with most teeth—medium size to small—we can just take out the teeth, then everything heals up and then we go from there in terms of what are we going to place. We’re going to place a regular bridge or we’re going to place an implant.

“But when you’re dealing with the traditional implant, which is bigger, it’s not a simple thing,” he continues. “I’ve got to take out the implant, then I’m going to have to do a bone graft to replace that space. So it’s never going to be a situation where I’m taking out an implant and then I’m just going to let it heal. It’s more involved because of the types of bone-grafting materials that we have now. I don’t feel that the specialists or surgeons or the periodontists shy away from that area because of a failing implant, meaning they’ll take the implant out, clean out that area, do a bone graft, and now we’re back to a new slate that can be ready for another implant. They’re of that mind-set. Now with that, the issue comes down to, OK, now that we have this new slate, what are we going to do?

“Are we going to change the angulation and are we going to change the type of restoration that’s going to go on top of this implant?” he continues. “Because we know that this was done in the past and it failed. So that’s something different moving forward. And that is going to either be a combination of changing the angulation, changing maybe the size of the implant, and then also changing the restorative options that were used so that it’s not going to be the same as the failed situation.”

If an implant case must be replaced, like so many other dental treatments, a number of factors go into its rectification, but the sooner treatment occurs, the better.

“Implant replacement rate of difficulty varies, again, case by case and depends on the situation, and the reason for the failure itself, along with how soon the problem is identified and treated,” Dr Shamardi says. “Earlier-stage intervention vs later makes a difference, and the source of failure [bacterial vs mechanical/occlusion vs implant fracture] also make a difference in terms of how the removal process will go. Implants that are heavily infected and mobile are easy to remove; those that still have anchorage may require further bone removal. All cases do require regrafting and reestablishment of bone support and some cases will require soft tissue as well; however, once fully treated and with proper healing time the sites can be reentered for a new implant. But there still have to be other considerations such as esthetics, for example, to take into consideration or possibly requiring sinus work. Thus, replacement can become a bigger ordeal depending on the case and, again, varies among many factors.”

“I would tell you that defining success of an implant is a variable,” Dr Graham says. “What is success of an implant? Is the success of an implant zero bone loss? Zero bleeding on probing? Total tissue health and no bone loss? And I would say that’s a successful implant. And then you get into, at what point is an implant a total failure? And a total failure, without question, is when an implant is loose. That is absolute, total failure and it must be removed. And the gray zone is how much bone loss has occurred before an implant really needs to be removed and replaced.”

Ultimately, Dr Graham observes that success comes down to 3 things.

“There must be enough bone, along with ideal connective tissue, and finally proper function,” he says. “All 3 must work for long-term success. In regard to a failing implant, one has to evaluate all 3 of the above factors and determine if the implant is salvageable or not. I feel one has to work closely with their specialist in such discussions [unless the general practitioner is trained in all phases of treating this themselves]. If removal is required, routinely, you’re dealing with an ongoing infection, and with such you’re not going to immediately place an implant back into an infected area. Once again, this may involve a potential temporary restorative solution and this is why you must work closely with your surgeon [unless you are performing both the surgical and restorative procedures].

“Ideally, implants would be optimally placed to begin with,” he continues. “But it doesn’t end there. Both patients and clinicians must maintain the implants for the long term. This is a team effort, both via the hygienist and the patient’s home care protocols. Again, knowing that implants have inherent risks necessitates great communication and planning with the entire dental team. Let’s take a common situation where a patient has areas of localized ongoing issues of bleeding on probing and has gone through periodontal hygiene procedures and potentially surgical and nonsurgical approaches, and yet they still have isolated areas of bleeding on probing and probings beyond 3 mm. We all have these patients in our practice, and the question is How best do we prevent further periodontal issues and, equally important, preserve the tissues around the implant/implants? One solution I have used for 8 years is a system called Perio Protect, and this is a system/product that both dentists and hygienists should be educated on. Perio Protect is a system based on [a Food and Drug Administration]–approved custom, lab-fabricated tray with a gasket-type seal. This seal is the key as it keeps a hydrogen peroxide gel in direct contact with the gingival pockets. By wearing these trays 10 to 15 minutes a day, you have a true oxygenation occurring within the pocket and those anaerobic biofilms are placed now in a far more defensive mode. Add sonic brushing and sonic flossing [Slate will redefine flossing] and you have now a far more preventive approach for your implant patients. One additional hygiene product to consider would be the water flosser, but we only recommend the plaque seeker tip. If you aren’t aware of this tip, Google it…it’s the only tip we recommend with the water flosser.”

Scrooge was haunted by the ghosts that visited him that Christmas Eve, each teaching a valuable lesson, leading to his ultimate redemption. Dentists heeding the lessons learned from poorly placed implants can help patients avoid their own nightmares.

Learning from poor past implant placements can help improve future outcomes. 

Ghost of Implants Past

How to Connect with Patients from Different Generations When Presenting Treatment Plans. Image: © 

It’s not hard to imagine an old caveman watching a younger caveman hunting with a spear and thinking to himself, “Kids these days don’t know how good they have it! Back in my day, we had to throw a rock at our prey, and we are grateful to have those rocks!”

Generation gaps are nothing new. While that distance between generations can be frustrating at times, it can be especially difficult when a doctor of one generation tries convincing a patient of a different generation to accept a treatment plan. Luckily, it’s not impossible.

Finding common ground is difficult enough when trying to accept another generation’s beliefs, behaviors, and preferences, but when one’s health is involved, it can be an especially tough sell.

“It is a challenge to connect with patients in general when it comes to treatment planning and presentation resulting in case acceptance,” Xavier Gardner, Director, Customer Success Operations at Planet DDS says. “Whenever you tell a person something is wrong with them, health-wise, it is a challenge. It is a unique skill for a clinician/treatment coordinator to be able to build rapport and trust with a patient where they can eloquently present a diagnosis in a manner that the patient can comprehend and accept.”

“Connecting with patients across the generational spectrum presents its unique challenges,” Diana McQuirter, DDS, Dental Director at Great Lakes Family Dental Group adds. “Each patient carries an individual canvas of experiences and attitudes toward dental health. Age certainly factors into this equation. We often encounter patients holding on to long-standing beliefs about dentistry, their perspectives shaped by decades of interaction with a particular dental office or dentist. So, as dental professionals, the onus is on us to delve deeper and ask incisive questions that help us understand their oral health, personality, and other dynamics at play that may influence patient communication and treatment plan acceptance.”

That disconnection isn’t always blamed on a generational divide.

“Connecting with different generations can be challenging, however, it is important to note that the difficulty is not solely attributed to an age gap, but instead surrounds education around a dental practice’s techniques, tools and technologies,” Russel Morrow, DDS, Chief Dental Officer at BIOLASE says. “Each generation has its own unique dynamic and characteristics that can impact how they communicate and engage with dentists and their care teams. It is my goal to provide each patient with the best quality standard of care, whether that is with conventional methods due to the patient’s comfortability or advanced dental laser technology for its quick and easy use, I accommodate each patient’s preference around their oral hygiene care. Once patients are comfortable, no matter the age, there is always a personal or professional aspect I can connect with them on, which improves the experience for everyone.”

Dr Morrow notes that those educational differences tend to manifest themselves differently in each generation.

“Although there are differences between generations and how best to approach as a provider, the only difficulties I face surround education,” he says. “There is an educational gap from where dentistry was 40 years ago to now, which explains most preconceived notions around dental treatments. For example, Baby Boomers may prioritize a more personalized experience and approach to care with some hesitation around new technologies, while Generation X may value efficiency and convenience, while being more receptive to advanced technologies. Millennials, on the other hand, may insist on prioritizing technology and transparency in their interactions with dental professionals. It’s also important to consider that each patient is an individual with their own unique experiences, beliefs, and values that can influence how they approach the dentist offices. Therefore, it’s essential to listen to each patient and tailor communication and treatment to their specific needs.”

Gardener observes that each generation has its own preferred treatment communication style, styles that can be helpful to learn.

“I think for some elderly patients, they would prefer to have a dentist who has experience rather than a recent graduate, but for others that don’t have a preference, it is more based on specific generations having their own dynamics which the office needs to cater to,” he observes. “For Baby Boomers, most of them have had something previously performed in their lifetime so it is more a matter of speaking in layman terms and being a bit more direct when trying to present treatment. Often, they prefer a cheap fix rather than preferred diagnosed treatment. For Millennials and Gen Z patients, it is more about patient education and overcoming objections related to financial and time restrictions (these generations are used to doing everything on their phone and are a bit less loyal to businesses as they can go on Yelp and find another one if they don’t like their experience), while feeling like their practice has state of the art technology.”

Whatever the style, Dr McQuirter observes that generational differences are dynamic; that is, what might be apt today may not be the case tomorrow.

“The key challenge doesn't lie in the generational gap but in understanding the evolving landscape of the dental profession and your patient's unique dental history,” Dr McQuirter says. “The tapestry of dentistry has seen tremendous advancement over the last half-century, both in terms of materials and techniques. When we understand a patient's past interactions with the dental world––both positive and negative––we gain invaluable insights that help us truly personalize treatment strategies.”

For instance, she notes that technology continues to change the face of dentistry.

“Patient expectations and preferences have evolved with rapid advancements in dental technology,” Dr McQuirter says. “As a dentist who has collaborated with a diverse range of colleagues, from seasoned professionals to new practitioners, I've discovered how generational differences offer unique opportunities to enhance treatment plan acceptance for both patients and dentists.”

What is the best way to reach across that generational divide to find a mutual understanding? For Dr Morrow, simply by virtue of the fact that he is in between generations gives him a trusted voice in each.

“I, fortunately, am in between an older generation and a younger generation,” Dr Morrow says. “This allows me to relate to both generations and their concerns while infusing new technologies, approaches, treatments, and procedures to their care. As the older generation may be used to a fearful and painful experience at the dentist, new technology that has come to light has allowed me to adjust their thinking and approach to certain treatments. Historically, root canals used to take around 4 visits, but since introducing BIOLASE dental lasers into my practice the procedure can be minimized to a single treatment. What used to be needles to numb, are no longer necessary as we are now able to enhance treatments with advanced technology, allowing for pain-free visits. This allows the younger generation to have instant results and a pain-free experience. This is causing a shift in the growing demand for the adoption of new technologies. Additionally, instead of outsourcing to an endodontist, this technology allows the patient to save time on appointments and money in their pocket. Overall, I think there is a fine balance between the generational gap, but half the battle is educating my patients so they understand the benefits and can have a better patient experience.”

Older generations may come across as technologically unsavvy, dismissive of modernization. However, those patients may be especially enamored with what’s new.

“When interacting with older generations, I've found that they often marvel at the technological strides we've made in dentistry when we are excited to tell them about it,” Dr McQuirter says. “Suppose you're taking over a practice from a retiring dentist who might not have kept pace with modern advancements. In that case, these patients could be experiencing dental technology, such as intraoral photos or scanned images of their teeth, for the first time. It's about presenting this technology with humility and confidence; otherwise, patients might misinterpret the rise in costs as unnecessary expenditures on flashy gadgets.”

And technology only continues to evolve and improve dentistry.

“Artificial intelligence (AI) has recently taken a front-row seat in patient communication, dramatically changing how we present our findings,” Dr McQuirter says. “For example, our team uses VideaAI from VideaHealth, which provides chairside AI x-ray analysis. Using a data warehouse AI Factory, the technology is constantly improving its algorithms, which have already been trained on 50 times more images than any dentist will see in their lifetime. This increases detection capabilities that help our team home in on potential areas that require further investigation and provide easy-to-understand visual aids for case presentation.

“The cutting-edge software in our scanners allows us to help get patients what they need faster,” she continues. “It stitches images together, fills in missing areas, alerts us when more data or adjustments are required, and even allows us to draw on 3D images to relay messages to our lab. If harnessed correctly, AI can be a tremendous boon in terms of time and cost efficiency.”

But while older generations may marvel at technology, the younger generations expect––and may judge you––by what you do and do not have.

“As for the younger, more tech-savvy generations, they are likely comparing your practice to others via social media platforms,” Dr McQuirter says. “Aware of the highly personalized patient education tools offered by other offices, they might be deterred by a practice perceived as ‘outdated.’

Listen and empathize: Genuinely listen to your patients, understand their concerns, and empathize with their experiences to build trust and rapport across generational differences.

Educate using technology: Use modern dental tools to educate patients about their oral health effectively. Intraoral photos and other visual aids bridge the gap between your knowledge and your patient's understanding.

Adapt your communication style: Tailor your communication style to each patient's preferences. Some may prefer detailed explanations, while others appreciate a more concise approach. Asking patients about their preferred communication method is the fastest way to build connections.

Showcase your expertise: Share "after" photos of completed restorations to demonstrate your skills and the benefits of the treatment plan. This step builds trust and motivates patients to invest in their oral health. Train dental assistants to always take pictures after restorations for efficiency.

Emphasize prevention: Promote the importance of prevention and early intervention to patients of all generations. Explaining the advantages of modern techniques and materials increases treatment plan acceptance and encourages patients to prioritize their oral health.

“The root of these difficulties often lies in inadequate patient education from the dental team,” she continues. “Incorporating AI into our practice necessitates the entire office's shared enthusiasm and motivation. For example, when we demystify AI and explain to the patient what we are doing when we scan their teeth, I've found that most patients are genuinely impressed. As we gain experience and engage with more colleagues, we develop more concise, clear explanations to use with our patients, which can help alleviate fears and misconceptions about AI and who we are as dentists. This is especially relevant when we meet patients for the first time.”

While technology does a lot of heavy lifting toward case acceptance, interpersonal skills remain king.

“Establishing trust with patients is a critical aspect of dental care,” Dr McQuirter says. “Patients either trust a long-term dentist or require a new provider to make a connection. Actively listening to patients, understanding their perspectives on oral health, and learning about their past dental experiences is essential in guiding our approach to care. Often, patients leave their previous dentist due to feeling unheard or being ‘sold’ something they didn't want.”

Technology, especially AI, is a great tool for the clinician, but don’t lose sight of its use as an educational tool.

“From a software standpoint, some items that come to mind for younger patients that are differential,” Gardener says. “AI for imaging is a form of patient education to enhance case presentation/allows AI to underscore the need for treatment; sending electronic treatment plans via text or email, consent forms, payment portal links help attribute to patients saving time in the office; the ability to create a payment plan to provide more financially flexibility for patients to accept treatment and pay monthly via card on file or via third party financing options (ex. CareCredit); and online appointment booking allows them to easily book their appointment once they have agreed to the treatment.”

As with anything in life, money talks. No matter the generation, effectively communicating, the true costs of a treatment plan are essential.

“When it comes to cost and financial considerations this can certainly impact the communication,” Dr Morrow says. “It is important to be transparent about costs and payment options upfront to help patients make informed decisions about their care. Some patients may be hesitant to accept a treatment plan such as dental lasers due to the preconceived notion that it might be more expensive. This is why taking time to answer questions and discuss options with patients is so key. Often, after a few minutes patients are receptive and eager to move forward, especially once they understand that doing treatments in-house and not outsourcing to specialists, saves them money and time. It is crucial that we detail the small print to patients so that they are comfortable, and rest assured knowing they are receiving the best possible care.”

“Transparency and consistency are the bedrock of my approach to treatment planning,” Dr McQuirter adds. “I aim to develop plans that another dentist or hygienist would perceive as thoughtful and well-informed. I believe in establishing a precise diagnosis before proposing any treatment, which provides the patient with a rationale for our recommendations. By attentively listening to the patient's desires and constraints, we often can present them with viable options that align with their budget.”

AI can be used to leverage their work performance and communication.

“Setting the expectation for younger dentists to anticipate their work - be it crown preparations or fillings - to be displayed on large screens in front of their patients will prepare them for an impending shift towards more comparative assessments of dental work,” Dr McQuirter says. “Accurate coding of procedures, utilizing AI to ensure nothing is overlooked or needs adjustment before the patient leaves, and maintaining a transparent dialogue with patients are key elements in this transition. If properly adopted and integrated, AI has the potential to be your most valuable investment, driving significant improvements in efficiency and patient satisfaction.”

Ultimately, however, it all comes down to communication and the interpersonal skills between clinician and the patient.

“No matter the generation, people all want to know that you care about them and that you are treating them in the best possible way,” Dr Morrow says.

“Generational differences play a role in treatment plan acceptance in dentistry,” Dr McQuirter adds. “By understanding our patients, leveraging modern tools, and emphasizing prevention, we can overcome these differences and provide the highest quality care to individuals of all ages. Optimizing AI's potential in our dental practices can lead to significant savings in terms of both time and money while enabling better patient care. Together, we can advance the field of dentistry and create lasting, positive impacts on our patients' oral health. An individualized approach helps patients understand and accept your treatment recommendations, ultimately achieving the best outcome for each patient.”

Generation gaps have existed, forever, and likely will persist into the future. understanding the differences between what patience of different generations want and expect can help the doctor and acceptance for his or her treatment plan.

Every generation has a different set of expectations and needs from their clinician. Here we discuss some of the best ways to bridge this generational divide to best treat patients of all ranges. 

How to Connect with Patients from Different Generations When Presenting Treatment Plans

Although endodontists make their best faith efforts to relieve patients’ pain as quickly as possible, they may not be able to do it fast enough. The treatment may take time to heal or, even worse, they may not be able to begin treatment right away. In either case, endodontists have a number of tools at their disposal to help make those patients more comfortable.

Sometimes it is simply not avoidable. Even in the face of agonizing pain, some patients may just have to wait for their ultimate treatment and can only be seen for an initial visit.

“Generally, what will happen is endodontists or oral surgeons or specialists––or general dentists who are making time to see patients for emergencies––sometimes [only have] enough time for an emergency visit,” Nicholas Pappas, DDS, MSD, an endodontist from The Woodlands, Texas, says. “When I make my schedule, I have certain spots for emergencies, certain spots for treatment and evaluation. We do our best to be able to accommodate any type of emergency. However, if we cannot see a patient immediately, we are trying to see that patient the following business day. So from my personal experience, if we have a patient [who is] in pain, the longest they’re waiting is a business day.”

However, some practices make every effort to deliver treatment, in an effort to help patients alleviate pain.

“It’s our practice’s philosophy that if somebody comes in in extreme pain, I’ll never turn them away without providing some type of help,” Ryan M. Walsh, DDS, MS, Diplomate of the American Board of Endodontics, and endodontist at Advanced Endodontics of Texas in Keller, says. “And most of the time that involves initiating treatment of one type or another. If it’s something where the tooth is going to be clearly extracted, most of the time I will call an oral surgeon or…the referring dentist and let them know, ‘Hey, this has to be extracted right away.’ Rather than me starting any treatment, let’s get to the endgame first. But what you have to first determine is where the pathology’s coming from––or where the pain’s coming from. Is it an endodontic infection? Is it a periodontal infection? Is it an infection at all? Is it just an inflammatory response? Is there deep decay? Is there a crack or a fracture causing it? …Those things could change the way I manage this patient and/or help determine what’s the best course of treatment, long-term, and the best course of treatment, short-term.”

Patients can present with several pain profiles, any of which call for a different pain management regimen.

“From an endodontic perspective, it is important to diagnose the source of a patient’s discomfort,” Dr Pappas says. “For example, irreversible pulpitis, nerve pain, can be manageable if you’re keeping stimuli away from it, meaning we’re not eating ice cream, we’re not drinking cold water, we’re not chewing on that side. When there’s possible necrosis, that pain might present as the dull, constant ache. Spontaneous discomfort––pain that wakes a patient up at night––that typically is not going to be something that you can manage by taking away a stimuli…. The problem with necrosis is that that pain can be constant and can’t be turned off.”

The most obvious way to treat pain is through medication. It may be something as simple as analgesics, nonsteroidal anti-inflammatory drugs, or it may be as potent as an opioid. However, Dr Walsh prefers opioids to be the last thing he prescribes.

“I try to use opioids as the last line of defense, because I think so much pain can be treated and managed without it,” he observes. “Our leading pain experts suggest that over-the-counter medications work better than opioids in controlling endodontic pain. So being able to use something that has no addictive potential, has no intoxicating or mind-altering effects, and treats endodontic pain more effectively, that’s a win-win.”

That’s not to suggest that opioids don’t have their place in reasonable pain management strategies, but given the effectiveness of over-the-counter medication, opioids tend to be the last thing suggested.

“I still prescribe opioids in cases where, if it’s an acute apical abscess or an acute infection, the pain has not been controlled with over-the-counter medications,” Dr Walsh says. “I still think there’s a time and place for opioids. I just think we have to be selective about when we use them, as opposed to using them as our first line of defense.”

No matter the protocol, it all starts with knowing the patient and his or her needs––and their history.

“Generally, when we prescribe medications, it’s usually when we’ve seen the patient and completed a proper medical history,” Dr Pappas says. “I feel it is important to see a patient and prescribe a regimen that is appropriate for their medical history. Secondly, it’s important to administer the right medication for that diagnosis. For example, if we have a case of irreversible pulpitis where the nerve is vital, an antibiotic is not necessarily effective or necessary. Now, if we diagnose the nerve as being necrotic, an antibiotic could…be indicated if there’s a sign of swelling or fever, et cetera. Generally, what I like to start with is over-the-counter medications, specifically acetaminophen and ibuprofen. [Results from] recent studies have shown that a combination of acetaminophen and ibuprofen, when taken together, can work as effectively as an opioid. So as we try to scale back our prescriptions of opioids, we’ve actually found that over-the-counter medications, when taken together, have extremely potent effects.”

Painkillers are not the only medications used in the quest for pain management. The problem is a war that must be waged on several fronts.

“I would not say antibiotics are used for pain management, per se,” Dr Walsh says. “Antibiotics are used as the name would suggest––to help reduce bacteria in the body. I think there’s a time and a place for those in endodontic treatments as well. I think of endodontic pain as having a triad of causes and a triad of treatments. In other words, we have bacteria (or we potentially have bacteria), inflammation, and pain. And so, if we can effectively manage the bacteria and the inflammation, both by treating it endodontically and by using over-the-counter [medications], most of the time the third leg of that triad, the pain, is controlled all on its own without really having to use a lot of pain medication to control it. So if we can control the sources of the pain, it usually is much more manageable.”

Regrettably, endodontists must be on the lookout for drug seekers. Fortunately, it is not as prevalent a problem as it used to be.

“Drug seeking is still out there, but I’ve seen it diminish over the past 5 to 7 years, probably because of internet-based tracking software,” Dr Walsh says. “For instance, Texas has a pharmaceutical management database where we have to enter the patient’s name and other identifying information to see how frequently and how often they’ve been prescribed medications from other providers. So by going to these digital platforms, I think that kind of puts dentists in connection with physicians who may also be prescribing and when.”

Obtaining pain medication from an endodontist, Dr Pappas observes, may not be drug seekers’ first choice, because access to endodontists is not an easy route.

“Endodontic offices are generally not the first thought in a patient’s mind when experiencing dental pain,” he says. “Since most of our patients are sent via referrals, it can be fairly laborious for a drug seeker to end up in our chair. Therefore, most drug seekers are looking for easier access, such as walk-in clinics and urgent care facilities . So I personally do not see much drug seeking; however, it does happen.”

Medication isn’t the only tool that can be used to mitigate patients in pain.

“I'll look for pain that’s caused by a certain stimuli, meaning patients complain of pain while chewing or when drinking cold water,” Dr Pappas says. “My first step would be to try to avoid any of those stimuli. Sometimes there’s pain associated with swelling or fever, so in certain cases, cold compresses can help just relieve discomfort. But generally, there’s nothing better than getting to our office for definitive treatment as soon as possible.”

Of course, the best way to alleviate pain is to remove the source in the first place.

“We take as kind of a hallmark of our practice that if you’re in pain, you will get treated that day, not just managed,” Dr Walsh says. “One of the things we have at our disposal is local anesthetics to numb the location of the pain, which not only helps the patient feel better, but sometimes can break the pain cycle and allow them time to get more over-the-counter medications on board to effectively manage the pain when it returns. Sometimes even breaking the pain cycle, allowing the patient to get some sleep and some mental recuperation, will help in the pain management protocol.”

Ultimately, it is in the patient’s best interest to deal with their problems sooner rather than later, which can prevent a small problem from growing into a big one.

“From a practice management perspective, we’re built for emergencies,” Dr Pappas says. “So sometimes a little bit of hesitation can just delay the patient getting into the chair. Always feel free to give us a call, because definitive treatment cannot be administered until I have seen a patient. So the sooner we get involved, the sooner we can help.”

Dental pain can be torturous, and endodontists see a lot of it. Happily, they have many tools at their disposal to help patients alleviate their pain.

Dealing with dental patients who must wait for treatment.