Terri Lively

During the COVID-19 pandemic shutdown, which necessitated a change to business as usual and closed many dental practices to all but emergency care, online continuing education (CE) programs flourished. Dental education companies had surges in participation in their online offerings that they never had seen before. Even after restrictions lifted and many practices reopened for routine patient care, online CE participation has remained high.

However, as the vaccine rolls out and travel restrictions begin to lift, will online CE become the standard? Here’s what some dental education experts have to say about what they saw change during the pandemic and what the future holds for CE.

Philip Klein, DMD, CEO of Viva Learning, says his company has been seeing an upward trend in online CE engagement for some time. However, he says that although the closure of live CE events brought attention to Viva Learning’s program, the quality of the company’s premium content qualityis what maintains their numbers.

“We’re seeing average attendance at our CE webinars more than double, and month after month registrations on our site continue to rise,” Dr Klein says.

In late February 2020, Dr Klein says Viva Learning began a significant effort to create high-quality online CE programs that focused on COVID-19 and the dental practice. The Viva Learning team worked with top dental educators in infection control and launched more than 25 hours of training for the year, including CE webinars and podcasts.

“Dental professionals consumed it at a rate we’ve never seen before. I’m talking 2000 to 3000 attendees on a webinar and thousands listening to the podcasts. New Viva accounts were skyrocketing at a rate of [more than] 10,000 new users per month. Our efforts proved successful in disseminating critical COVID-19 information—during the height of uncertainty and fear—in a simple to understand, easy to access format,” Dr Klein says.

Dr Klein says this strategy grew Viva Learning’s user base to almost 300,000 users, including GPs, specialists, dental hygienists, assistants, office staff, and dental sales representatives.

“It is currently the most highly visited dental CE site in the world,” Dr Klein says. “Dental professionals realize that there are real benefits to taking their continuing education online.”

Lou Graham, DDS, founder of Catapult Education, is the clinical director of Midway Dental Supply, a dental distributor that also has an educational platform. Dr Graham says the pandemic necessitated that the 2 companies create a significant shift from predominately live programs to unique online formats.

Midway Dental, which hosted numerous monthly programs at its Midway Education Center sites before the pandemic, shifted 100% to an online platform. Midway Dental also created a 20-minute live interview program called “The New Norm” with Dr Graham speaking to various industry professionals, particularly on COVID-19–related dental subjects. The show gathered thousands of followers with its biweekly broadcasts, he says.

“There were so many things happening all at once that the show, in a sense, brought some reality to the ongoing changes,” Dr Graham explains.

Catapult Education also made significant changes to its speakers’ platform. Before the pandemic, Catapult’s 25-plus speakers were presenting at more than 400 live events nationwide.

“In an instant,” Dr Graham says, “all live events were shut down, as were our practices.”

Like Midway Dental, Dr Graham says Catapult Education had to change its platform to a combination of traditional webinars and unique 3-hour symposiums.

“Now, with 50,000 YouTube followers on our channel and growing monthly, there is no doubt this shift is constantly expanding,” Dr Graham says.

Catapult’s core speakers, along with additional outside speakers from the United States and abroad, designed an educational experience Dr Graham describes as interactive and informational. With a moderator hosting 3 to 5 speakers, presentations are 30 to 45 minutes long and focus on specific subjects with a Q&A closing panel discussion. Dr Graham says that questions came flying in, making the symposiums fun.

“Doctors and teams want to interact, and we must provide the formats to allow it. This format is a new way. People lose their attention span when it’s multiple hours of the same person presenting online. It’s tough to hold an audience,” Dr Graham says. “The manufacturers love these symposiums that we’ve done because the audiences are very involved, and it’s a great learning experience.”

“A full day of digital can be a huge challenge when it comes to implementing adult learning styles,” says Dawn Gregg, DDS, training director for Millennium Dental Technologies.

Dr Gregg says CE had become more automated, less personal, and less “connected.” Platforms since have evolved, becoming more secure and offering opportunities for interaction via chat function or microphone use if the presenter or administrator allows, she says.

Online CE became popular, Dr Gregg says, when offices closed and doctors had more time. She says individuals who typically would prefer in-person CE were “thrown into a technology world” and adapted quickly.

Without a doubt, online CE was the necessary standard for 2020. But will it remain so after the pandemic passes? Dr Klein thinks so.

“In my mind, the pandemic brought online CE to the forefront of the profession, especially for those dental professionals who had not yet experienced e-learning. Now, many of those folks see the benefits and the value and will continue to rely on online CE going forward,” Dr Klein says.

Dr Klein says that the convenience and efficiency of the online model are appealing to dental professionals. Viva Learning offers a plethora of timely dental information, he says, and users can search content by keywords, dental topics, or speaker. The content, which includes podcasts, videos, and live interactive webinars, is available from any device at any time. Dental professionals can listen, watch, or participate in a live event and earn participation and self-study CE credit.

“When you compare that with taking time away from your office, driving to a location where you have to park your car, and everything else involved with traditional in-person CE events, the benefits of online CE are pretty clear,” Dr Klein says. “Of course, there is always a need for hands-on programs that require in-person attendance, but, for the most part, online CE just makes more sense for most dental professionals.”

Dr Graham has a different take based on what happened last year. As Midway Dental was hosting 

 and Catapult was ramping up its symposium-style education programs, there also was a deluge of free CE onlineDr Graham says . People could spend up to 8 hours a day getting CE credits. He says a lot of it was good, and some of it was redundant. However, Dr Graham says that by June people were tired of webinars that were 45 minutes to an hour long.

Jody Rodney, vice president of marketing and education at Planmeca, agrees that online CE leaves a little to be desired. She says that there is a craving for in-person interaction. Planmeca’s digital academy shifted from 100% in-person to 100% virtual continuing education at the beginning of the shutdown. Like Viva Learning, Planmeca also had unprecedented attendance numbers at their live, virtual programs at the beginning of the pandemic, often with participants numbering in the thousands. However, as soon as they could, Planmeca returned to in-person training to meet the demand.

“Honestly, everybody had a little bit of cabin fever,” Rodney says. “And for those who were willing to risk it, they were ready to travel.”

Rodney says the pandemic made her team much more adaptable. At the beginning of returning to in-person education, they learned the importance of versatility, mainly when last-minute changes to guidelines affected in-person events. Without a backup plan, these changes caused a lot of stress for the team.

“Now we’re much more proactive and we’re planning for multiple scenarios,” Rodney says. “If the guidelines change and we know that we can only have so many people in 1 room, we can have a plan B and have additional facilities available for the customers.”

Rodney says virtual training is still available and Planmeca continues to optimize it. The education team instituted self-guided work the participants do before the virtual training session. Rodney says the pretraining work kickstarts the learning process. To respond to clinicians who want more training in specific areas, Planmeca offers 1-on-1 sessions with clinical specialists after the virtual training. Rodney says it gives practices a chance to focus on areas of technology where the end-user doesn’t feel comfortable.

“We’re doing more planning and building to help them be more prepared, especially in those virtual environments where we can’t be there. We can’t watch them scanning, designing crowns, or positioning the patient, so you have to be more flexible and adaptable and more available to them,” Rodney says.

Rodney says Planmeca prefers to offer in-person training. Planmeca’s customers agree. Rodney says the virtual training is not requested as much as the team at Planmeca anticipated outside of specific areas with strict travel guidelines. Practices still want the team to train them in person, and Planmeca is happy to do so.

“The biggest thing that we want is to adapt and try to provide as many personal interactions with the doctors as possible because they want it. We want it. We’re humans,” Rodney says.

Dr Gregg also says their training relies on in-person, hands-on, synchronous learning to teach the LANAP® protocol for treating gum disease. The training benefits from real-time faculty-participant discussion, peer interaction, and active participation to teach the surgical procedure.

“What we have found over time is that to make our training successful—as evidenced by positive, reproducible, regenerative patient outcomes—the training has to be done in person, not on a CD-ROM, not on Zoom, and not even on pig jaws,” Dr Gregg says.

Dr Gregg says Millennium discontinued in-person training until pandemic-responsive protocols could be developed and implemented. While the training was on hiatus, Millennium launched “Webinar Wednesday,” a series offering free CE on a variety of topics.

“We also launched podcast series to round out our online presence and create more engagement. While this wasn’t CE, it is storytelling and adding a human connection that is missing from a lot of CE platforms,” Dr Gregg says.

Millennium was the first live-patient training center to reopen. Dr Gregg says this meant increased safety protocols in the classroom and the clinic when treating patients. In addition to the usual COVID-19 social distancing, personal protective equipment, and screening requirements, the company upgraded the air purification during lectures, included new high-volume evacuation units, and added PECO and ultraviolet air filtration systems in each operatory.

“Being in Southern California, our restrictions have continued at a higher level than many other parts of the country,” Dr Gregg says. “We continue to survey doctors about their comfort level regarding the precautions taken during training. Most respondents are very comfortable with the precautions we have taken and have no concerns about the live patient treatment.”

Dr Gregg says that online CE has both advantages and disadvantages. The on-demand feature makes online CE convenient for dentists and easy to share on a global platform. However, some instruction cannot be done online, such as the surgical training they do at Millennium, which requires tactile learning.

“Surgical training on live patients still needs to be in person for immediate clinical feedback and adjustments. Though surgical demonstrations can be done using online platforms, the Institute for Advanced Laser Dentistry uses live-patient treatment where the instructor imparts proper hands-on muscle memory to the student. This cannot be done remotely,” Dr Gregg says. “Using laser light to modify tissue has a different tactile sensation than traditional hand instruments. This must be felt with one’s own hands to be fully understood and internalized. Viewing a demonstration online doesn’t suffice.”

Mark Hyman, DDS, MAGD, an adjunct full professor at UNC Adams School of Dentistry in Chapel Hill, North Carolina, and an international speaker for the dental industry, agrees that in-person learning is better than virtual. Moreover, his best learning experiences happened in person.

“When you’re in a class lecture room with your colleagues, and people are shoulder to shoulder, and there’s the energy and the vibe, and you are focused and dialed in, you learn dramatically better,” Dr Hyman says. “Some of the best learning in my life has been at dental meetings and then talking to people after the lecture and going to the exhibit hall and test-driving things.”

Dr Hyman’s love of teaching in-person influences his opinion about online learning in part. Dr Hyman estimates that he spoke to more than 30,000 people last year on Zoom, but he says teaching 82 students in person at the dental school was far more rewarding.

“I loved it. I love the eye contact. I love the sharing and the participation,” Dr Hyman says.

However, he doesn’t think virtual CE is all bad.

“For someone who doesn’t have access to in-person CE and for young professionals, virtual learning is a fantastic start to education,” Dr Hyman says.

Dr Hyman also appreciates how dental organizations and companies, including the American Dental Association to Jameson to The Pankey Institute to Spear Education, all made their information available online with podcasts and webinars during the shutdown. Many dental professionals took online courses during the shutdown they would never have had the time to take during regular practice.

“We took lemons and made lemonade,” Dr Hyman says about online CE during the shutdown. “Virtual learning is here to stay, but I guarantee you it cannot be as impactful as in-person learning. We are a profession that needs hands-on learning.”

For 2022 and beyond, in-person CE programs will resume, but Dr Klein thinks there will be fewer of them. He believes study clubs will thrive because dentists enjoy in-person discussions, collaboration, and social activities with their colleagues. Also, Dr Klein sees value in hands-on programs because it is important to attend in person when it comes to using new technologies and equipment. However, Dr Klein also sees a future where technology improves to the point that online CE can accomplish many of these things.

“No doubt, the world of dental CE has changed forever, and online CE will be the predominant way the entire dental team maintains their professional development and continuing education,” Dr Klein says.

Dr Gregg says that the future of CE will be in-person or online based on the topic. She believes advanced training on implants and periodontics, which requires hands-on learning, will rebound to in-person but that basic courses and top-level learning will stay online. However, the overall formula of CE at trade shows may not return to what was before the pandemic.

“When you combine the younger generations’ preference for online learning and comfort level with technology with this huge shift of all companies providing online education, there will be a significant amount of people who don’t want the extra expense involved in traveling for basic types of CE,” Dr Gregg says.

Dr Graham also doesn’t think online CE is dead. He says that dentistry will look back and see that the pandemic created a huge shift in virtual education—and it’s just beginning.

“There are many great formats of online education, and they can come in subscription platforms, as 1 example, or an approach that uses a combination of physical learning materials that come to registered users who learn online like college students do today,” Dr Graham says. “We are dentists, we love to touch and feel what we are using, and this will absolutely be offered more and more in online programs.”

However, Dr Graham also sees the limitations of online education.

“It’s tough to entertain, teach, and keep a crowd when you have no interaction,” Dr Graham says. “So, I don’t think that will be the future. I do not think people will want to sit in front of their computers for 6 or 7 hours and listen to 1 speaker at a time.”

In addition, Dr Graham thinks that all-day in-person programs will change. In-person sessions will be offering more hands-on components with the lectures because listening all day to 1 speaker, he says, leads to the question, “Who stays after lunch?”

“The future will also be blended,” Dr Graham says, “with learning live and online mixed together in many different formats.”

Dr Graham sees the future of blended learning taking a modular format. The first mode would be a live course. Then, once dentists complete the live class, the next series would be online modules with the same attendees followed with community learning. The community learning would be led by 1 of the module speakers.

“Community learning will be considerable because now you could have a group of 50, 100, or more doctors learning and sharing their cases and experiences,” Dr Graham explains.

Another significant change to CE’s future is snippet learning, which is facilitated by technology and artificial intelligence. Dr Graham says that people want quick hits of information. Catapult is creating fast, 2-minute lessons on different topics to capitalize on this interest. Then, based on cookies collected by browsing history, Catapult will push these snippets out to dentists interested in the various topics. The program would then make a recommendation for further education courses. Snippet learning could also direct dental professionals toward speakers they like, Dr Graham says.

“Snippet learning is a huge thing. It will be big on Facebook and other social media. It’s like a mini-YouTube, and you’ll see a lot of that coming down the road,” Dr Graham says.

Dr Graham sees these blends of live and online learning modules facilitated by communities driving CE’s future, particularly with younger doctors. Millennials want to do CE when and where they want. As this generation of dentists takes over dental education, Dr Graham says they will want blended learning.

Even before the pandemic hit, Dr Graham and other Catapult speakers saw these changes in preferences. As speakers, they routinely saw dentists 50 years and older in their audiences, but not the next generation of dentists. He thinks the changing balance of demographics and younger dentists with different family responsibilities and work schedules will influence how dental professionals get their CE. Dentists see the benefits of online, blended learning at their convenience rather than attending full-day, live programs, and the industry has been preparing for it. Moreover, the past year accelerated the transition to the new way of delivering CE.

“You are going to see huge changes in dental education that have been fast-forwarded because of the pandemic,” Dr Graham says. “You are going to see that if you want to learn implants, you are going to learn them live and online. You are going to learn dental sleep live and online. That’s going to be, without a doubt, the future of where we’re all going together.”

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The way dental professionals earn their continuing education credits changed during the COVID-19 pandemic. But will the change be permanent?

Will Online CE Become Standard?

The materials for same-day dentistry have changed, and these advances are increasing the care that can be delivered in a single day. Here, we take a closer look at what materials clinicians can use for same-day dentistry, what these materials make possible, and what materials are coming soon to the industry.

Various materials are available for use in same-day dentistry, says Alex Kalmanovich, DDS, ABDSM, a dentist in private practice in Laguna Beach, California. These material types include glass ceramics, resin nanoceramics, zirconia, ceramic composites, ceramics, and resin composites.

Nathaniel Lawson, DMD, PhD, director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry, says these materials can be divided into 3 categories:

 The original glass-based materials were not too different from porcelain but were slightly more robust. The material that revolutionized CAD/CAM is milled e.max® (Ivoclar Vivadent), which is lithium disilicate. Lithium disilicate is a strong, glass-based material with the esthetics and bondability of ceramics that can be milled and crystallized in-office. Although e.max was the first, other brands of lithium disilicate materials are now available—likely without a significant compositional change from e.max.

 Another class of less-used milled materials is resin composites. These are similar to direct-filling materials, meaning they contain glass or ceramic fillers within a resin matrix. Still, same-day dentistry resin composites are optimized for in-house milling. Resin composites are heat and pressure cured and then given to the CAD/CAM dentist as a milling block. This polymerization process enhances cross-linking, which improves mechanical properties. The advantage of this version of resin composites is that they are softer, making them easier to mill. Another advantage is clinicians can repair them with composite. Also, because resin composites don’t need crystallization, clinicians can make them faster. However, resin composites for same-day dentistry do not have the strength of ceramics, and the bond achieved is not as reliable.

 One of the more recent entries into same-day dentistry, zirconia is a polycrystalline material, which means it doesn’t have glass in it. Many everyday items—from dishes to lighting—contain zirconia.

Unlike the fabrication method used for glass-ceramic or resin composites, zirconia is milled in a chalky form and then sintered in a furnace at a higher temperature than what’s used to crystallize lithium disilicate. It is tougher than lithium disilicate, which allows it to be cemented with conventional cement. However, zirconia does not offer the same aesthetics as lithium disilicate, and the clinical evidence is not as robust for the bond between zirconia and resin cement as it is for lithium disilicate.

“Probably the biggest advancement in milled materials that has occurred recently is the availability of in-office zirconia crowns,” Dr Lawson says. “The reason that zirconia could not be fabricated in-office previously is that it would take 8 hours to sinter in a furnace. So, the real advancement was a new furnace that could sinter zirconia in 18 to 30 minutes.”

Jeffery Rohde, DDS, MS, practices same-day dentistry in Santa Barbara, California, and says he likes lithium disilicate because it delivers excellent esthetics and flexural strength. He prefers e.max because it is an easy material to use, contains no metal, and is biocompatible. When he describes it to patients, he says it mimics enamel.

“The phrase we use is, ‘It’s like we are putting a little shell of enamel back on the tooth,’” Dr Rohde says.

If he needs more strength, he looks to the Katana™ product line (Kuraray Noritake Dental). The material comes in a variable translucency block, which he says is similar to the Empress CAD Multi blocks (Ivoclar Vivadent). The opaque base gets more translucent vertically as you approach the incisal edge. Dr Rohde appreciates how the Katana zirconia material allows the light to interact the way it would in a natural tooth.

The Katana Zirconia line from Kuraray Noritake Dental.

“Katana is very translucent, so the light can enter the tooth and play around in the material, and [it] mimics enamel,” Dr Rohde says. “I would have no problem putting this material in the anterior. It requires a little more staining and glazing or dipping, but it would look great. And instead of 4 times [the strength of] enamel, it’s 10 times in terms of strength.”

One material that has Dr Kalmanovich's attention is zirconium oxide. He says it has become a popular material in recent years due to its superior flexural strength. Also, clinicians can cement zirconia restorations conventionally, making the cementation process simpler.

“In the past, [although] zirconia restoration materials had great properties in terms of strength, the material lacked the beauty and lifelike feel and look of the glass-ceramics. However, in recent years, companies such as Dentsply Sirona and Kuraray Noritake have worked on developing great products that improve the esthetics of zirconia restorations,” Dr Kalmanovich says.

Manufacturers package same-day dentistry materials in blocks, which has practical benefits. The blocks’ fine–particle-sized microstructure helps resist machine damage, improve mechanical properties, reduce polishing time, and increase the wear resistance of the restoration.

Dr Kalmanovich notes another practical benefit of block-form materials. “Same-day CAD/CAM dental restoration materials are manufactured in monolithic form, which decreases the risk of chipping,” he says.

Dr Kalmanovich adds that it’s crucial to use a material indicated for the intended restoration type and placement and to be aware of the proper preparation requirements for the chosen material to ensure there’s room for adequate material thickness.

“Keep in mind some materials require specialized firing protocols in a dental oven as well as specific polishing procedures,” he says. “Make sure you have the equipment and supplies you need to use the block you choose. Also make sure you follow the manufacturer’s instruction for fabrication, preparation design, and bonding to ensure the success of the restoration.”

Same-day dentistry allows clinicians to deliver restorations in a way that improves the patient experience. As Dr Kalmanovich points out, same-day dentistry also provides benefits to a dental practice’s bottom line.

"Same-day restorations offer our patients the convenience of only having one appointment [and] a more accurate fit while also reducing production time and costs—benefiting both the office and our patients,” he says.

Dr Rohde agrees, sharing an example of how he was able to deliver a replacement to an older patient who had fallen and shattered her bridge. When she came in that morning, they did a CEREC scan and sent it to the lab to get a 3D “digital” wax-up. The lab sent back the model STL file that Dr Rohde printed to make a temporary stent.

"We made her a good stent, rather than just cobbling together some alginate and wax and trying to sculpt something that looked half decent,” Dr Rohde says. “In the meantime, the lab made the final restoration, and a week later, she had her new bridge that fit perfectly and looked awesome. Not to pat ourselves on the back too much, but the template was as good as her original bridge because we had a good design and scaffolding to work from rather than trying to spackle some stuff on there.”

The Solea all-tissue laser from Convergent Dental.

Moreover, Dr Rohde says that gums like some of the same-day dentistry restorative materials enough to allow him to do same-day crowns—with the help of a laser—in cases for which he would have previously referred to a specialist first. For example, same-day crown lengthening is possible with his Solea® all-tissue dental laser and e.max materials.

“Let’s say someone broke a corner off a tooth, and that fracture went well below the gum line,” he says. “In the past, [you would] have to send the patient to a specialist that would first do a long surgery, after which the patient would have to heal for 8 weeks. In this case, we can laser away the tissue and then place a biocompatible restoration in that position, which is much better than any bis-GMA temporary material.”

About a year ago, the introduction of full-contour zirconia in bridge span blocks of approximately 25-to-30-mm spans put bridges in the same-day category. This material type allows clinicians to get zirconia’s strength in a same-day, premolar to molar bridge span.

“The milling takes longer. Rather than being done in around 15 minutes, it is more like 45 minutes, depending on how long the bridge is,” notes Dr Rohde “But that’s still 2 weeks faster than a traditional way.”

Same-day dentistry materials also offer a long-term provisional tooth that is better than what is available with traditional methods, Dr Rohde says. For example, in an anterior edentulous space for which time is needed to create the final restoration, Dr Rohde can make a milled temporary out of material rather than working with a denture tooth that may or may not match the surrounding dentition. Dr Rohde’s team uses one of the same-day dentistry materials that doesn’t require firing and can be stained and glazed to get to the right color. Then he affixes it to an Essix retainer.

“Now they have a perfectly matched, Invisalign®-type Essix retainer with a tooth made from a decent material,” Dr Rohde says. “It takes an hour to fabricate.”

He also likes other provisional materials that allow clinicians to create an esthetic temporary that a patient can wear for 6 months to a year. He likes Telio® CAD (Ivoclar Vivadent) and BioTemps® NOW (Glidewell Dental). These are materials like polymethyl methacrylate (PMMA) but very hard. In some cases, when the patient needs to wear a provisional for a while, such as an implant case with grafting, these materials are hard enough that the temporary can hold up for the duration. The Glidewell version is only for use on the Glidewell milling system, but the Telio CAD works on other mills.

"I can make the provisional in-house now by milling it out,” Dr Rohde says. “I have a bridge that will hold up for all of that 6 to 12 months, and I did it all in one day.”

He describes a case in which a patient with 2 anterior extractions that needed grafting went home with a Telio CAD provisional that same day. After 2 rounds of grafting and 15 months into the case, that patient still has the same temporary, and it is in the same condition as it was over a year ago. Dr Rohde credits that to the density and hardness of the material.

“It comes in a bunch of shades, and you can modify it with composite resin too—if you want to do a little characterization on it,” Dr Rohde says. “You have a same-day, long-term provisional.”

The science of same-day dentistry materials continues to advance. Dr Rohde remembers back in 2006 when there was just a handful of materials to choose from versus the numerous materials available today, with different qualities and benefits. The variety makes a difference, he says.

“It opened the door to allow us to provide higher-esthetic, higher-strength restorations rather than putting weak porcelain in across the board,” he says. “The materials along with advances in scanning and milling...legitimized the category.”

The new materials have made it so that a clinician can do almost anything in-house that a lab can do, Dr Rohde says, noting that doesn’t mean clinicians do not need a lab.

“If you want to stack porcelain, labs are awesome. If you want to do something laser sintered like a partial, labs are awesome. There’s always going to be a reason to have great relationships with the lab,” he says.

Dr Lawson says that when it comes to same-day dentistry, there are 2 types of materials: those for milling and those for 3D printing. Although many 3D-printed dental materials are not meant to replace teeth long term, some companies do have biocompatible resins available for 3D printing permanent crowns now. Formlabs launched its Permanent Crown Resin last year.

 Saremco Dental AG also released a polymer for 3D printing crowns, inlays, and veneers. Carbon and Dentsply Sirona are also collaborating to produce new resins for denture fabrication.

“Milled materials have been around for a while, Dr Lawson says, “but 3D-printed permanent restorations are brand new.”

The manufacturers present these 3D-printed, biocompatible resin materials as permanent crown solutions. However, Dr Lawson says the materials have some compositional drawbacks that make him question that claim.

“The limitation with 3D-printed materials is that [they] are fabricated from a vat of liquid monomers. For a polymer-based material to have strength, it needs filler particles,” he explains. “Incorporating fillers into 3D-printed materials or some other method of strengthening the polymer would be needed for these materials to have adequate strength to be used as permanent materials.”

Dr Rohde says the pushback on same-day dentistry is that the esthetics, fit, and margins are not as good as traditional dentistry for restorative work. However, he says those problems are due to operator error, not the materials.

“These restorations can look as good as you want them to,” Dr Rohde says. “If you take the time dipping the zirconia or staining and glazing, they can look beautiful. And I’ll put my scanned zirconia margin up against any traditional impression PFM [porcelain fused to metal], and it’s going to be better every time. It’s just a more accurate method.”

Another common pushback against same-day dentistry is that some dentists think the lab does a better job with zirconia restorations than dentists milling chairside. However, Dr Rohde says these critics should realize that the lab is also milling zirconia. The lab might be doing more milled zirconia restorations at a time than a dentist would chairside, milling out of a puck, but it’s still milled the same way. Moreover, Dr Rohde says same-day dentistry is the next generation of care that delivers a restoration that seals the tooth better than the traditional method without temporaries and multiple appointments.

Dr Rohde says that it really comes down to the type of practice you want to build.

“If you want to grow your practice by impressing patients and creating an unparalleled experience for them, then maybe you want to look at some of these new technologies,” he says. “We have an obligation to consider these new materials and methods in a way that creates a better experience for our patients.”

Embracing new materials and technology, however, is not only crucial for the patient experience but also the dental practice’s bottom line, says Dr Rohde. Using materials that provide a better patient experience enables a dentist to grow their business for the right reasons.

“If we’re adequately taking care of our patients and giving them a better experience, then everybody wins,” he says.

What are zirconia crowns? Colgate. Accessed March 8, 2021. 

https://www.colgate.com/en-us/oral-health/cosmetic-dentistry/bridges-and-crowns/what-are-zirconia-crows-0417

Giordano, R. Materials for chairside CAD/CAM-produced restorations. 

Hanaphy, P. Formlabs launches new Permanent Crown Resin and Soft Tissue Pack for dental 3D printing. 3D Printing Industry. December 10, 2020. Accessed March 10, 2021. 

https://3dprintingindustry.com/news/formlabs-launches-new-permanent-crown-resin-and-soft-tissue-pack-for-dental-3d-printing-181006

Embracing the advances in materials and technology is not only crucial for the patient experience but also for the dental practice’s bottom line.





Same-Day Materials: What's Possible?

A universal material that you can use anywhere sounds excellent to many clinicians. However, one material that works in every case and every mouth sounds too good to be true, which may leave some dentists feeling skeptical. We spoke with 2 dentists about universals today and whether the term “universal” is accurate or aspirational.

Universal materials describe products that you can use anywhere in the mouth, on any tooth, and expect to get consistent results. For example, a universal composite resin is intended for use in anterior and posterior cases. It should produce long-lasting restorations that have the mechanical properties and esthetics needed for either area. Dental professionals want to ensure that a universal composite has:

enough strength to stand up to compressive forces;

sufficient esthetics to look natural and blend in with surrounding dentition;

satisfactory polishability to maintain the restoration's luster; and

adequate handling that can produce the desired results when working with it.

Jeff Lineberry, DDSDDS, FAGD, FICOI, AAACD is a cosmetic dentist in private practice in Mooresville, North Carolina. He has a streamlined definition.

“It’s a no-nonsense, keep-it-simple kind of resin,” Dr Lineberry says.

Jason Goodchild, DMD, vice president of clinical affairs for Premier Dental Products, says the idea of universals comes from 20th-century hybrid composites. In the earlier days of composite resin technology, dentists used macro fills in the posterior for their strength and micro fills in the front for their esthetics. The next idea was to mix the resin’s particle sizes to make a hybrid, which had the macroparticles strength and the microparticles esthetics.

“It’s almost like universal composites may be evolutionary of hybrid composites because we used to use hybrids everywhere,” Dr Goodchild says.

Simplicity is essential with universal composites. Dr Lineberry uses shade matching as an example of how universal composites streamline the restorative process. Also, he says many universal composites are more translucent than other composite resins, creating the chameleon effect so the composite blends with the surrounding dentition. The chameleon effect makes it easier to shade match with a single shade, which is convenient for dentists.

“People want a composite where they don’t have to figure out shade. They don’t want to have to think about whether it’s an A2 or a B3. They want something they can stick in the tooth, and it blends in well. They don’t want to have to think about it much more than that,” Dr Lineberry says.

Dr Goodchild says manufacturers and dentists would also like to get to a place with universal materials where there are fewer things to consider. He thinks dentists would like to know if they see “this,” then they use “that”—what he calls “cookbook style” dentistry.

“That ‘if-then’ approach is beneficial for a dentist, who is moving fast and encountering so many different clinical situations,” Dr Goodchild explains. “Wouldn’t it be nice if you just had a material that works everywhere?”

Does Universal Really Mean Compromise?

Today’s universal composites are no longer struggling with the balance of strength and esthetics. Dr Lineberry credits that to the development of nano-hybrids and the mechanical properties their composition produces. Esthetics are a concern only in specific cases when using a universal.

“It’s where you get into some of the odd colors or characterizations when you see that one composite doesn’t do it all,” Dr Lineberry says.

Knowing the limitations of your product is essential too. Dr Lineberry says that he would not layer enamel and dentin shades with a universal on a complicated case because the results might not be as predictable as if he used his composite kit. Moreover, those universals that rely heavily on the chameleon effect for shade matching might not work in every case you encounter in your chair.

“It works,” Dr Lineberry says of universal composites that use the chameleon effect, “and probably for a lot of your patients, they will be excellent. But if you have an esthetically demanding situation, it might not fit the bill for that.”

Part of the desire for finding that universal material is feeling overwhelmed by the number of new materials that launch in the industry. Dr Goodchild says it is a lot to digest and challenging to stay up-to-date to get the best results possible.

Dr Goodchild counts himself among dentists who want a material with minimal considerations that can work almost anywhere with as few compromises as possible. However, he adds that it isn’t possible to have one material optimal for use in every tooth and area of the mouth for every clinical situation without making compromises. The manufacturers’ approach, he says, is to give clinicians a material that minimizes those trade-offs—an approach that goes beyond composites.

“That’s true on every level in dentistry. That’s cement, adhesives, composites, and even impression materials, although we don’t call them ‘universal’ impression materials,” Dr Goodchild says. “We want to be able to use them anywhere in the mouth.”

What to Look for in a Universal Composite

Some dentists love digging into the details of materials. Others only want what produces consistent results, which means they might be using a composite that’s been around for 10 years or more. Moreover, Dr Goodchild says, if dentists can get a universal material that works pretty well most of the time, then why change?

“It takes a lot to get the dentist to switch because that’s an unknown for them,” Dr Goodchild says. “They think, “I know how this stuff works. I don’t know how your stuff works.’”

He says the idea of a universal material is still evolving. Manufacturers and clinicians are still working on what universal means to them. Does it mean inject it into the cavity in one step? One layer and done? Or should there be a couple steps so that it blends into the tooth? Moreover, there are different features that clinicians like more than others. For example, in the traditional packable composite category, 3M™ Filtek™ features excellent handling, but in the chameleon category, Tokuyama’s Omnichromalends exceptionally well, he says.

“Having both would be better. To me, that’s the home run if you have the chameleon effect and the handling all in one,” Dr Goodchild says of the universal composites.

He adds that the improvements now are incremental, not monumental. The characteristics he notices now about the different composites are details like whether it blends, works well in his hands, tends to pull back, or packs easily.

“Don’t get me wrong,” Dr Goodchild says. “I don’t think we’ve reached the pinnacle of resin technology in dentistry. We still have room. But on our current path of methacrylate-based resins, we’re doing incremental changes.”

Dr Lineberry agrees: “Most of the universal composites, and composites in general, have the same wear characteristics, volumetric shrinkage, and things like that. But some handle differently. Some stick to the instruments. Some slump and are not as firm. Others are very firm. So I would say find the one that works well in your hands.”

In addition, Dr Goodchild notes that the universal label in dentistry might be overused, with many players in the market now with different universal features.

"There are the packable ones, the blending types, and the ‘all in ones,’ which are like self-cures,” Dr Goodchild explains. “It doesn’t necessarily simplify things, and now we’re numb to the idea of universal because we hear it so much.”

“It’s kind of a marketing thing,” says Dr Lineberry.

That being said, Dr Goodchild says that choices and options are good for universals and that he enjoys the fact that if you ask 10 dentists about how they do a composite, you get 10 different answers—which, he says, is OK as long as the result is the same.

“It’s like typing an address into Google Maps. You get 3 different ways,” he says. “Each of them gets you there. They are just taking you on a different path.”

Although they’re marketed as well-suited for restorations anywhere in the mouth, some dentists remain skeptical about whether they’re really suitable for every case.

How Universal are Universal Materials?

3D printing technology has many capabilities for restorative dentistry regarding patient experience and practice growth. 3D printing also opens up many possibilities for same-day dentistry. We spoke to two of our dental technology experts to hear how you can incorporate 3D printing into your restorative workflows. Here's what they had to say. 

John Flucke, DDS and Technology Editor for DPR, uses his 3D printer in restorative workflows in many ways. For example, his private practice in Lee's Summit, MO, uses the 3D printer for temporaries, surgical guides, and virtual implant placement, among other capabilities. He says 3D printing ramps up what you can do in same-day dentistry for a patient with a missing tooth (or teeth) or mixed dentition that wants their teeth "fixed." With a cone-beam device and a 3D printer, you can treatment plan implant placement. He says you can put the implants in precisely the places you want them down to the tenth of a millimeter and 3d print the surgical guides.

"Somebody can walk in either completely edentulous, edentulous with an ill-fitting denture, or partially edentulous, and within 24 hours, they could have implant surgery and have the situation rectified," Dr Flucke says. "And that is something we have never been able to do before."

Moreover, the surgical guide provides such precision that you don't have to guess if you have the placement correct, he says. Dr Flucke says that hand skills in these cases are not as important as the skill in designing with the software.

"The actual drilling of the holes in the patient for the implant anybody could do because it's been so simplified," Dr Flucke says of the 3D printed surgical guides. "But you have to know what you are doing with the software."

Dr Flucke says you can print anything you can imagine, adding that on his desk, he has a butterfly he printed. You can print dentures, screw-retained temporary crowns that you place on the day of surgery, or occlusal guards, to name a few. Like the surgical guides, it is best to design the appliance in the 3D printer's software to optimize the fit and minimize adjustments. 

"In the computer, you can design a nightguard and then print it and it fits. You can line it up, just like everything else, so that when you put it in the patient’s mouth, you don't have to make adjustments," Dr Flucke says.

However, you can make adjustments to your restorations if necessary, he says, and they are easier and more efficient with 3D printers. For example, in a full-mouth reconstruction for a heavy bruxer who has worn down their teeth by several millimeters, you can make a prosthesis that is a few millimeters taller than the teeth are now to see how it feels in the jaw joint when the patient chews. If the prosthesis isn't tall enough, you add a couple of millimeters to the design and print a new one to see how that feels, Dr Flucke says. 

"Printing one of these in an hour is so nice," Dr Flucke says. "It used to be when people would do this, they literally would do it either with plastic crown and bridge temporary material or sometimes building the teeth out one by one with composite. You can imagine what that must have been like for both the doctor and the patient."

3D Printing is also great for when a patient loses a denture. The practice can print a new denture from the existing digital files, and the patient or caregiver can come to pick it up. It will fit because it is the same denture they had before.

"That is the great thing about all this digital stuff," Dr Flucke says.

Dr Flucke had a patient who called in because her dog ate her occlusal guard. It was simple for him to replace because the files were in the cloud. Like a Word document, he says, you can print as many copies of the files as you want.

"I said, 'okay, you want a new one? Let me just hit the print button, and in about 52 minutes, you can come by and pick it up,'" Dr. Flucke says.

Dental materials manufacturers release new 3D printed permanent materials so dental professionals can 3D print final crown restorations instead of milling them. Right now, there are at least three available, which are resin-based monomers. However, they are brand new, so there isn't much research on whether these materials can hold up long-term.

Dr Flucke says that he wouldn’t be worried about using these materials. Still, he would set proper patient expectations and only use the materials for a permanent restoration on a case-by-case basis at this point. For example, he would have concerns about using these materials with a placement where powerful occlusal forces exist or where the patient has broken crowns before. Furthermore, any restoration placed with these materials would need to have appropriate preps and margins before feeling comfortable. He says exercising caution with untested materials is paramount because you are "dancing on the edge" of innovation. 

"When you have something brand new, you want to make sure you are using it in the most judicious way possible," Dr Flucke says.

Dr Flucke says that you and the team must be comfortable working with the software for your 3D printer. He also recommends making it part of what the team members do in the office. It not only frees up the dentist's time for the hands-on work he or she needs to do, but it gives the team more job satisfaction to work with technology. They appreciate it.

"If you're compensating the team with a bonus based on production goals, then printing more occlusal guards in a month is good for everybody. It's not like the team members feel like, 'Oh great! One more thing I have to do,'" Dr Flucke says. "My team looks at it like it helps them get closer to hitting their production goals for the month. That rising tide floats everybody's paycheck."

Jeff Rohde, MS, DDS, has a private practice in Santa Barbara, CA, and has been delivering same-day dentistry care for many years. He feels that same-day dentistry technology like his 3D printer allows him to provide the same high-quality care he always has, but faster.

"Same-day dentistry is not hurry-up, garbage dentistry," Dr Rohde says. "Same-day dentistry is a way to deliver high-quality care, just using new technologies."

Recently, his 3D printer allowed him to provide a temporary stent for an older adult in her 70s who had fallen and shattered her bridge, which extended from the back molar to the front tooth. Dr Rohde did a CEREC® scan, which he then sent to the lab for a 3D Digital wax-up. They sent the model as an STL file, which Dr Rohde printed in-house. A week later, the lab returned her permanent restoration. When Dr Rohde compared the final bridge with the temporary one he had printed a week earlier, he saw that the temporary was as good as her original bridge, which he credits to the design software and scaffolding with which he had to work. 

Another area where the 3D printer comes in handy is with long-term Provisionals. For example, Dr Rohde says, if a patient has knocked out teeth in the anterior and may or may not have an implant, you need to make a flipper. Dr Rohde and the team do a digital scan, print the model, which he says takes about thirty minutes to print, and then scan the model into the system. He then designs an Essix retainer with temporary tooth mills out of a material that he doesn't have to fire and then bonds into the retainer's edentulous space. The patient leaves with a perfectly-matched, clear aligner Essix retainer with a tooth on the same day. All of this takes an hour to fabricate, he says.

These are only two recent examples of how he uses the 3D printer. He says there are many ways to use it to deliver the care you want faster with the help of same-day dentistry technology. Moreover, that workflow is the future of dental care.

"That's where we are going," Dr Rohde says of the same-day dentistry workflow using 3D printing. "How can we do more rapid treatment to the final result without compromising?" 

Dr Rohde knows that some dentists are resistant to the idea of incorporating same-day dentistry and 3D printing technology into their workflows. He says he often has conversations with dentists that say they don't want to design their restorations. Dr Rohde explains that the software has improved to the point that it is not difficult to create restorations. 

However, Dr Rohde also says that the decision to move forward comes down to how the dentist wants to grow their practice. Same-day dentistry experiences are better for patients and provide quality care faster. You only have to numb patients once, and patients don't have to come back. While it's not the only way to provide quality care, Dr Rohde thinks using same-day dentistry technology like 3D printers is the better way to do so.

"We should be using the latest materials and technology that can give our patients a better experience," Dr. Rohde says. “What kind of practice do you want to have?”

3D printing has the power to capture our imaginations for what is possible in same-day dentistry. We spoke to a couple of our dental technology experts to find out how to incorporate 3D printers into restorative workflows.  

How to Incorporate 3D Printing into Restorative Workflows 

We have been through a lot the past year as a nation. We can see the light at the end of the pandemic tunnel as vaccines roll out across the country, and that light is shining on a new normal for the dental hygienist. What can we expect as we get back to business as usual?

JoAnn Gurenlian, RDH, MS, PhD, AFAAOM, is a professor and the graduate program director for Idaho State University and the American Dental Hygienists’ Association's (ADHA) Return to Work chair. Gurenlian appreciates how the pandemic necessitated ramping up safety measures in practice. While hygienists have always been diligent about adapting to improved safety measures, hygienists now provide a higher safety level in their approach, consistent with national guidelines.

"So even though we have this pandemic, and it's extremely serious, and patients may have felt reluctant to come to a dental practice setting, they should feel assured that we are putting forth every possible effort to ensure we protect their health and safety," Gurenlian says. "That is a win all the way around."

Katrina Sanders, RDH, a practicing dental hygienist, dental hygiene educator, and international speaker, says the most apparent safety changes are the layered approaches hygienists take to protect their patients and themselves. Sanders thinks the emphasis on infection control will have lasting implications for hygienists.

"Many of us have known for a long time that we should be wearing appropriate PPE [personal protective equipment] and using high-volume evacuation (HVE) with our aerosol-generating procedures. We shouldn't be leaving the office in the same scrubs that we treated our patient in to go to the grocery store," Sanders says. "We acknowledge that these are things that we've known we've needed to do, and now we have been pushed to action."

Tina Clarke, RDH, MEd, an instructor at Lane Community College in Eugene, Oregon, and owner of Teacher Tina RDH, has perspective as a practicing clinician and as a dental hygiene educator during the coronavirus 2019 (COVID-19) pandemic. Like Sanders, she has advocated for HVE and face shield usage every time hygienists use ultrasonic device instrumentation for years. However, she said, most people thought these infection control precautions were something you did only in school, not in a real-life operatory. She also appreciates the widespread adoption of infection control measures over the past year.

"For me, it's like people are finally listening and understanding the value behind it," Clarke says.

We are heading into a new normal for dental hygiene. But what will that look like in a post-COVID era?