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Our experts share the most common complaints they hear from patients when it comes to wearing dentures. 

5 Biggest Patient Complaints About Dentures – and How to Solve Them

	Here at Dental Products Report, we spoke to denture experts to discover what are some common complaints patients have about their dentures.

According to our experts, here are the five biggest complaints patients have about dentures - and how to solve them.

Trending article: The biggest evolution in dentures is almost here

	Dan Elfring, CDT, has been making dentures for more than a decade. He says that conventional dentures often result in a reduced biting force. Patients can’t bite as hard, and it creates problems eating certain types of foods.

	Also, the plastic on the maxillary covers the whole palette for suction, which reduces the effects of their taste buds. Elfring says that patients say they feel as if they lost their taste buds and they can’ tell if food is hot or cold.

	Since there are no implants used with conventional dentures, the bones will continue to deteriorate. As the bone deteriorates, the soft tissue changes and the denture doesn’t fit as well. The denture will then move around and make sore spots. Elfring says for all these reasons, the denture has to be relined periodically.

More from the author: Increasing FDA involvement in CAD/CAM dental restorations

	The lower denture is also problematic because the tongue and the floor of the mouth move, and it wants to dislodge every time the patient moves his or her tongue. Moreover, as the bone resorbs, the lower ridge gets flatter, making it more difficult for a lower denture to stay in place.

	“Then they are flopping all around. That’s when patients come to us for implants, and then we secure it,” Elfring says.

	Elfring estimates only around 30 percent of his lab’s patients have conventional dentures. Pickle Prosthodontics, which is where Elfring is the in-house lab technician, does mostly implant-related solutions. If patients complain about bite force, then Elfring says implants are the first level of solution.

	“Then we can retain it, and the bite force is directed to the bone and not the soft tissue. The implants also help to stop bone loss,” Elfring says. “There are lots of advantages of putting two to four implants per arch. We would try to talk them into that.”

	Implants would also help with taste and hot and cold sensitivity that patients lose with conventional dentures. By using six implants on the maxillary arch, the palette is freed from the acrylic denture base that obstructs patients’ taste buds and nerve endings.

	Every patient doesn’t opt for implants, however, for a few different reasons. Usually, the cost is an issue since implants are more of an investment than conventional dentures. Another reason could be the patient is in poor health and doesn’t want to put the stress on this or her body with the surgery. Also, some patients have too many medications they take that could interfere with the procedure and recovery.

	However, patients going with implant-retained dentures often have great results. Pickle Prosthodontics received a letter for a hybrid case where the doctor extracted teeth, treated the infection and did an all-on-four procedure. The patient can eat better and his health is improving.

	“The patient is going to try to get off of the blood pressure medication now,” Elfring says. “Nutrition equates to good health. Being able to eat proper foods for nutrition is a bigger deal than so many of us think about.”

	Many denture patients think their dentures don’t fit because the denture moves in their mouth when they chew. This movement can make it difficult to eat and cause sore spots due the denture causing friction on the mucosa. To correct the denture fit, patients come in for an adjustment, which results in chair time for which the dental professional usually doesn’t bill for. If billing does occur, then patients typically stop receiving treatment and use denture adhesive.

	Many times, however, dentures can fit and function properly. Marc Wagenseil, CDT, DD, is a denturist in Alberta, Canada, and an international lecturer for VITA North America and VITA Zahnfabrik in Europe. He believes the perceived fit issues stem from a few critical aspects of denture teeth design and construction.

	Denture teeth are historically made flatter and with less anatomy than natural teeth. Wagenseil says the teeth were designed this way to prevent rocking of the denture base when the patient chewed.

	Working and balancing describe how denture professionals use bilateral balanced occlusion to stabilize the denture when the patient chews. However, Wagenseil says denture design forgets the concept of freedom in centric or the wiggle room our natural teeth have.

Related reading: How digital dentistry and 3D printing are changing dentures

	“Our natural teeth and temporomandibular joint are not locked upon closing in centric,” he says. “Both can move horizontally, so to speak. When one holds their teeth together in centric, they can wiggle them while holding them together. This is the freedom in centric principle. We require denture teeth that can wiggle a little bit.”

	Per Wagenseil, not all denture teeth incorporate these occlusal or centric “landmarks.” He prefers to use VITA premium denture teeth, which incorporate the freedom in centric design. He says denture teeth that don’t incorporate freedom in centric cause the denture “waggle” on the gum when the patient chews. The movement gives the patient the mistaken impression that the denture doesn’t fit.

	Another area of improvement for fit (and also bite force) is to incorporate lingualized occlusion into the denture design. Wagenseil says it helps people chew like they do with their natural teeth.

	“Because lingualized occlusion is more of a mortar and pestle type of approach, it crushes food like natural teeth do,” Wagenseil explains.

	Since adopting his denture designs to incorporate lingualized occlusion with freedom in centric functionality, Wagenseil says he doesn’t have as many patients complaining about the fit as before, and the use of adhesive and soft liners has also greatly diminished.

	Wagenseil says he consistently delivers dentures with zero to one adjustment, down from the average adjustment rate of two to five.

	“You have to look at the economic value of that. If you estimate $400/hour for an American general dentist and a patient comes in for two adjustments, and let’s say they take 30 minutes at a time, that’s $400 off the profit that the office lost. That’s a lot of money,” Wagenseil says. “It is more than what denture tooth is the cheapest. It has to function in relation to the human chewing cycle. The savings are in your adjustment time and costs, which more than offset the denture tooth cost.”

	Wagenseil lectures about these concepts to try to help other denture professionals do the same for their patients.

	“As a denture professional, we change lives. Patients trust us to help with their chewing ability. Eating is life,” Wagenseil says. “We change lives because we are able to help rehabilitate someone’s chewing cycle. Since incorporating freedom in centric denture teeth, I am able to do so with better predicable results and far less issues.”

	3. “My dentures don’t look natural.”

	Wagenseil says patients want natural-looking dentures, not artificial-looking ones. Ideally, patients don’t want anyone to notice they’re wearing dentures.

	“Sure, they want a light color because we are conditioned to that,” he says. “But it should still look like enamel or a real tooth.”

	Real teeth have opalescence and fluorescence. Fluorescence, in particular, gives teeth vitality because it reflects the phosphorous in our teeth.

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	“This phenomenon happens under incandescent, fluorescent or natural lighting. Teeth should have that fluorescence, that vitality, in them and not all denture teeth do,” Wagenseil says.

	Wagenseil adds that people will always pick function over esthetics. While they don’t want Chiclet-type teeth, it’s more important that they function.

	“When choosing a denture tooth, provide one which incorporates both; they do exist!” he says.

	Achieving both high-functioning and natural-looking dentures is the best-case scenario. Wagenseil recommends working with denture materials that have the proper appearance regarding color and natural light reflection and function harmoniously with the chewing system.

	4. “Is my denture made from brand-name materials?”

	Justin Marks, CDT, and founder and CEO of Arfona, worked in customer service for Valplast, a manufacturer of flexible denture material typically used for partial dentures. His job in the call center gave him an opportunity to interact with patients directly. 

	“When working with customer service, I was in a unique position to speak with patients. Most dental lab technicians are not,” Marks explains.

	Marks says the majority of the call volume was patients who wanted a name brand material for their denture or partial denture but didn’t get confirmation the dentist used it. While it isn’t always the case, Marks says sometimes the patients want brand names for their denture materials.

More from the author: The top 10 things that scare patients the most

	“I might catch some flak from dentists for saying that, but patients do more research online than they used to,” Marks says. “It’s not to say that the patients are right, but they are more aware of materials heading into the dental clinic than they were in the past, and there is nothing wrong with that. So, if they are looking for a specific brand or procedure, at the end of the day, they are entitled to ask for it.”

	Sometimes laboratories substitute materials and don’t inform the dentist. Marks says the lab could have many reasons for the switch, but usually it’s because of price or familiarity with one material over another.

	Marks suggests knowing which materials the lab uses to ensure there are no substitutions or vulnerabilities in the supply chain. Also, the dentist should ask what the denture is made of if the lab doesn’t disclose this information, especially when the patient asks for a specific denture material brand.

	Marks also says to educate patients when the doctor or lab prefers a different material than what the patient wants. 

	“At the end of the day, the dentist is writing the prescription, and it is his or her professional responsibility,” Marks says. “Make sure you discuss everything with the patient.

	5. “I can’t get used to this thing.”

	Dr. Paresh Patel, DDS, a private practice dentist in Lenore, North Carolina, who has practiced for just over 20 years, says that some patients just can’t get used to a denture. He has patients who come in with their removable denture in their pocket or their pocketbook.

	“So you ask, ‘Do you wear this?’ They will answer, ‘Only when I go out in public,’ or ‘only when my wife makes me wear it,’” Dr. Patel says.

	Dr. Patel says that for many patients, having a denture is an unknown experience. Some patients can adapt, while others can’t. 

	“It’s a drastic change,” Dr. Patel says. “You have a hard time as a dentist and a healthcare professional explaining to somebody what that experience might be because it’s unlike teeth. Especially if they haven’t had a partial, they don’t know what they don’t know about how something is going to feel in their mouth.”

Related reading: What you need to know about the evolution of dentures

	Dr. Patel imagines the same principles apply to sleep apnea and CPAP machines. While a large population might benefit from a CPAP, they might not like using it. 

	“Maybe they are a side or stomach sleeper, or maybe they are claustrophobic. All of these things bring down the acceptance and the ability for people to adapt to that kind of prosthesis as well,” Dr. Patel says.

	Dr. Patel says everyone has his or her own unique experience and it is what it is. He has heard all of the following complaints from patients:

		I don’ t like how it makes my lip pooch out.

	“Certainly, there have been times when we give a patient a denture and we never see them again,” Dr. Patel says. “Sometimes you can’t even insert the denture or give the patient a denture without them gagging or simply pushing it out of their mouth with their tongue.”

	Dr. Patel says that for those people who can’t adapt to wearing removable dentures and who can afford something else, he encourages them to consider implant-retained dentures. However, in most cases where budget is an issue, he encourages them to keep trying to get used to it and wear it more often.

	“It’s a prosthetic just like any prosthesis,” Dr. Patel says. “We have people who lose limbs, and we spend a lot of time making these prostheses. Some people can learn to walk with them, and some people learn to walk but get sore spots where the prosthesis is attached to their amputated limb. The denture is as close to teeth as we can give them that is not attached to an implant."
	 

5 biggest patient complaints about dentures – and how to solve them

	How does FDA oversight affect the lab and what does it mean to the clinician? Our web feature this month seeks to clarify the issue and present best practices for clinicians and labs to comply with FDA regulations. 

	Computer Aided Design and Computer Aided Manufacturing (CAD/CAM) have revolutionized dentistry. Not only has the technology improved the way restorations are designed and created, but it has also increased the speed of delivery the patient. CAD/CAM technology has also made some restorations possible that at one time might have seemed impossible. 

	Conversely, CAD/CAM dentistry has also created concerns in the FDA about the need for oversight and regulation. Some dental laboratories began receiving FDA compliance letters a couple of years ago, regarding product descriptions on their websites. Many dental professionals and dental technicians wondered what the FDA’s involvement meant for the future of dental labs that use CAD/CAM technology.

	What are the FDA regulations for CAD/CAM manufacturing of dental restorations?

	It started with the implant abutment. Dental laboratories adjusted implant/abutment interfaces by hand for years without FDA oversigh, and many still do.

	Evo820 is a consulting firm that helps dental laboratories who use CAD/CAM technology comply with FDA regulations. Tim Torbenson, President of evo820, says that dental laboratories have been enjoying an exemption from FDA registration and listing requirements under Code of Federal Regulations Title 21. 21 CFR 807.65(i).

	As Torbenson explains, the modifications of implant abutments were exempt because everything was done by hand and every lab has their own way of doing things. 

	“It was a craft and less like device manufacturing, where each device was handmade specifically to accommodate a patient. There was no way for the FDA to regulate that because everyone did it differently,” Torbenson says.

	Steve Tapie is the implant manager for Keating Dental Arts Dental Laboratories with 35 years’ experience working in dental labs. He says they modify stock titanium abutments because the companies they work with are already cleared by the FDA, but not with a machine.

	“We can alter them a little bit,” Tapie says. “We don’t have a mill we put them in, they are hand-altered.”

	However, as more labs milled custom implant abutments with CAD/CAM technology, the FDA began to take a closer look. The FDA wanted to ensure that labs are using mills and materials validated for use with the software and in-lab milling.  

Torbenson says that the FDA did not change its stance concerning dental laboratories and the restorations that they manufacture, but that some dental laboratories have moved into a position that now may require more FDA compliance when they advanced and incorporated some of the new technologies.

	“The FDA has always been very clear that the abutment that goes into the implant - the implant abutment interface - has always been subject to a 510(k),” Eric Thorn, in-house counsel for the

 National Association of Dental Laboratories (NADL)

	According to Thorn,  labs began incorporating more CAD/CAM into their implant making back in the early 2010s, which triggered inquiries from the FDA. 

FDA classifies dental implant abutments as Class II medical devices

. A Class II medical device is an object that a healthcare professional uses to diagnose, cure, or treat a patient that affects the structure of the body and poses a moderate to high risk to the patient. Most medical devices are considered Class II medical devices, 

	The FDA considers dental laboratories that use CAD/CAM to make Class II medical devices as manufacturers. Manufacturers of certain Class II medical devices such as sleep apnea devices and importers have been required to register with the FDA for over twenty years. Moreover, the oversight is not limited to implant abutments made with CAD/CAM - all restorative devices are subject to quality systems regulations, even when made by labs that are otherwise exempt from registration.

	Manufacturing of most Class II medical devices requires a 510(K)-pre-market clearance. 

 that says what the manufacturer is producing is at least as safe as a similar product already on the market. The cost for a dental laboratory or a 510(k) holder to register a facility with the FDA is $4,884 annually.

	In most cases, Torbenson says thata dental laboratory does not need to have its own 510(k) for the restorations they produce. “The exceptions here would be for laboratories that choose to market their own branded sleep devices or orthodontic sequential aligners,” he says. 

 component companies, hold CAD/CAM 510(k) clearances. If dental laboratories follow what is outlined in the 510(k) and can provide the proper documentation to support it, they will be FDA-compliant without their own 510(k) clearance.

	“In meetings with industry groups going back to at least March of 2014,” Thorn wrote in a 2016 article for the 

, “FDA’s direction had been that as long as the dental laboratory follows the manufacturer’s specific instructions, and the manufacturer’s specific instructions have been 510(k) cleared by the FDA, a dental laboratory may mill the collar/post for a specific patient pursuant to a dentist’s prescription without the lab having to obtain a separate 510(k) clearance.” 

	Torbenson says that the documentation is still vital. The FDA regulates CAD/CAM technologies in the dental laboratory under the 

 which providesa framework for Current Good Manufacturing Practices (CGMP), and quality management procedures used in the manufacturing of Class II medical devices. 

	Dental laboratories producing dental restorations by hand or with automated manufacturing technologies have always needed a Quality Management System (QMS), which documents internal processes and procedures to demonstrate that the lab follows CGMP and abides by Title 21 CFR 820. 

	The FDA wants to know that the dental laboratories have a consistent and deliberate process for manufacturing that produces quality devices - and they want to see it in writing. 

	Evo820 helps dental laboratories by creating a customized QMS specific to the laboratory’s needs. Torbenson says that it will not take much for most labs to become compliant.

	“Everything that the FDA is asking us to do or document … are things that we are already doing,” Torbenson says. “So, it’s not a tremendous leap to become FDA compliant. You just have to know how to do it and what to document.”

	So far, the FDA has mostly sent compliance letters to a few dental laboratories that mill implant restorations. As more dental laboratories adopt automated technology and more dental restorations are produced via CAD/CAM, the FDA is changing their approach.

	“The FDA has increased its scrutiny of dental laboratories and is looking at industry publication advertisements, internet blogs, and other social media outlets to find laboratories that are manufacturing Class II devices,” Torbenson says.  “It is not just those laboratories that are registered with the FDA. They start with a telephone call, but this can lead to an FDA audit if it is deemed that the laboratory is manufacturing these devices.”

	Torbenson reports at least two incidents of FDA audits of dental laboratories. The FDA audit is to determine that the lab operates under a QMS and they want to see the documentation that validates it. He describes what a lab could expect in that situation:

	“The FDA will inform a facility four to five days prior that the FDA is sending an inspector to perform an audit.  They will also inform the dental laboratory of what sections of their Quality Management System that they are going to audit as well as the approximate number of days the audit will take.  With that information provided by the FDA, the dental laboratory can begin to prepare for the audit.  

	“There is a very specific protocol for the audit. The auditor will arrive at the dental laboratory and present a 482-Form that is the formal announcement of the audit. The inspector will then ask to meet the company’s management and the quality representative for an introduction and an opening meeting.  Once this is completed the audit will commence, and the inspector will tour the facility and begin to request certain documents to review. Once the audit is completed the FDA inspector will hold a closing meeting and present his/her findings verbally and in a written report.”

	The good news is that Torbenson says it is not burdensome or expensive to become an FDA-compliant dental laboratory. The materials, products, and components the lab uses have 510(k) clearances. Moreover, he says most dental laboratories do all that is required by the FDA with only one area that needs improvement: documentation. 

	“The FDA wants to see documentation that specific procedures and processes are completed properly,” Torbenson explains.

	Tapie says Keating Dental Arts is 100 perfect FDA-compliant with documentation for the Keating Custom Abutments, which are CAD/CAM custom-designed titanium abutments. Tapie explains that when Keating Dental Arts buys a part for a case, they make copies of its accompanying documentation to apply to the doctor’s prescription for the patient along with the lot number. Then, they scan the documentation into the Keating Dental Arts system’s records, and the doctor gets a copy for the patient file. 

	“If the FDA came knocking on our door and checked our records, I am fully confident we would have no issues whatsoever,” Tapie says. “We document everything.”

	Also, Tapie says the software serves as another line of defense against using non-compliant materials. For any product they use, if the company isn’t FDA-cleared, then the software will not allow the technician to download the .dne file. 

	“Even our software protects us,” Tapie says.

	Another option for a lab to be FDA-compliant is to outsource milling to a 510(k)-holder facility, which is what Thorn says many labs do. After receiving the digital scan from the doctor, the lab designs the abutment and then sends it out for manufacturing. 

	“The 510(k) abutment manufacturer has done all the metal fatiguing and all the other tests that need to be done to get a 510(k). The hard stop on that is the 510(k) holder because they won’t mill it outside the design parameters… that’s what makes it acceptable to the FDA,” Thorn explains.

	How dentists can protect themselves and their patients

	The FDA does not regulate the practice of dentistry. That means a dentist that produces restorative materials via CAD/CAM in-house for use in the practice on their patients are not subject to FDA oversight. Torbenson says the clinician mostly needs to be aware of the situation regarding dental laboratories and ensure they can trust their lab to be compliant. 

	“The clinician needs to be aware of these FDA requirements when choosing a partner laboratory and should be working with an FDA compliant dental laboratory for Class II restorations,” Torbenson says.

	Thorn agrees that clinicians should work with a reliable partner, preferably one where you have visited the facility and observed how they work. While Thorn says most labs are ethical and follow the rules, the clinician has the duty of diligence because dentists put the implant or other restorations in the patient’s mouth.

	Thorn says dentists should ask the following about implants and other dental restorations in today’s global marketplace:

			What were the qualifications of the technician who made it?

Related: 5 thing severy lab needs to know about outsourcing

	“It’s important that the clinician know where the lab is that made it, what is in it, and the qualifications of the dental lab technicians that fabricated it, so they know they are getting good quality,” Thorn says. “As a dentist, I would want to ensure that my good dental work is not undermined with inferior lab work. That’s a matter of due diligence.”

	If a dentist ordes an abutment from a laboratory, Thorn suggests requesting a written document that includes the 510(k) number of the abutment manufacturer, if applicable.

	Dental laboratories and clinicians need to work with reputable manufacturers. Thorn cautions labs not to order off the internet based solely on price. Major manufacturers provide documentation of the composition of the materials, and some smaller manufacturers can be fine, too. 

	“Make sure it’s a good operation with a quality product,” Thorn says, “If any work is coming from overseas, it should be from an FDA-registered foreign manufacturing establishment and you should ask for their FDA registration number and written point of origin and materials content disclosures. Not all the work is suspect; some good work comes from overseas..”

	Tapiealso suggests dentists request the FDA-Clearance sheet for the product to ensure that every part of every piece needs to be compliant.

	“If they are cleared, the FDA 510(k) clearance sheet should be easily available,” Tapie says. “It doesn’t hurt to ask questions. Especially for something this important for the patient and the liability of the doctor.”

	Since standards aren’t always the same all over the world, the first step to ensure you have a manufacturer following the FDA’s rules is to get the documentation that they are an FDA-registered foreign device manufacturer.

	“If it were a non-major manufacturer, I would want to make sure that I had been there, seen it, or done something to assure that my good work wasn’t being done with substandard materials,” Thorn says.  

	The ‘who’ of the equation is also a significant concern. Thorn says a qualified technician should make the end product, preferably a Certified Dental Technician (CDT). If a CDT does not make the restorations, Thorn says it is important that there is a CDT on staff at the lab. 

	“A CDT on staff shows that someone on the premises attends continuing education courses and is keeping up with new developments in materials and methods. Also, CDTs must pass objective written and practical exams showing they have met an objective standard of skill to do the work,” Thorn says. “These qualifications are significant for a restoration like an implant that is going to be in somebody’s mouth for a long time.”

	The bottom line from our experts is that the clinician should do their homework, whether on labs to partner with or any systems they buy to use in-house. Tapie says he has talked with doctors that buy systems for their practice, but can’t use them because the supplier didn’t have all the FDA-clearances they needed. 

	“Everybody has to keep abreast of the newest and latest things coming out. Also, make sure you research any of the new implant systems and software coming out,” Tapie says.

	“Dentists can get documentation if they are asking for it, and they should be asking for it in order to protect their patients,” Thorn says. “It puts the lab on record. If they have a problem, dentists can protect themselves.”

	Torbenson says there is much fear in the marketplace that is misplaced.  The FDA is not trying to make things difficult or put dental laboratories out of business. They are doing their jobs.

More by this author: How to implement digital impressions in your dental practice

	“What’s the Difference Between the FDA Medical Device Classes?” 

. 2 February 2018. Web. 17 October 2018. <

https://www.bmpmedical.com/blog/whats-difference-fda-medical-device-classes-2/

	Johnson, Pam. “Under the Microscope: FDA oversight increases as laboratories transition to CAD/CAM production.” evo820.com. Web. 22 October 2018. <

https://evo820.com/blogs/under-the-microscope/

Outsourcing manufacturing has led to increased regulatory oversight, but most labs might already be FDA compliant.

Increasing FDA involvement in CAD/CAM dental restorations

It has been 30 years since the first digital impressioning systems entered the market. The same decade that brought us Pac-Man, the smartwatch and the Pet Rock introduced us to the intraoral scanner. It also presented the idea that taking pictures in the oral cavity and stitching them together with software could produce images that would facilitate dental restorations and replace a tray of impression material.  

Digital impressions have changed quite a bit since the 1980s. The technology processes faster, the wands are smaller and more comfortable in the mouth, and the scans are more detailed than they were back then. Plus, you can access them from your smartphone if you want. Best of all, you no longer have to sell that vintage Swatch collection on eBay to raise funds to buy one.  

Despite these improvements over the past three decades and the increasing adoption of digital impressions in dental practices, traditional impressions are still more prevalent than digital impressions in the dental industry.

So what’s the story? Should intraoral scanners replace traditional impression material and trays? What benefits can one expect from using the technology and should dental professionals invest? Are digital impressions ready for their close-up? 

We talked to several industry experts about the state of digital impressions today. Here’s what they had to say. 

Related reading: The 5 biggest benefits of digital impressions

Digital impressions are past ready for prime time

“This is the future,” says Dr. John Flucke, DDS, and Technology Editor for Dental Products Report. “Digital is the future; impressions are the past. Impressions are like black-and-white TV or a modem.”

Dr. Flucke has been in private practice in Lee’s Summit, Missouri, for nearly 30 years and has been using digital impressions for the last 10. He has never regretted the investment. 

“From the day I bought the machine, I was glad I did it,” he says. “The only reason I can think of not to have a digital impression system is if you can’t afford it. Other than that, there is not one advantage that traditional impressions have over digital. Digital wins, hands down.”

“It’s another piece of technology making dentistry easier, better and faster. People are adopting it and marketing that they use it. But still traditional impressions have a big place in the market,” says Dr. Jason Goodchild, DMD, director of clinical affairs for 

Trending article: Are digital impressions REALLY the better choice?

Dr. Goodchild says it helps that the trend toward moving to digital impressions means that they can be used for a broader array of treatment areas than before. In the past, digital impressions were used for inlays, onlays, and the occasional crown. However, now dental professionals can use digital impressions for clear aligner therapy, multiple-unit crown or bridge, implant planning, and even full denture treatments, to name a few. Additional applications emerge all the time for the techy dentist. For example, scanners integrate with software and imaging technology. 

“You have scanning integrating with cone beam imaging and software that puts it together and helps with restorative or clear aligner planning,” Dr. Goodchild says. “You are getting lots of integration with other pieces of technology, which is exciting for planning and showing patients what’s possible as well as education and diagnosing.”

Dr. Nathaniel Lawson, DMD, Ph.D., division director of the division of biomaterials at the UAB School of Dentistry, thinks many of the new scanners are fast and easy to use. He also says the elimination of powder from most systems and the introduction of color scans improved the experience for dental professionals. 

“Digital impressions are extremely accurate for single-unit crowns, assuming the dentist has performed good tissue retraction,” Dr. Lawson says. “Now full-arch scans are becoming more accurate, even those including edentulous areas. This allows for the possibility of digital impressioning for partial dentures.” 

, has been working in labs for the past 20 years. He works with all types of doctors, so he says he gets to see everything. Many of his digital impressions come from newer dentists and the group practices that team up and share the expenses. Also, he sees them from the tech-savvy doctors who want to be on the cutting-edge of technology, to have the latest and greatest. 

Trending article: How to use digital technology to make cases easier

However, Gall says he receives more physical impressions than digital ones. He feels like the reasons are a combination of a generational stage of career, personal preference, and expense. 

“There are still a lot of Baby Boomer dentists that prefer old-school impressions or that maybe are midway or three-quarters through their career and don’t want the added expense of digital impressions. They don’t want to take on a $60,000 expense at this stage if they are going to retire soon,” Gall says. 

Tija Hunter, CDA, agrees that intraoral scanners are still not commonplace, but that in another 20 years or sooner, they will be. She says the new graduates use them in school and want them when they start practicing. 

“These kids are video game kids. They were raised on video games and raised on technology. They adapt to it so much easier,” Hunter says. “We are going to see a huge shift in the next several years because of those video game kids.”

Dr. Goodchild also recognizes that the transition could be generational. As more dental schools include digital scanning in the curriculums, graduates will expect to use it when they start their practice.  

“It will be a wave of digital impressions that comes over us in the next 10, 20, 30 years, just as the older dentists accustomed to impressions retire,” Dr. Goodchild says, noting that Creighton University School of Dentistry, where he’s a clinical instructor, now has 38 acquisition units and 24 milling stations as part of a significant technology curriculum. “Lots of schools are going the same way. When students apply to these schools, they are looking for an education in these technologies knowing that when they get out, they will be equipped to join a practice and jump in and use them.”

Trending article: The state of digital technology in 2018

Dr. Goodchild says the data regarding penetration of digital scanning indicates traditional impressions are still more prevalent than digital impressions. However, the growing number of players in the field have increased the competition and, as a result, the machines are improving and the learning curve is getting less steep. The cost of entry has also gone down, which makes it easier for doctors to convert their practices if they want all the advantages digital impressions offer. He feels the trend is toward digital impressions long-term even if traditional impressions rule the day today. 

“We are moving in that direction, but it’s just slow. Dentists can be slow to change and overcome the inertia of existing procedures and materials that ‘work well in their hands,’” Dr. Goodchild says.

“They are past ready for prime time,” Dr. Flucke agrees. “Prime time is now. I truly believe that.”

Per all our experts, the most significant benefit of undertaking a digital impression is the improvement in the patient experience. It’s no secret that patients don’t love fighting the gag reflex while the impression tray is in place. Patients aren’t fans of the impression material either, despite considerable improvements in set times that shorten the impression process, viscosity adjustments that prevent dripping down the patients’ throats, and flavorings to make it taste better. 

 showed that when it came to choosing a preference between traditional and digital impressions, the participants unanimously chose digital 100 percent over conventional impressions.

“From a patient standpoint, digital scanning is a whole lot better,” Dr. Goodchild says. 

“Nobody wants the goop,” Dr. Flucke agrees. 

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However, another enormous advantage digital impressions have over traditional that Dr. Goodchild points out is how they affect the workflow with the lab. Better communication with the lab, fast transfer of the images, and quick return of lab feedback increase efficiencies chairside that translate back to the patient as well.

Gall names predictability as the most significant advantage he experiences when working with digital impressions. It allows a lab to identify potential issues or concerns immediately, even before any model work is fabricated. He also appreciates how digital workflows allow him to plan cases with the dentist because changes to the digital design can occur before his technician builds the restoration. It avoids remakes and delays in the final placement.

“After we receive the digital scan or after we receive the model and scan it on our end, we can get a nice clear digital view of the case that we are going to be doing, like an esthetic veneer case or even a full-arch smile makeover. We can then send some images of that designed case on the computer to the doctor to view and say, ‘You know what? The centrals look a little too short. Let’s make them a little longer, or maybe let’s round the incisal edges a bit more,’” Gall explains. “You can do all that digitally with a couple of clicks as opposed to wasting the time of the technician creating all of those restorations first and then having to adjust them later.”

Gall says eliminating the need to adjust already completed restorations, like full-contour zirconia crowns, also preserves the integrity and the shade matching of the restorative material. It also decreases the patient time in the chair. Gall says if the dentist uses digital impressions and communicates with the lab early and often, the patient could have a full-mouth restoration in as little as three visits. With traditional impressions, it could take as many as six visits. 

“In any case, using digital impressions just decreases the timeline, increases predictability and shortens the patient time in the chair. As a patient, no one wants to be in a dental chair longer than necessary, especially sitting through a lot of adjustments to get it the way you hoped it would be. All of that can be avoided if you can see it all beforehand and be sure you are getting what you are expecting,” Gall says. 

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Dr. Goodchild agrees that digital scans streamline the treatment planning and collaboration with the lab and patient and set up the outcome for success. He also appreciates the ability to integrate digital impressions with other technology and imaging, particularly for large-scale restorative work that involves a specialist, like a periodontist or other practitioners.

“Thirty years ago, you would talk to a patient about eight veneers or crowns or a bridge, whatever, but there was no real way of involving the patient in the process,” Dr. Goodchild says. “Now you show them what it is going to look like and why it has to be a certain way. Patients become real partners in the diagnostic process.”

He’s also keen on the real-time feedback you get from many of the systems. From rating whether the impression was good to assess whether you’ve reduced the tooth enough, many of the systems have prep tutorials or prep guides. Some even have alerts that flash red and direct the dental professional to rescan or reduce the tooth more. 

“It may not be appropriate for every crown, but you get enough feedback that you might be able to fix it, or the system could point you in another direction. It’s amazing technology,” Dr. Goodchild says. 

Dr. Goodchild also likes the ability to store a scan, which makes re-impressioning easier as well as eliminates casts in some cases. “With digital CAD/CAM, the optical scan goes right into the mill,” he says. 

Dr. Flucke appreciates the accuracy produced by today’s digital impressions. Many digital impression systems will not allow you to send scans if they have distortions or don’t meet the system’s accuracy standards. With traditional impressions, there’s no gatekeeper for subpar restorations. Dr. Flucke says this accuracy with digital impressions minimizes the amount of time you spend adjusting a restoration for your patient. 

“When they come back from the lab, the amount of time you spend at the cementation appointment is minimal. We don’t adjust these restorations much because you don’t have to. We sometimes do, but it is way less than it is with traditional systems,” Dr. Flucke explains.

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Hunter thinks that the detail a digital impression produces is key to the precision of the fit. 

“When you can take that little tooth and take a picture of it and blow it up to 500 times its size, you can see your margins better,” she says. “You see every little nook and cranny, so whether you are making the restoration or sending it to a lab to produce, the fit is going to be so incredibly accurate, so much more accurate than a traditional impression could ever be.”

Dr. Lawson says the most significant advantage of digital impressions is how proximal and occlusal contacts are reliably achieved for crowns and realized during the try-in. He attributes this accuracy to eliminate the errors that occur with pouring and mounting casts for restoration. 

“Digital impressions allow the dentist to improve the quality of his or her preparation by viewing the occlusal clearance and a magnified view of preparation while the patient is still in the chair,” Dr. Lawson says.   

Also, Dr. Lawson thinks the practical advantages, such as faster and lower cost production from the lab and the digital record that you can save, are significant. 

Traditional impressions have their place - for now

Despite the many advantages our experts shared, many of them feel traditional impressions still have their place. However, as the technology improves, even those areas might prove conventional impressions have run their course. 

The one area most of the experts agree that traditional impressions are superior to digital impressions is when the margins are subgingival. 

“I still prefer to take a traditional impression when my crown margins are more than about 1 mm subgingival. Impression material is able to slightly displace gingival tissue, which cannot be achieved with a digital scan,” Dr. Lawson explains.

Gall agrees that when the margins are questionable or not clear, a traditional impression might be better, for now. Also, when there’s a lot of decay or other trauma in the mouth, physical impressions might be better than digital. 

“When you have a deep margin or some tricky tissue with the prep or something, there is still a need for traditional impressions to be there,” Gall explains. “Or maybe it’s just the perfect tooth that is just right at the gum line with visible margins, but you get the scan done and it doesn’t translate to the lab for some reason.” 

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However, Gall says that there are far fewer computer glitches than physical impressions that aren’t ideal. 

Dr. Flucke rarely takes traditional impressions, but he does when the patient has a removable partial denture and the crown he’s placing is the retainer tooth for it. 

“The machine does not know what to do when you scan that with the partial in place. The machine just can’t do that. It will someday, but they aren’t there yet,” he says.

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