Terri Lively

	They squint. They nod. They say all the right things. But as their dentist, you know your patients do not always understand what you are showing them on the X-ray, and sometimes not even what you are showing them on the intraoral scan. Worst of all, you know patients don’t know why the treatment you are recommending for them is the best course of action for their dental health.

	Patient acceptance of treatment plans depends on many factors, and you cannot control all of them. However, you can control what your patients understand about the current state of their dental health. It doesn’t require a dental degree to understand it either. As many a clinician who has invested in technology knows, seeing is believing. When you can show patients pictures of their teeth and blow it up on a screen for them to see magnified, patients will have the information they need to make a sound decision about their dental care.

	Many technologies help communicate this information in new ways-digital radiographs, intraoral cameras and even laser diodes that emit light to give a digital readout that denotes decay. However, in 2014, 

, a caries detection system that specializes in helping dental professionals show patients what they need to know.

Related reading: Using DEXIS Platinum digital sensors and DEXIS CariVu

	DEXIS describes CariVu as a “compact, portable caries detection device that uses patented transillumination technology to support the identification of occlusal, interproximal and recurrent carious lesions and cracks.” But for Dr. Angela Boehler-Homoky, who has been practicing for 23 years and is based in Port Charlotte, Florida, CariVu is a new way for her to communicate what she wants her patients to know about the state of their teeth in a way that they can see for themselves.

	We spoke to Dr. Boehler-Homoky about her experience with CariVu. Here’s what she had to say.

	What were you using before you got CariVu, and why did you start using it?

	I was first using film radiography and then digital radiography. Then I started using intraoral cameras with that. I was looking to purchase a new intraoral camera and learned there was something new also from DEXIS, the CariVu.

	What were some of the things you liked about CariVu that were different from what you were using?

	I like anything I can show on the screen to my patients so they can see and understand. With some radiographs, I felt my patients were taking my word for it. I’d say, ‘See that spot right there?’ and they’d go, ‘Yeah…I guess.’ I always tell people, ‘This is your body and your health. I want you to understand why we’re doing things and to be included in the decision-making process.’

	With digital radiography, you can blow it up and change contrast and try to show them those carious lesions. But many times, they’ll point to a filling. So, I still never felt like they really knew. With intraoral cameras, I thought, ‘Ok great, this is really going to show the patients.’ But I’m finding that with intraoral cameras, when patients see stain, they point to a tooth and say, ‘Oh my gosh, that tooth is horrible!’ And I say, ‘No, that’s an old filling, but it’s doing ok. I’m looking at this.’ And I am pointing to something else, and it’s not the thing that they notice.

	With CariVu, they seem to see it, and it differentiates between the normal and not normal teeth. Patients can see why the tooth needs a crown or why it needs a filling.

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	So does that increase patient acceptance rates?

	What do you like best about using CariVu?

There are a lot of different things that it does that are unique and useful, but the No. 1 thing I like it for is fractured teeth. I used to call a fractured tooth the mystery tooth. I would say, ‘If a tooth is acting funny in a bunch of different ways, that leads to me to think fracture.’ But I felt like it wasn’t certain and I don’t like that. I like to show a person the crack. Unless it’s an incredibly large fracture, you can’t see fractures on an X-ray at least 99.9 percent of the time. I wear loupes, too, so sometimes I can see them. An intraoral camera sometimes can pick them up. Sometimes there are superficial cracks everywhere. With CariVu, when you suspect the tooth has fractures, you put it on and take an image. I can put that image up on the screen, and the patient can see it just as easily as I can. And the insurance companies can see those cracks as well. I love CariVu for that.

	I would think the patient would love that the insurance company can see it.

	That’s true. Insurance gets kicked back with, ‘Why are you putting a crown with an occlusal amalgam?’ I send them the CariVu image and say, ‘Because there’s a huge fracture going through it, and the patient is going to break this tooth.’ The insurance company can see it, and everyone agrees. You can’t argue with facts.

Trending article: DEXIS introduces the new DEXcam

	What advice would you have for a clinician struggling with patient acceptance rates or some of the problems you were having?

	With intraoral cameras and CariVu, patients get it. I want my patients to trust me, but I also want them to see what I see without having to have a dental degree. And this is the easiest way.

	From the patients’ standpoint, they don’t get that much out of the X-ray. They get some information out of the intraoral camera, but then they really see with the CariVu. From the doctor’s side of things, if there was overlap on the bitewing, which happens all the time with crowded teeth, you can miss the decay. But it shows up on CariVu images even more than on an X-ray. There’s no guesswork with the CariVu looking for interproximal decay. It’s dark; it shows up. For a dentist’s eye, there’s no question now.  

	Is there anything else you want to mention about the system or the integration?

	Occlusal decay. Not a lot of devices show occlusal decay well. I have another product I use to check for fissures and things, but I don’t think it does well around existing restorations and sealants, I don’t feel. Sometimes I’ll get a false or high reading around some sealants and some restorations. Or if there’s plaque or calculus, it will give a false reading because that’s not very dense.

	On occlusal decay, I don’t like devices that give false readings because now you’ve got information that you can’t utilize. It’s something thrown into the mix to confuse you. With CariVu, there’s no false reading. It can look through composites and sealants and calculus or plaque. It’s just showing the decay that’s there or the restoration of the tooth.

	And X-rays don’t really show occlusal decay very well either unless it’s big enough. Most of the time when the occlusal is big enough to see on a radiograph, you can see it visually. So CariVu is good for those smaller ones.

	Do you have any tricks from using CariVu that you would share with other clinicians?

	A newbie mistake that I see is not drying the teeth out first. If one of my assistants is trying to use it and takes a picture when the teeth are not dried out, we get a nice picture of bubbles. A quick blast of air over those occlusions usually gives you a much easier to read picture for sure.

Read more: DEXIS delivers enhanced CariVu software

	Are there any other tips you have picked up along the way?

	There is a small learning curve because it’s a different instrument than probably anybody has, as far as putting it on the tooth. But it’s a quick learning curve that only takes one or two tries of practicing on each other. It’s easy to use.
	It works alongside DENTRIX easily. When I’m going to use CariVu, if I already have an X-ray or a picture, and most of the time you do, as soon as you put the CariVu in and select what tooth you’re taking a picture of, it pulls up the X-ray in a side-by-side screen. Then, it pulls everything that you’re going to present to the patient or look at for comparison automatically. I know I sound like a commercial, but I’m not trying to. I’m just saying what it is. It makes it easy. It not only integrates, but it also has bells and whistles that make it even better.

Articles

One dentist’s take on how CariVu helps patients better understand their treatment.   

Enhancing patient communication with DEXIS CariVu

	When Dr. Scott Dickinson, DMD was beta testing the Dentsply Sirona’s new Resurge Ultrasonic Cleaner, he kept asking his staff if they were using it. He couldn’t hear it. They assured him they were. It was just that much quieter than the ultrasonic unit they had been using previously. He was surprised-and impressed. He called it his first aha! moment with the new equipment.   

	“Ultrasonics tend to be that thing that when you turn it on, everyone in the office knows it’s on. It’s like a squeaky wheel,” Dr. Dickinson says. “When the Resurge runs, you don’t know it’s on.”  

	His second “aha! moment” was when his instruments came back squeaky clean from their first run through the ultrasonic unit. No composite or bonding agent remained that tends to accumulate over time, build up that Dr. Dickinson admitted had probably been there a while. He asked his assistants if they had scrubbed them before putting them in the new unit. They hadn’t. The Resurge had blasted everything off. 

	“I said, ‘I’ll take it! At that point, I knew I wanted one,” he said. A week later, his rep delivered Dr. Dickinson’s new Resurge unit to his busy practice. 

Related reading: Applying the Resurge Ultrasonic Bath in your practice

	Ultrasonics get plenty of use, running in some practices at least a dozen times a day. It’s a part of the daily routine that most dental professionals don’t think about very much. Everyone throws their instruments in the ultrasonic after they use them. Dr. Dickinson admitted that after practicing 19 years, he never paid attention to the ultrasonic unit. It was only after he agreed to try the new one that the ultrasonic was on his radar at all.

	“It’s like the dishwasher,” Dr. Dickinson explains. “All of a sudden you get a new dishwasher and you are like, ‘Whoa! My dishes have never been clean like that before. What’s going on?’ That’s the way it was when I got to use the unit. It looked cool, and it was significantly better than the ultrasonic I had used prior to it.”

	The quiet operation and the powerful clean are not the only benefits that Dr. Dickinson experienced. He also appreciates the digital self-timer that he can run for different things. “Most ultrasonics have those old kitchen timers, where you spin the dial, and they count down,” he says. “They go ‘ding,’ and then they turn off. Sometimes they get stuck. This one is different. It’s just nice. It’s clean. You can set it for any time you want.”

	He also appreciates the size of the unit. Dr. Dickinson estimates he sees a patient an hour. His hygienist does, too. Then they have overflow patients as well. That means the practice goes through many instruments in a day. “I run a busy office, but this ultrasonic is big enough that I only run it every two hours versus some of the smaller ones that I would run constantly,” he notes. 

Trending article: Dentsply Sirona Endodontics introduces new software and advanced technologies

	Dr. Dickinson cleans his instruments in cassettes and can get six cassettes in there per cycle. “It accommodates a busy office,” he says about the 2.0-gallon unit he purchased.

	Dr. Dickinson thinks the little things can make a big difference in the patients’ perception of the practice, including the appearance of the sterilization bay. After all, patients walk by it and look in there. It makes an impression. “Your sterilization bay needs to look sterile, clean, and modern. He compared the appearance of other ultrasonic units to props from “Lost in Space,” the 60s Sci-Fi televisions show. 

	“‘Danger, Will Robinson!’” he says, laughing, “They are 1950s technology. We can do better. This is the first time I have ever seen anybody put effort into making something like this look nice. The Resurgence Ultrasonic is very modern; it’s streamlined; it’s digital. It has a LED light read out.”

	Dr. Dickinson is also a fan of Dentsply Sirona. A sometimes lecturer for the company, he often tells other doctors something he admires about Dentsply Sirona is that they always have a beautiful product, and it’s always high-end. “I’m a guy, so everything is cars, right?” he says. “When I am training, and I say the nice thing about Dentsply is that whatever they decide to do, it’s a Lexus. You might pay a little bit more for it, but it’s so worth it. “

	Dr. Dickinson appreciates that Dentsply Sirona kept to that standard, even when they work with these small instruments. “They did a bang-up job of it,” he says. “They could have made a lousy ultrasonic unit and sold it by default because they are who they are, but this is an excellent unit. It’s encouraging to me. If I want something, I will go to them first. They always do it right.”

	People sometimes react poorly to change. It’s no different in the dental practice. Doctors and staff are used to what they have and don’t always consider what could be if they were to switch equipment. Dr. Dickinson remembers when digital X-rays first came on the market. “Dentists were resistant to that at first but now if you walk into an office that doesn’t have digital X-ray you think it’s a dinosaur,” he says. 

More about the Resurge Ultrasonic Cleaner

	For nearly two decades, Dr. Dickinson has not worked in an analog office. He loves how digital dentistry has improved the science. “I was using digital coming out of residency and I didn’t look back,” he says. The difference with this change is that if an office buys a better ultrasonic unit than it is currently using, there isn’t the same degree of disruption to the status quo that adopting digital radiography might have had on a practice. 

	The Resurge Ultrasonic unit is also simple to use. As far as the set up went, Dr. Dickinson says they took it out of the box, plugged it in and filled it with water. “It doesn’t get any easier,” he says. 

	Not only that, unlike digital radiography and other technology outlays, the ultrasonic unit isn’t a high-ticket item, making the decision to upgrade equipment an easier one. “It’s not one of the things you have to dwell on whether you want to make the investment. This one is a no-brainer,” he says. 

	For those clinicians that sometimes resist adopting new technology, Dr. Dickinson would advise them to embrace the improvements that come along with the change. “We are gadget guys, and we are reluctant to change. We worry, ‘Oh. It doesn’t look like the old one.’ It’s OK. Cars don’t look the same either!” he says, laughing. “Things are getting better. This ultrasonic is significantly better than the other one. In 10 years, there might be one even better; you just have to go with it.”  

DPR interviews Dr. Scott Dickinson about his experience using the Resurge Ultrasonic Cleaner from Dentsply Sirona.

I Use That: Resurge Ultrasonic Cleaner

	Many dental professionals think that if they refrain from unprotected sex with an infected person at the dental office, they are safe from contracting a sexually transmitted disease (STD) there. But they are wrong.

	The fact is you could contract a number of STDs at your office without engaging in sexual contact, including:

	·      Human Immunodeficiency virus (HIV)

	·      Human Papilloma Virus (HPV)

	Infections can occur through exposure to an infected person’s blood, which can occur through splashes to unprotected eyes, nose or mouth, as well as percutaneous injuries. In the case of HSV2 and HPV, infections can occur through exposure to an infected person’s saliva. In addition, you could sustain exposure to many viruses including the other human herpes viruses (there are eight in all), influenza and Epstein-Barr. You could even end up exposed to diseases like measles, mumps, rubella and polio-and this list is far from comprehensive.

Trending article: 5 infection control mistakes you might be making and not even realize

	The fact is you could be exposed to all kinds of bacterium, viruses and other microorganisms that cause disease in the dental office.

	Or you could be exposed if you don’t take the universal precautions as specified by the Occupational Safety and Health Administration (OSHA) or the standard precautions by the Centers for Disease Control (CDC).

	Dr. David Reznik, DDS, is the founder and President of  

, a nonprofit organization assuring that people living with HIV disease have access to quality dental care. Per Dr. Reznik, OSHA’s universal precautions (or standard precautions per the CDC) provide all the protection you need from these dangerous and contagious diseases people bring into the operatory.

Trending article: 5 equipment considerations to improve infection control

	“Unless you sleep with the patient without any protection, you're not going to get syphilis or gonorrhea or HIV or any of those diseases that can be sexually transmitted. So, it's a matter of following the safest dental visit practices,” Dr. Reznik says.

	However, the concerns for exposure to these conditions doesn’t stop in the operatory. Dental laboratories should also employ OSHA’s universal precautions to protect themselves from contracting STDs in the lab.

	“The dental laboratory owner must protect his workers by using universal precautions. The same processes and equipment would be used in the manufacture of the dental device regardless of the patient’s medical condition,” explains Mary Borg-Bartlett, President of 

., a regulatory compliance consulting firm that helps clients meet safety requirements set forth by OSHA.

Next: Why you should practice as if all patients are infectious...

	Dr. Reznik said most medical history forms patients fill out include questions about sexually transmitted diseases they might have. Upon seeing that a patient has a sexually transmitted disease, some dental professionals might think they need to take additional precautions. However, in the case of patients with HIV, which is a protected disability, taking extra precautions can be a violation of the Americans with Disabilities Act. “You have to do what you do for everybody else. So, your standards, which are easily found on OSAP, are what you need to follow and make sure you're following the checklist,” he says. 

	“There should not be a difference in how one patient is treated over another. You have to presume they are all infectious,” Borg-Bartlett says.

	Universal precautions protect dental professionals and employees from exposure to diseases patients might not know they have, Borg-Bartlett explained. Some infections like the hepatitis and HIV can be asymptomatic in some patients. Unless they have had a blood test informing them otherwise, patients won’t disclose that information because they don’t know themselves. “You could live a lifetime and not ever know. So, that's why universal precautions and standard precautions must be practiced presuming every patient has a disease,” she explains.

Trending article: CDC unveils new guidelines and checklist for infection prevention practices in dental settings

	In the cases where the patient might not yet know they have contracted an STD, Dr. Reznik feels that dentists should be able to recognize how some of these diseases present orally and refer them to the appropriate medical personnel. Also, dentists should screen for certain conditions and refer the patient as necessary. “We're healthcare professionals, and people are going to come in with a variety of illnesses. It could be diabetes that's uncontrolled. Or it could be so many different things. I feel very strongly that since oral health is a component of primary care that it's our job to identify these and refer as necessary,” he says.

	In some cases, Borg-Bartlett said patients might not disclose their condition for fear of not being treated. Dr. Reznik agrees, remembering his private practice days in the 80s when the dental profession was scared. When no one in Atlanta would treat patients with an HIV diagnosis, Dr. Reznik would and did, usually for free.

Trending article: 5 ways to ensure your team practices good infection control

	“My mom was a Holocaust survivor. I'm Jewish and have multicultural influences in my life. Ever since I was a small child, I've felt discrimination in any form is wrong in my mind,” Dr. Reznik says. “And so I couldn't see turning away people based on a medical disease. So that's why I was getting all the patients. The patients felt comfortable, and I wasn't worried about catching the disease because I didn't plan on having relations in the dental chair.”

	After five years of advocating for and treating these patients for free, Dr. Reznik joined Grady Health System, the fifth largest public health system in the U.S. Dr. Reznik is now the Chief of the Dental Service for the Grady Health System. Since then, he feels that dental professionals have done an excellent job of communicating appropriate information regarding transmission of HIV and other STDs in the dental setting.

Next: Why practices AND labs must both be vigilant...

	In the dental lab, the risk for exposure continues, particularly in those diseases that can live outside the body, such as HBV and HCV. Impressions and implant components could have saliva and blood present. If the lab worker isn’t in compliance with the universal precautions, it can lead to an infection. Borg-Bartlett cites the universal precautions as the best defense against these types of exposures, starting at the dental practice. “Prior to packaging items that have saliva and blood on them, the dental staff should remove the blood and disinfect the items,” she says, then explains that the lab should also rinse and disinfect the items before proceeding with any manufacturing, per OSHA’s requirements in the Bloodborne Pathogen Standard and the recommendations by the CDC. 

Trending article: 10 questions you need to ask about infection control

	In states where dental technicians can perform chairside services in the operatory, the technicians should also use personal protective equipment (PPE). PPE includes gloves, mask, safety eyewear or face shield, and gown. If the PPE isn’t provided by the lab, then the practice must provide them. “Dental technicians must abide by all state and federal regulations regarding participation in procedures such as All-on-4’s,” Borg-Bartlett says. The 

 will have guidelines on the legality of these types of relationships in the dental operatory. 

	One additional consideration pertaining to HIV exposure Dr. Reznik would add is for dental professionals to be aware of post-exposure prophylaxis, a short-term antiretroviral treatment to reduce the likelihood of HIV infection, and know how to get the treatment within two hours of the potential exposure. “You want to get that as soon as possible, preferably within two hours. We have no data for effectiveness after that, but the sooner, the better,” Dr. Reznik says. “They should have protocols in place. Whether it's corporate offices or private offices, you should have a protocol if there is a needle stick.”

	In 2016, the CDC released a summary that reviewed the practices in place and made recommendations to improve infection control practices. Borg-Bartlett explains that one of the new recommendations pertained to safety when administering anesthesia through a needle. The CDC recommended reducing the risk of a needle stick by looking for safer devices.

Trending article: The importance of battling antimicrobial resistance

	The CDC also recommended that each facility, dental practice or dental laboratory, needs to appoint an Infection Prevention Coordinator. “The CDC gives a good checklist in that summary. So appoint someone who is responsible for infection prevention,” Borg-Bartlett says.

	Both experts contend that when the dental practice or the lab follows the universal or standard precautions, there is no risk of contracting STDs and other serious diseases in the dental practice-at least not from dental work.

	“Both dental practices and dental laboratories must practice 

universal precautions as required by OSHA

. This is for the protection of the employees in those organizations. To the best of my knowledge using universal precautions will protect these employees from STDs,” Borg-Bartlett says.

CDC recommendations for standard precautions

 on how to follow them and what steps should be taken,” Dr. Reznik says. “And then there's nothing to worry about.”

What every dental professional needs to know about contracting STDs in the dental practice.

The dangers of STDs in the dental practice

	When designing your operatory, you probably consider many aspects. From your practice goals to the staff’s needs to your equipment footprint and even your future technology acquisitions, each factor is vital to your workflow and desired level of patient care. However, in the pursuit of efficiency and productivity, one area often overlooked is the design esthetic-and it can have repercussions for your patients’ experiences.

	Here are seven reasons that operatory esthetics matter to your patients.

	Reason 1: Our emotions influence our perception of a patient experience.

, founder and CEO of Beyond Philosophy, a global customer experience consultancy, explains that our brains use their conscious and subconscious experiences to look for clues to decide how we feel during the appointment. These clues could be colors of the walls, materials used for the furniture, cleanliness, organization styles (or lack thereof), and even sounds or smells. Each adds to the patient’s perception, either positive or negative.
	
	“Every dental practice has a conscious and subconscious experience,” Shaw explains, “but they aren’t always deliberate about them. Dentists don’t always realize how each of the moments in the appointment affects the patient’s feelings. How things look can be one of these overlooked moments.”

	Reason 2: We make judgments based on appearance all the time.

	You have heard you can’t judge a book by its cover, well-intentioned advice meant to discourage us from making judgments based on appearance. However, we all do it. How something looks influences our opinion of it on several levels. It’s true of restaurants, cars and, yes, dental operatories. We start assessing as soon as we enter the treatment room. It affects our perception of our patient experience, good or bad.

Trending article: How better dental office design can prolong your career 

, agrees that esthetic design for dental operatories is integral to presenting the proper atmosphere for your patient experience.
	
	“The look and feel of your practice is your brand. So, if you have worn chairs or delaminating cabinets, patients may associate the lack of maintenance to the quality of care they are receiving,” she says.

	Reason 3: Proper esthetics help distract patients struggling with anxious feelings.

	Many people coming to the dentist’s office feel stressed about the uncertainty of what is going to happen next, anxious feelings that compound upon entering the treatment room. Dental environment designs reflect a trend to reduce these uncomfortable feelings. The 

,” explains that more dental offices are designed with the patient in mind.  Many seem more like a spa than a dental office.
	
	Shaw supports this idea of designing with the patient in mind, adding that he is always surprised “that when I’m sitting in the dentist chair, very little is done to distract me.” Shaw recommends a patient-focused experience, which could include having TVs to watch or having the patient choose music to play during his or her appointment. He also suggests using lavender scent to reinforce the calming effect.
	
	“Calm surroundings and a pleasant environment are critical,” Shaw says. “Creating the environment that you’re not visiting the dentist is ideal.”

	Reason 4: What’s out of sight is out of a patient’s mind.

	There is a lot of equipment in a dental operatory. You see practical tools to treat patients efficiently. However, some patients see instruments they don’t understand and feel anxious. Clean lines without a lot of visible equipment can help put a patient’s mind at ease.
	
	“Dentistry tends to use gear,” 

, Chief Technology Editor of DPR, says. “And we just keep adding equipment. It might not even be big stuff, it might be small, but we just keep adding things. We don’t think about it as much in the field, but when people come in and see all kinds of gear and they don’t know what it’s for, some of it looks a little scary.”
	
	When Dr. Flucke and his wife had their first child, their labor and delivery room resembled a nice hotel room rather than a medical space. However, the space transformed when it was time to deliver the baby, with equipment that came out of cabinets, closets and even the ceiling. He used the same concept when he designed his operatories.
	
	“One of the things I wanted was to be able to hide a lot of our stuff, so when people come in, they don’t see a lot of scary-looking equipment,” he says. “We try to keep it hidden.”

Related reading: Form and a lot of function

	“When you hide some of the clinical items, things one might see in a doctor’s office, it puts a person so much more at ease,” Treon agrees.

	Up next: How lighting can affect patients' moods...

	Reason 5: Lighting affects the patient’s mood.

2014 study out of the University of Toronto

 suggests that human emotions feel more intense when experienced under bright light. The findings published in the Journal of Consumer Psychology suggests that dimming the lights can promote rationality.
	
	Per the ADA guide, design experts tout lighting in the dental office as one of most revolutionary changes to treatment room design. Creative solutions for indirect lighting and natural light can produce a stress-free atmosphere.

Trending article: Why it's critical to design with the future in mind

	Dr. Flucke's first practice was in a strip mall, so the reception area was the only place with windows. Dr. Flucke used to ask his patients for a weather report.
	
	“I never knew. It was like working in a mine,” he says.
	
	When Dr. Flucke built his new practice, he took advantage of natural light by placing large windows in his operatories, which patients appreciated. Not only do they provide a light and airy environment, but the windows in the operatory open.

	“When it’s 70 degrees outside, we kick the windows open, and you can hear birds chirping and the breeze comes through and it’s all nice,” he says.

	Reason 6: Colors can color patient perceptions of an experience.

	The colors you choose for your design can also affect a patient’s mood. While some experts claim certain colors are more relaxing than others, others argue that culture and individual experience influence color preferences. However, one truth about color is that use of it attracts the eye and creates a theme, helping patients make positive associations with the office.
	
	Treon explains that some dentists use color to promote their brand, put their patients at ease, or convey a treatment room that is warm and inviting instead of cold and clinical.
	
	“Some might go as far as making their cabinetry colors different in every operatory or making it the focal point of their office design,” she notes.
	
	The ADA’s guide suggests hiring a professional to help choose a color scheme, with a focus on the establishment of these themes and presenting the desired “office image.” Dr. Flucke hired an interior designer as part of the construction team when he built his office. He appreciated her suggestions for the office since his favorite color is black and he tends to favor dark tones. They opted for bright colors in his practice, choosing the cabinet color first and working off the cabinets for the other elements like walls, flooring and upholstery. He believes in hiring professionals who are specialists for this kind of work.
	
	“Find people that are good at what they do and let them do it. Just get out of their way,” he says.
	
	Treon sees the same trend in cabinetry styles and finishes that dentists choose. 

has several options for materials, colors and finishes to accommodate changing tastes.
	
	“It doesn’t look cold and clinical. It looks like something you would see at a studio or a really nice home,” she says.

	People like to have their personal space. The ADA recommends open designs, starting at the waiting room. They also recommend that all the treatment rooms are the same size and equipped the same, to prevent having a “preferred room,” which can cause problems in scheduling. However, the size of the operatory should also keep all the equipment within reach for the dentists and the assistant.
	
	Dr. Flucke’s first practice space was less than half of what he practices in now. He described a waiting room where people sit knee to knee with strangers. With his new practice, he could spread out and give patients a little breathing room. The larger office makes people feel comfortable.
	
	“Patients comment on the fact that it doesn’t feel crowded, that it’s very open,” Dr. Flucke explains. “It’s a lot more relaxing. It helps them deal with being in a dental environment, which most people aren’t real crazy about.”
	
	When designing the building, Dr. Flucke had the operatory chairs face the large windows that looked out over a small wooded area.

More from the author: How integrating technologies can help your practice 

	“They are not looking at a parking lot of a Krispy Kreme donut [store],” he laughs. “They are looking at something very peaceful. We have animals come up out of the woods, which is very nice. We have a whole bunch of bunnies lately, but we also had a family of foxes. We’ve seen some deer. Lots of stuff that adds to it.”
	
	Obviously, not everyone can build their practice from the ground up overlooking a wooded area and all its furry inhabitants. But taking advantage of the space you have is paramount to creating a good patient experience.

	Reason 8: People return because of their memory of their patient experience.

,” last fall about how psychology influences people’s buying decisions. One of the tenets he promotes is that people don’t return to your experience because of the experience they had; instead, they return because of the experience they remember they had. Therefore, creating the best possible memory is crucial for your practice.
	
	Memories of a patient experience form from the most intense emotional point and how the experience ended, a concept called the Peak-End Rule. Esthetic decisions, from general appearance to lighting and color choices, and even to what they don’t see (i.e. scary equipment hidden in the cabinet) all influence how these moments occur in their patient experience and the resulting memory from it.
	
	“Creating a positive memory requires managing the peak emotion of the experience, which is probably easy to identify in a dental surgery,” Shaw notes. “It also means managing how the experience ends, and sometimes, in an everyday experience, that can be the sum of a lot of little things. The key is to recognize what those little things are.”
	 

Why your design decisions have a much bigger impact than you might think.


8 reasons operatory esthetics matter to your patients

	Before Simplifeye, Dr. Anna Ashley, DDS, PA and her office manager Patricia Valadez had a communication system for the team that worked well-until it didn’t. After Simplifeye, the team had a system that communicated well and worked for the team.

	With two full-time hygienists, two full-time assistants and only one doctor, 

 was in high demand. The team used a paper card system, color-coded in neon colors for each team member, which they held up in the hallway outside the room where Dr. Ashley was working. The card indicated where the doctor was needed next for a patient.

	“If it was urgent, then they would have to hold up a card that said, ‘Room 1, ASAP.’ We lived off of cards when I was working,” she says.

	At first, their low-tech system was helpful, but as the practice grew, it became impractical. The team began to fall behind schedule on a regular basis. Furthermore, it was inefficient. The team felt the need to wait outside the room or Dr. Ashley’s office to ensure the doctor knew they needed her. Valadez described the scene as a constant flow of team members up and down the hall.

Trending article: Simplifeye helps dentists stay up-to-the-minute with their practices

	“If Dr. Ashley was in the middle of something, I would have an assistant or hygienist standing in the hall with the card and shaking it. There are times when the doctor is in the middle of a procedure, and she cannot get up. When someone is there hovering, and you are in the middle of something, it’s more frustrating,” Valadez explains.

	“When I was in my office they would come stand and hover in my office or knock on the door,” Dr. Ashley says. “If I was on a phone call, it was intrusive and difficult.”

	It was also affecting the practice. Dr. Ashley and Valadez knew it was time to get a new system. “We have been in practice for 18 years. We needed a change. The cards weren’t working, and it was a source of contention among the staff,” Dr. Ashley says.

 team at the Texas Dental Association Meeting. Instinctively, she was drawn to how Simplifeye used consumer technology like Apple Watches and iPhones to improve how the team communicated. She also liked the integration they had with 

, her practice management system, so she decided to “give it a shot.”

	Valadez liked how her front office staff members could manage the workflow from their computer.  

	“For us in the front, it keeps us from having to go to the back to let the team know their patient is here. We use the dashboard on the computers. We click the team member’s page when the patient is in the waiting room. They have the watches, so it instantly alerts them who is here and what they are having done. It’s useful in comparison with what we were doing before,” Valadez says.

	Dr. Ashley doesn’t like to be interrupted while working, so she appreciates how the system allows her to complete a task or find a stopping point in a procedure to respond to the team’s needs. “They can page me if I am in a room working or if I am in my office on the phone. That’s been nice because I know I can find a stopping point,” she says.

	One of the biggest surprises for Dr. Ashley was that the learning curve was short. “I wasn’t expecting it to be so easy. I thought there would be a significant learning curve. It wasn’t bad at all. They came in and showed us how to use it, and the girls caught on very quickly,” Dr. Ashley says.

	Valadez agrees, saying the team jumped in immediately. “It was simple to use but difficult for everyone to get adjusted. Some still wanted to call her, but I would ask them if they paged her. They hadn’t, so they would run back and page her using the system. It took a couple of weeks to get used to it because it was new,” explains Valadez.

	The practice has been using Simplifeye for a year, and already the team finds it indispensable. Dr. Ashley can’t imagine running the practice without it-and the thought of not having it is unimaginable. “I like it that much, and we use it that much,” she says.

More from the author: 6 challenges in adopting dental technology

	Without Simplifeye, Dr. Ashley predicted they would see fewer patients, communicate poorly and produce less revenue. With Simplifeye and Dentrix, they streamline the workflow to accommodate their growth. Moreover, she no longer feels uninformed when she enters the exam room. She taps on the watch, and all the patient information is right there.

	“Before I felt like I was flying by the seat of my pants. We do have morning huddles, but you can’t remember everything. So, pulling it up on my watch is amazing,” Dr. Ashley says.

	Dr. Ashley says patients feel like they are getting personalized service, which they are because she feels prepared for their appointment. She sometimes shows patients what information about them is available on the watch. “They are impressed that it’s all on my watch. It shows that we are a modern practice using modern technology.”

	“Being an office manager, I feel it made our flow a lot better and more efficient than before. I don’t have people running down the halls trying to track down the doctor,” Valadez says.

	Dr. Ashley feels valued by the individualized and immediate support she receives when troubleshooting or updating the system. “They know your name, your account. You talk to the same person every time. It’s not like you are shuffled to 10 people.”

	Simplifeye’s dedication to improving and adding system features is another aspect Dr. Ashley appreciates. They also own the quality control, so should a problem occur with equipment, Simplifeye switches it out-no questions asked.

	“The customer service is fantastic, and in this day and age, I don’t think there’s a lot of great customer service out there. But they have it,” she says.

	Valadez appreciates how the practice runs on schedule now and has decreased wait times for the patients. Patients have noticed the difference, too. “When we first started using it, patients said they felt special because the doctor was using technology. They saw that she had invested in her practice,” she says.

	Dr. Ashley says few things have changed how she practices dentistry, but Simplifeye is one of them. It has reduced stress, streamlined the patient workflow, and improved efficiency and productivity. For those who are reluctant to adopt new technology, she advises them to be open to it. She recommends embracing the system and learning to use it correctly because teams will love it and wonder how they ever got along without it. “It doesn’t matter if you are straight out of school or in your 70s, it’s an easy thing to do and incorporate into your practice. And it’s better for your patients.”

How one practice changed its communication system and increased productivity.  

Using Simplifeye to streamline workflows

	Since its inception in 1955 when Dr. Michael Buonocore first discovered that you could adhere to enamel using acid, adhesive dentistry has changed the way dentists treat patients. However, while Buonocore’s findings serve as the basis of adhesive dentistry, much of the science has changed. Moreover, advances have made adhesive dentistry more streamlined.

	Dr. Daniel Poticny, DDS, who practices in Grand Prairie, Texas, explains that cementum, dentin and enamel bond differently. Enamel bonds are durable while dentin bonds may start strong but can weaken with time. Cementum bonds, on the other hand, are notoriously poor because their structure doesn’t lend itself well to adhesion.

	The gold standard for adhesives resides with the “fourth-generation” products using three bottles (acid+primer+adhesive), regarded as difficult to use but that yield the best overall performance. Subsequent generations five through seven simplified things yet yielded mixed results.

Related reading: How to achieve clinical confidence with universal adhesives 

	A new category of adhesives now exist that transcends the generational approach. Dr. Poticny believes universal adhesives are in a class of their own, with efficacy that rivals the fourth-generation adhesives but without the complicated procedures. “Doctors would be well served to strongly consider the use of universal adhesives today,” Dr. Poticny says.

	Dr. John Burgess, DDS, MS, and dean of clinical research at the University of Alabama at Birmingham, agrees that dentists should use universals. “When you get to second- and three-year recalls on a material and you're getting great results, this is very good material.”

	Universal adhesives can be used with the self-etch, selective-etch and total-etch bonding technique. The adhesive MDP monomer contained in most universal adhesives enables effective bonding to calcium, dentin, enamel, zirconia and metal alloys.

	But there are some important facts that many dentists might not know about universal adhesives. Our experts shared their expertise about these versatile and efficient materials, including these seven things you probably didn’t know about universal adhesives.

	#1: The first universal adhesive has a 100% retention rate after three years with a total-etch approach.

	Universal materials were introduced in 2012. Dr. Poticny says he has used universals since then and believes his own observations agree well with the controlled clinical and in-vitro data generated over nearly five years.

 was the first universal adhesive introduced. “It has the 10 MDP Monomer [10-Methacryloyloxydecyl dihydrogen phosphate], an adhesive phosphoester monomer, so that particular adhesive monomer bonds the adhesive directly to the calcium and to zirconia and other materials, particularly base metal alloys,” Dr. Burgess says.

	Dr. Burgess and his team are working on the 5-year recalls for 

 used in a total-etch and self-etch mode. While those results are not yet available, the 3-year recalls had a 100 percent retention rate using the total-etch technique. Retention dropped to 94 percent with self-etch, and there was more leakage around the restoration. Dr. Burgess recommends using either total-etch or selective-etch approaches when using universal adhesives, not only because of the improved retention, but also due to the decreased marginal staining around restorations using the total-etch technique.

	#2: Universal adhesives have a higher pH level than other adhesives.

	Phosphoric acid etches enamel well and, as Dr. Poticny says, “enamel likes an aggressive etch.” In the generations of adhesives, pH has been a factor for bond strengths. In particular, the self-etchers had challenges with bond strength.

	“They later discovered that was because the acid was weaker in the self-etchers, it was also a weaker bond to the enamel,” Dr. Poticny says. While the mild etch pattern was good for the dentin, it was poor for the enamel. “There were tradeoffs,” he says.

More from the author: Why better adhesion means happier patients 

	The pH of phosphoric acid ranges from .3 to .4. The pH of the primers ranges from .7 to 2. Dr. Burgess explains that universal adhesives have a pH of 2.3 to 3.2, so they won’t etch enamel as well as phosphoric acid and should be used with a selective or total-etch technique.

	#3: The application techniques are simplified with universal adhesives.

	Universal adhesives work with direct and indirect restorations, desensitization, sealants and restoration repairs. Universal adhesives also allow separate etching of the enamel (unlike self-etch-only products) without compromising bonds to dentin. Moreover, universal adhesives achieve high bond strengths to enamel in comparison to the self-etchers.

	“It's got everything in it,” Dr. Poticny says. “Simply put, it will enable bonding to virtually any substrate or material with exception to high noble metals. Dentists can throw all this other stuff away that they've got in their office. And because there's only one system that you need to know, it's easy to repeat the same technique every time.”

	Bonding is an active process, so agitation is still necessary. But since universal adhesives are filled materials (from 4 to 8 percent), a reliable bond will develop even with fewer applications.

	“With older generation adhesives, at least two applications were needed to develop an adequate bond. With universal adhesives, one single application seems to be adequate,” Dr. Burgess says.

	“The biggest thing for me is streamlining workflows and reducing the number of adhesive systems needed while improving consistency and outcomes,” Dr. Poticny says. “I've been in hundreds of dental offices over the years and watched doctors operate. Typically, they inventory three adhesive systems or more depending on the dental procedure.  This is costly. It also requires familiarity with numerous products and their use, as well as the need to monitor inventory for expiration and the like.  Just remembering instructions alone can be a challenge.  Either way, one system makes sense if outcomes are not compromised.”

	Dr. Burgess says that a good curing light is essential for excellence in adhesive dentistry and recommends placing the light as close to the tooth as possible, preventing movement of the light guide and then curing it. Furthermore, he also suggests directing an air stream over the end of the light guide if you are close to the pulp when curing.

	“That dissipates the heat that's being generated in your curing light,” he says.

	He also advises frequent tests of the curing light.

	“If the curing light has been dropped, take the light guide and put it on newspaper print. If the print is displaying accurately on the end of the light guide that is visible, then you know that the light guide is not fractured along its length. These light guides run from $120 to $180, so don't replace them capriciously. But at the same time, you want to replace them when they are chipped or fractured because that diminishes light output,” Dr. Burgess explains.

	#5: Universals are much more resistant to contamination than their predecessors.

	The fourth generation, two-bottle, total-etch systems were susceptible to contamination because of their longer application times and multiple steps for each application. Contamination lowers the bond strength of all adhesive systems, but older two-bottle, total-etch systems are more prone to contamination. Dr. Burgess and his team have worked with 

 and the Scotchbond Universal adhesives and noted that with the shorter application time, the window for contamination for these materials is significantly shorter.

	“Even though the bond strength may not be quite as high as with some of the fourth-generation materials, clinical success seems to be better because the universal adhesives can be applied quickly (with fewer steps), reducing the negative effects of contamination,” explains Dr. Burgess.

Trending article: 3 ways mishandling adhesives contributes to restorative failure 

	Dr. Poticny agrees, saying, “Doctors would do well to investigate universal adhesives from any one of the reputable manufacturers. They tend to be a little bit different, but they're all designed with the same intent in mind. Could you give something up in the way of bonds? Yeah, but I don't think it's clinically significant today. They're that close in performance to the Gen 4 materials.”

	#6: Universals have a separate bonding mechanism in addition to the hybrid layer formation.

	All bonding agents create a hybrid layer consisting of collagen encased adhesive. Total-etch hybrid layers are thicker and more consistent than self-etch hybrid layers. However, Dr. Burgess explains that universal systems have a separate bonding mechanism by creating a chemical bond from the 10 MDP monomers to the calcium in the tooth. This makes the bond more durable-and getting more so all the time.

	“We're looking forward to another generation of adhesives that is even a greater breakthrough,” he says.

	#7: Most universals bond well to zirconia.

Two adhesive experts share their expertise and insight about universal adhesives.