Temporomandibular disorder (TMD) is painful and frustrating, and patients are seeking relief. According to the National Institute of Dental and Craniofacial Research, approximately 11 to 12 million adults in the United States report pain in the region of the temporomandibular joint. TMD is twice as common in women as in men.

 There are a lot of methods to treat TMD, but unfortunately, many are not backed by science.

That means patients often spend a lot of time and money and still end up hurting. I spoke with Anthony P. Urbanek, DDS, MD, MS, who has dedicated his life to exploring and researching effective treatment for patients with TMD. He reports incredibly positive results with his Urbanek TMJ Device, which is designed to relieve the inflammation that causes TMD.

Lou Shuman (LS): Tell us about your background and experience.

I’m an oral maxillofacial surgeon in Nashville, Tennessee, for the past 43 years. I love research and have a dental degree from Indiana University, a master’s degree in cell biology and anatomy from Indiana University – [Purdue University] Indianapolis, and a medical degree from Vanderbilt [University]. I was a fellow with the National Institute of Dental and Craniofacial Research for 2 years. My early career focused on major facial reconstructions—orthognathic surgery, cleft palates, trauma, cancer reconstruction, and microneural procedures.

My interest in TMD increased as I performed about 2000 temporomandibular joint surgeries, both open joint and arthroscopic. Over those 30 years, too many patients would return with pain. I started researching and interviewing patients and encouraging them to tell me everything about their symptoms. I found a common thread. If the patient put their finger or pencil eraser between their front teeth, it would feel better. With that in mind, I created a device that went on the roof of the mouth behind the front teeth that patients could wear consistently, except for mealtimes. After using the device on patients with various symptoms, at an average of 3 weeks, [I noted that] roughly 70% of their symptoms were diminished or gone if they followed the protocol. Some of these patients had [experienced] 20 years of headache, earache, [and] jaw and neck pain.

LS: What are the main symptoms this device can help with

3. Pain in and around the temporomandibular joint (ear pain or jaw pain radiating in and around the temporomandibular joint)

4. Dizziness or ringing and fullness in the ears.

LS: What happens during “the Urbanek exam?”

First, measure the interincisal distance. Are there limitations on opening?

Second, use your finger to put pressure on the coronoid process. Move up toward the joint—everyone who has TMD will basically jump off the chair.

Number 3 is looking for exostoses—mandibular tori, palatal tori, and maxillary or mandibular exostoses on the lateral part of the jaw. Exostoses proves that they brux (which is a component of TMD).

Next, ask the patient to open as wide as they can. On the outside of the patient’s face, place your fingers firmly in the depression where the condyle comes out of the glenoid fossa. Press firmly in the glenoid fossa, and ask them to bite as rapidly as they can into occlusion. If there is inflammation in the joint, they are going to feel some pain.

If the patient has these symptoms, the exam is positive.

LS: If the patient has exhibited the symptoms, what next?

Armed with the information, the dentist needs to educate the patient and explain that inflammation within the temporomandibular joint will cause all these symptoms.

Then, explain that the way to relieve the inflammation that is causing the pain is [with] the Urbanek appliance.

The device, customized to each patient, unloads the joint just like a set of crutches unloads an inflamed knee. The patient starts by wearing the device 24/7 for 2 months, and then at nighttime only for the rest of their life. That works for about 85% of the patients. We have completed 4000 patient cases with a success rate of 95%, [which indicates what can happen] if they follow the protocol.

LS: How can a dentist learn the Urbanek method?

Dentists can take the 2.5-hour online course to [be] successful and safe with the basics of the method. After listening to the whole course and taking a short test for CE [continuing education] credits and certification, they receive certification to use the device. Also included is a package to promote and educate their patients and referrals on this life-changing TMD treatment, and of course, personalized customer support.

The goal of every innovator is to teach, educate, influence, and impact. The goal of every practitioner is to improve the quality of life of our patients. Practitioners are echoing the patient success that Dr Urbanek describes. Kevin Stoller, DMD, of Simpsonville, South Carolina, says, “This device has successfully eliminated the TMD-related symptoms of my patients who have been suffering for years.” Brittany Westerman, DMD, of Florence, Alabama, concurs: “There is no better feeling than eliminating the pain that my TMD patients struggle with.” Even though researching and finding treatment for TMD has been a rocky road, it is refreshing to see someone who has approached this condition with Dr Urbanek’s level of professionalism.

For more information about the Urbanek TMJ Device and Protocol, visit 

1. TMD (temporomandibular disorders). National Institute of Dental and Craniofacial Research. Updated March 2023. Accessed June 6, 2023. https://www.nidcr.nih.gov/health-info/tmd

Articles

The Urbanek TMJ Device is designed to relieve the inflammation that causes temporomandibular disorder, and the results have been promising.

Reducing Inflammation Is Key to Relieving TMD Symptoms

Fossil Creek Dental Partners in Fort Worth, Texas, is mainly a restorative practice. Chad C. Duplantis, DDS, FAGD, and his staff treat patients of all ages with a focus on high-level restorative dentistry.

Prior to switching to Hemaseal & Cide, Dr Duplantis, who has been in practice for more than 20 years, was using 2% chlorhexidine. “I had tried other antimicrobials in the past, as they are important to adhesive dentistry. The benefit of an improved bond strength is something that I was always looking for, as are most dentists. Chlorhexidine has been proven effective following etching in reducing MMPs (matrix metalloproteinases), which can have a detrimental effect on bond strength. Much of the research led me to believe that chlorhexidine was extremely beneficial,” he says.

Hemaseal & Cide, in addition to having 4% chlorhexidine, has the added benefit of 2-hydroxyethyl methacrylate (HEMA) for penetration of the bonding agent into the dentinal tubules, and because it also has 4% chlorhexidine, Dr Duplantis wanted to try it in his practice. “I felt that this was a really great combination to further enhance my bonding strengths,” he explains. “There is a lot of research on the benefits of both ingredients. So, this unique combination was a must. Additionally, 

 had tested the product and found that it had an extremely favorable zone of bacterial inhibition. With this being said, I feel that this is the perfect union of 2 products for increasing bond strength AND reducing sensitivity.”

Hemaseal & Cide is easy to use and to apply and provides a confidence boost for bonding of restorations, according to Dr Duplantis. “The biggest improvement is something that the naked eye or any practitioner will not be able to truly appreciate. As with any bonding agent or enhancement product, I want something that is easy to use, enhances longevity of the restoration and does not create postoperative sensitivity,” he says. “My restorations are lasting, it doesn’t disrupt my workflow, and my patients do not have sensitivity. So, this checks all the boxes—long-lasting restorations and no sensitivity.”

The desensitizer is hard on bacteria, as it prevents microleakage around restorations, yet soft on the surrounding soft tissue so that it does not sting the gingiva upon contact. Application of Hemaseal & Cide is simple—apply with a microbrush, remove the excess, and that’s it.

When asked how the product might be improved or whether he might switch to another product, Dr Duplantis says: “The only thing that I’d love to see is it delivered in a syringe with a brush tip or sponge to scrub it in, but it works great as is.”

Texas dentist Chad C. Duplantis, DDS, FAGD, adopted the use of Hemaseal & Cide in his practice and says he is glad he made the switch.

Up Next: Hemaseal & Cide Desensitizer

Back in 2014 I was at a place in my practice where I was doing well but hitting a plateau being in preferred provider organizations (PPOs). I was working long hours and questioning why dentistry seemed so hard.

I was giving my best and feeling I was not being compensated for the quality I was providing. Taking a long, hard look at where I wanted to be in 3, 5, or 10 years, I knew I needed to find a way to brand my practice to achieve the growth I wanted but also to figure out how to have a life away from the dental practice. I also wanted to work smarter, not harder.

Feeling motivated, my husband and I began our online research, looking for inspiration on how other practices like mine positioned themselves for growth. Though marketing is foreign to me, I can recognize a good dental practice website when I see one. The websites that most caught my eye had all been developed by the same company.

After seeing what was out there, I realized that the only way to really grow would be to place my practice in the hands of a partner specializing in dental practice growth. This decision has not only resulted in an increase in my annual pretax profits but has helped me understand how to gain more time off each year, better support my team both financially and physically, and made me a better business owner.

I am sharing my story because I want other dentists to have the same success I have had. I truly did not know what to do or how to do it, but I found a group who did. And they did not try to put me in a generic box or use a one-size-fits-all approach. Having solid marketing counsel has made all the difference in my life and the life of my practice. I am here to let you know you should run, not walk, to this company if you want to see your practice skyrocket to levels you never thought possible.

Change Is Inevitable, But Who You Partner With Can Make All the Difference

Rebranding and leveling up my practice had its challenges, but anything worth doing usually does. In the long term, I wanted to work less, get out of PPOs, and earn more. A core outcome was to implement a fee-for-service structure by diligently and consistently upgrading my cases. The biggest hurdle? Demographics in my area skewed strongly toward low-income households and PPO-dependent clients. This had been further exacerbated by the recession and housing crisis of 2009, creating a perfect storm for low collections.

I knew I needed a multipronged approach. As much as my research showed that first impressions matter, a simple website update would not be enough to help me grow my business. I wanted to focus on dentistry and the day-to-day needs of my team and patients. Handling this practice upgrade would require a partner experienced in practice growth, employing multiple marketing methods. This is when I reached out to Amplify360 for guidance and results.

We embarked on my practice’s evolution with a practice analysis and regular 360 Reviews to gauge the health of the business. Our main areas of focus were all geared toward helping me become a fee-for-service business, including the following:

Targeting big case marketing (in my case, dental implants)

Increasing regional web presence (I needed a new website, and visibility on Google required a serious boost)

Building strategic direct mail campaigns for untapped patient groups

Launching an in-house subscription membership club for uninsured patients

Establishing a unique brand identity to stand out in the local market

This may seem overwhelming, especially if you are trying to do it alone while taking care of your business, your team, your family, and yourself. But I was not alone. I had a marketing partner with decades of experience, thousands of successful clients, and proven outcomes.

Invest in Yourself, and the Results Will Follow

Leveling up your practice is not something that happens overnight. It takes strategic planning and calculated steps. My marketing partner equipped the practice with the proper training, proven marketing systems, and a detailed blueprint for how we were going to become a fee-for-service practice once and for all, all while increasing profits.

Throughout the process, whenever I had doubts or concerns that we would not hit our goals, my partner encouraged me to push forward. Their support is genuine. Many conversations over the years have been purely encouraging, helping me remain accountable to staying the course. Their unyielding support and expertise helped guide me to achieving a more successful practice, which has enabled me to have a better-balanced life.

I am thrilled to say that after 8 years of carefully configured moves and tactics, along with monthly check-ins with the Amplify360 team to ensure we were on track, my office dropped all remaining insurance patients. The exact date was February 15, 2018—the day I reclaimed my practice and started doing dentistry my way.

Our online presence is knocking it out of the park, and we have hundreds of positive Google reviews that keep attracting more and better patients. Being a fee-for-service operation means we decide what treatments to offer and what to specialize in, and because of this, we are seeing $1.7 million in annual pretax collections.

Not only is my practice earning more profit, but I get more time off throughout the year. My stress levels have decreased, and I have the flexibility and confidence to take time off (I worked 183 days last year) because of my well-trained, very capable team. They can take care of the practice, my patients, and the business while I enjoy what I have worked so hard to achieve. In my case, I wanted more time with my children.

Another welcome aspect of becoming a fee-for-service business is that my practice has taken a giant leap in estimated value. In 2009 it was hovering around $500,000. Now? I am happy to say it is valued at around $1 million.

Investing in marketing for your practice is not just about building a website, following search engine optimization best practices, or mailing postcards. It is about all-hands-on-deck training and education while syncing your practice systems to attract quality patients. It is about hiring the right marketing partner and investing in your business to ensure success.

Amplify360 is unique in that it focuses solely on the dental industry. They know our business inside and out, and that has significantly helped my practice. They are very involved in the process and never leave your side—even when profits skyrocket and goals are met. I am blessed and grateful for what we have accomplished with this marketing partner, and I am confident I will see my practice grow for the foreseeable future.

Using Amplify360, this clinician converted her practice to fee-for-service with notable results—more revenue, less stress, and fewer hours.

How To Collect Almost $2 Million by Being Fee-for-Service (You Too Can Do It)

Artificial intelligence (AI) has rapidly become an indispensable tool in various industries, and dentistry is no exception. The integration of AI technologies into dental practices has revolutionized the field, enhancing diagnostic accuracy, treatment planning, and patient care. Driven by the vision of improving oral health outcomes, AI has opened new doors for dentists to provide personalized and efficient dental care. In this article, I will explore the main uses of AI in dentistry.

One of the primary applications of AI in dentistry is in diagnostics. AI algorithms can analyze radiographic images, such as x-rays and cone-beam computed tomography scans, to identify abnormalities and assist in the detection of dental diseases. These algorithms can accurately locate and classify dental caries, periodontal diseases, and even oral cancers. By aiding in the interpretation of diagnostic images, AI enables dentists to make more informed diagnoses, leading to earlier intervention and better treatment outcomes.

Another significant use is in treatment planning. AI algorithms can process patient data, including dental records, medical histories, and imaging data, to develop comprehensive treatment plans. By analyzing large datasets and utilizing machine learning techniques, AI systems can provide dentists with evidence-based treatment recommendations. This not only improves the accuracy of treatment planning but also helps dentists consider factors that may be overlooked, such as drug interactions or patient-specific risk factors.

AI-powered virtual assistants have also found their place in dental practices. These assistants use natural language processing to interact with patients, answer their queries, and provide information about dental procedures and oral health maintenance. Virtual assistants can enhance the patient experience by offering personalized guidance and education, improving oral hygiene practices, and promoting preventive care. Moreover, they can streamline administrative tasks, such as appointment scheduling and reminders, reducing the workload of dental staff and improving overall office efficiency.

In the field of orthodontics, AI has made significant strides. Algorithms can analyze dental models and images to assist orthodontists in treatment planning and the design of orthodontic appliances, such as braces and aligners. By simulating tooth movement and evaluating different treatment options, AI systems can optimize orthodontic treatment outcomes. This not only improves the precision and efficiency of orthodontic procedures but also enhances patient satisfaction by reducing treatment duration.

AI-powered robotic systems have also been developed to assist dentists during procedures. These robots can perform tasks such as drilling, implant placement, and tooth preparation with high precision, reducing the margin of error associated with human intervention. Additionally, AI algorithms can analyze real-time data from sensors integrated into dental instruments, providing feedback to dentists and enhancing their decision-making process during procedures.

Furthermore, AI has been utilized in the development of teledentistry platforms. Teledentistry allows patients to remotely connect with dentists, enabling consultations, diagnoses, and even treatment planning without the need for in-person visits. AI technologies play a crucial role in these platforms by facilitating the analysis of patient-provided data, such as images and videos, to aid dentists in making accurate assessments. Teledentistry expands access to dental care, particularly in underserved areas, and improves oral health outcomes by ensuring timely interventions.

AI has revolutionized the field of dentistry by enhancing diagnostics, treatment planning, patient education, and procedural precision. The integration of AI algorithms and technologies has enabled dentists to provide personalized, evidence-based care and improve overall oral health outcomes. As AI continues to advance, we can expect further innovations and applications in dentistry, ultimately benefiting both dental professionals and patients alike. The future of dentistry is undoubtedly intertwined with the capabilities of AI, and it holds tremendous potential to revolutionize the way we approach oral health care.

Artificial intelligence is rapidly evolving. Tech expert Lorne Lavine, DMD, discusses all the different ways it is changing the dental industry forever.

Artificial Intelligence Changes the Dental Landscape

® reaches out to dental professionals across the United States to get a good idea of just what technologies are most important to working clinicians today. With direct, from-the-source feedback, the 

2023 Tech Census provided insight on just what technologies dental professionals use the most, the ones they’re most looking forward to using in the future, and what they’ve chosen to leave behind in the past.

There was a total of 121 respondents, and answers were rounded up or down to the nearest whole number. Demographically, more than half of respondents are dental practice owners with more than 20 years of experience in the dental profession. More than half are solo general practitioners, while around 30% of respondents are at single-office, multiple-doctor general practices.

More than half the respondents said research is most important when considering a new technology for the dental practice. This may be comforting for patients, knowing that their dental professional did their homework to determine what best fits their dental practice. This is a bit of a bump up from 2022’s results, where 56% of respondents claimed research as being the most important factor.

According to this year’s survey, dental professionals are still most confident in owning familiar technologies such as curing lights, practice management software, intraoral x-ray systems, and more. Emerging technologies such as artificial intelligence (AI) are still met with some resistance; however, plans may change, as 25% of respondents said they will purchase such technologies eventually. This is in stark contrast with 2022’s results, which indicated that only 9% of respondents would purchase AI software within the next year.

Considering a practice’s return on investment (ROI) is important to dental professionals, with 24% of respondents saying that ROI was a deciding factor for them. According to respondents, the technology with the smallest ROI was the same as that of 2022—a digital shade-matching system. Popular technologies in this category included curing lights and digital intraoral x-ray systems.

Regarding whether patients expected to see certain technologies at their appointment, respondents’ answers differed across the categories. Technologies such as artificial intelligence and 3D printers may still be a luxurious concept for patients, whereas other technologies such as loupes and curing lights are viewed as staples in everyday dental practice, per the respondents.

A technology that stands out in each response is artificial intelligence. This quickly growing technology has permeated other markets, so it stands to reason that its steps into dentistry are already taking place, and care may be improving because of it. Respondents also agreed that advanced restorative materials are primed to affect dentistry’s future, especially as the biology and science behind these materials is more widely researched and understood.

Respondents were split on what technologies were overhyped in the dental industry. Although 35% agreed that 3D printing may be overhyped, about 30% made the same claim for artificial intelligence. It can be difficult to come to a consensus on whether a technology is indeed overhyped, as some practitioners may find these systems work for their practice and others may not. Time will tell if these products live up to the claims or if they fall flat.

If money were not a factor, what technology would you add to your practice and why?

This open-ended question gave respondents the opportunity to voice their thoughts on what technologies would be worth another look if they didn’t have to worry about a steep price tag. Popular answers here included artificial intelligence for a second opinion to help doctors, CBCT systems for digital imaging capabilities, and CAD/CAM for in-office manufacturing. Lasers were also a popular answer, both soft- and all-tissue.

The results of Dental Products Report 2023 Tech Census are in, with answers giving insight into what dental professionals are using in today’s practice. 

Tech Census 2023: Looking at the State of Dental Technology Today

For this month’s column I found myself thinking about some of the dental technologies that never quite caught on. Some of those concepts were good ones, but just never gained traction. Others were not so good, and we are probably all better off that they were put out of their misery. In my dual role here as chief dental and technology editor, I get the chance to see and test a lot of products. I love the fact that our profession is always pushing forward with new technologies and new ideas.

Often in our profession, and in life for that matter, we see ideas that we inherently know just will not work. However, after we have determined they are hopeless, we then see other people using the idea or device with great success. I am sure you can think of something right now that you had doubts about that is now a mainstream success. How in the world does that happen?

Dentistry can be a closed-minded profession sometimes, and although that can be a good thing, it can also be a detriment. In a single-doctor practice, the doctor is the lord of the castle. The good news is that as more and more offices are becoming multidoctor, that means those offices are also multiopinion. There is more than one person who can make points from the doctor point of view and who can expand horizons and increase adoption of new technologies, techniques, and materials.

Expanding your horizons is a good thing, and I’m excited to see our profession opening up more and more to new procedures, new materials, and new thought processes. How do we do this the right way? How do we know what will work and what won’t? How does an office know when is the right time for change and what change to adopt? I have been a lucky guy in a lot of ways. I have made a career out of embracing change, and often I have had peers and patients ask me, “Why did you choose X?” or, “What made you decide on Y?” I am going to share some ideas that I have used (and some I’ve, ahem, borrowed) that have served me well over the years when it comes to integrating new ideas and new hardware into my workflows.

Whenever I am presented with a new idea for the clinical aspect of dentistry, my first thought is always, “What is the end result?” It is a simple matter of looking at what the procedure provides. If it gives my patients the same outcome or a better outcome than I am delivering now, then I decide to give it a closer look.

I have learned that change always requires time and effort. If I get a better result in the long run, then I am willing to invest that time and effort. However, if I get lower quality, where is the upside?

This rule applies to either procedures I am currently performing or procedures that a new technology might allow me to perform that I don’t want to do the current way. Two examples that come to mind are crowns and soft tissue surgery.

The crown proposal comes from in-office milling. There are tons of advantages. Things like no temporaries, no second appointments, and no lab bills are clear advantages and a win-win for the doctor and patients. But if the restorations are of lower quality I cannot, with good conscience, place them in the mouths of my patients.

However, when I analyzed the restorations produced by the DGSHAPE DWX-42W, I found that they were of equal or better quality than what I was delivering “the old way.”

I did not do much soft tissue surgery before I purchased my first laser. Scalpels and sutures don’t conjure the best images for referrals, so I referred those cases to specialists. When I explored the possibilities that came with the use of soft tissue lasers, a whole new world opened up for me.

I began providing cosmetic recontouring, biopsies, and frenectomies in a bloodless environment. Lasers provide almost pain-free recoveries and rarely require sutures. Those cases I had been referring became routine procedures. When you factor in things like troughing for fixed prosthetics (which eliminates retraction cord) and periotherapies, lasers created a whole new way for me to help my patients.

Quality is the most important factor, but time is next in line as far as I am concerned. No one wants dentistry to take longer. Certainly, our patients don’t want that. As we all know just from thinking about our own lives, the last thing we need is more things to do or less time to do our current tasks in.

I humorously tell people, although it is true, that in all my years of practice no one has ever asked for a procedure to take longer. Patients don’t want extra “drilling” or extra time in the rubber dam.

For the doctor and team, time savings is also a huge benefit. If a technology cuts minutes off a procedure, that is 10 minutes less the doctor and assistant spend in what I refer to as “the clinical posture.” Even with the best ergonomics, dentistry takes a physical toll on those of us who deliver it. The less time we spend in “the clinical posture” the better it is for us physically.

A few years ago, I learned that around 65% of doctors who file for physical disability do so because of neck and back injuries from practicing. That is a large number. Anything you can do to keep yourself out of that posture could very well save your career. Now, some of you reading this are probably thinking that if you can save time, you could see more patients and make more money. That is true, and if you are young and healthy that might work for you. For me, at this stage of my career, it is about staying healthy. And by the way, if you stay healthy and are not forced to retire early, that means more years of practice at a less hectic pace.

Like it or not, dentistry is a business. I dislike that fact probably as much as you do, but there is nothing we can do about it. As I have said plenty of times here, you can be the best operator in the world, but if you cannot make a profit and stay in business, your skills will not benefit very many people. Because of that, it is imperative that we make sure that any new things we incorporate also have positive cash flow.

There is one thing here I want to make perfectly clear: If you want to make a good living in dentistry, focus on your patients and not on dollars. If you do your very best and care about your patients, you will be just fine financially. My point here is that you need to make sure that what you buy helps your business and does not hurt it.

Using the examples I mentioned earlier of in-office milling and lasers, let’s explore the cash flow aspect. Milling crowns in the office reduces chair time, reduces lab bills, and can also reduce supply expenses. Those are all good reasons to consider a mill. It might not generate new revenues, but it cuts your costs and increases patient satisfaction, so the benefits are definitely there. When we incorporated our DGSHAPE DWX-42W into our workflow, not only did we get amazing clinical results and cut costs, we also got referrals from patients delighted and impressed with the services the mill delivers.

Lasers allow me to perform procedures that I had not been providing. When I referred patients to a specialist, that revenue went to another office. By keeping those procedures in house, I was able to increase revenue by doing procedures that I would not have done were it not for the investment in lasers. Considering the low costs associated with today’s diode lasers, the devices opened up an entirely new revenue stream for the office. Combining that fact with patient amazement and satisfaction meant we also increased referrals, which boosted the bottom line as well.

Any time you do something for the first time, you are going to make mistakes and/or have unexpected problems. That is a well-known fact. No matter what the procedure, we become more proficient by making mistakes and then integrating course corrections as we learn. That little adage holds true for anything you can think of, whether it is a complicated dental procedure or even learning to ride a bicycle. No one ever learns without making mistakes.

Because of that, it is important to try to work out all the kinks ahead of time. Before we ever “go live” with a new procedure or device, I work the details out on the bench. I am a huge believer in the expression “failing to plan is planning to fail.” That is why I sometimes spend hours trying things out in a controlled, nonclinical environment before finally going live with patients. That also applies to staff. Before we went live with design and milling, my 2 designated milling assistants designed and milled about 10 crowns each. By doing this, many of the mistakes or problems you might otherwise face in front of the patient have been discovered and corrected beforehand.

I love history, and one of the best examples I can think of for the benefits of bench testing comes from the May 1, 2011, raid by Navy SEALS of the Abbottabad, Pakistan, compound. When asked by President Obama, “Can you do the mission, Bill?” Admiral William H. McRaven replied, “Sir, I don’t know. I really need to bring the guys in, and we need to rehearse this.” The president asked how long that would take and McRaven told him it would take 3 weeks, to which Obama replied, “OK, you’ve got 3 weeks; report back to me in 3 weeks.”

Navy SEALS had performed multiple raids such as the Bin Laden mission multiple times, yet they still needed 3 weeks to work out the bugs for this very specific objective.Hopefully that tells you something right there. Even experts practice.

Too many times I have seen doctors try to “run before they learn to walk” when it comes to integrating new things. When that is done, things tend to go sideways and then everyone blames the technology and they go back to doing things “the old way.” My advice is to bench test to the point of over preparedness and then, for the first few procedures, expand the appointment time to more than you will need. It is much easier to deal with unexpected problems when you are not stressed about the schedule. Simplicity and adequate time are critical when learning and trying new things.

It is also critical to make sure you have your team adequately trained on the new procedure. No one wants to look confused or lost in front of a patient, so making sure that everyone has a clear comfort level is incredibly important. The more relaxed your staff is, the better the experience for the patient. That comfort comes from practice and understanding.

It is also tremendously important to get staff buy-in when you make changes. When the staff believes in the change and is excited about it, they want to succeed as much as you do. That enthusiasm is infectious. The assistant will spend more time with the patient than the doctor and if the assistant is on board and excited about this, that will transfer over to the patient. When patient, assistant, and doctor are excited about it, that creates a kind of “circle of positive energy” that makes everything go more smoothly.

We must remember that change is inevitable. The important part of change is how we handle it. History is full of examples of individuals, companies, and even empires that failed to embrace change and were swept away because of it. I find it fascinating how change is such an inherent part of our universe and plays such a critical part in everything around us, yet our instinctual reaction when we are faced with change is to resist it.

We are living in a time where change has accelerated our lives. I think it is fair to say that things are changing faster now than they ever have before. What was cutting-edge 5 years ago is frequently passé or even forgotten about today. That is why I continue to be excited about what I do both in my office and with all of you in my columns and my lectures.

As a lot of you know, I am a big fan of quotes. I have a folder on my computer where I keep them, and sometimes, in a quiet moment, I open that folder and browse through them. It is amazing how profound our fellow human beings can be and how much guidance simple phrases can provide us with.

To end this month’s column, I would like to leave you with a quote from Charles F. Kettering. He was an incredibly bright engineer whom, for some reason, many people have never heard of.However, you have heard of some of his inventions. He held 186 US patents and probably his most famous invention was the electric starter for the automobile, which did away with hand cranking and brought mobility to the world. Before his invention, the problem had been called “unsolvable.”

One of my all-time favorite quotes is this:

“I am not pleading with you to make changes. I am telling you, you have got to make them—not because I say so, but because old Father Time will take care of you if you don’t change. Advancing waves of other people’s progress sweep over the unchanging man and wash him out. Consequently, you need to organize a department of systematic change-making.”

Now get out there and let’s change the world!

Change is inevitable, and embracing change is a key aspect of succeeding in dentistry and life. 

How Not to Fail

Modern dental materials can inspire wonder and amazement. With a flash of blue light, previously soft substances harden into toothlike structures—just like magic.

However, although it sounds like a spell in a fantasy novel, polymerization is not enchantment; it’s chemistry. We spoke to materials science experts to reveal the chemical processes and how these fundamental building blocks affect what is happening with your materials.

We begin with an overview of some of the introductory chemistry that is involved with modern dental materials from Nate Lawson, DMD, PhD, MA, an associate professor of biomaterials, division director of the University of Alabama Birmingham (UAB) School of Dentistry, and program director of the UAB School of Dentistry Division of Biomaterials. As Dr Lawson explains:

Dental materials are either polymers, ceramics, metals, or a combination of these. Most dentists practicing contemporary adhesive dentistry use ceramics, polymers, and composites of these 2 types of materials.

Ceramics are composed of ionic or covalent bonds that typically form crystalline or amorphous structures. These ceramics may be very strong but are typically brittle, meaning they do not deform before fracture. Ceramics also have little water sorption, so they do not accumulate stains easily.

Polymers are typically composed of long-chain and cross-linked molecules. They generally are more flexible and ductile than ceramic, meaning they can bend before cracking.

Composites of ceramics and polymers can take advantage of both types of materials. The polymer (or resin) can typically act as the binder that holds the material together and provides some flexibility. The ceramic fillers give the composite strength.

Tim Sedlacek, research scientist and supervisor at BISCO, continues with the basics. He says most modern dental materials include a resin, a mixture of methacrylate monomers that are small and mobile enough to be flowable. Curing that resin means setting off a free radical polymerization chain reaction in which a series of electron transfers link the separate monomers into a much larger network. That chain reaction could be started by a light source exciting photoinitiators such as camphorquinone (ie, light cure), by an oxidation-reduction reaction of 2 or more chemicals in the resin (ie, self-cure), or both at the same time (ie, dual cure).

“Glass fillers measuring from the micrometers down to the nanometers can be mixed into the resin to make a paste with varying thickness, handling, and color desired for product use,” Sedlacek explains. “When the resin cures, the fillers are trapped in a polymer matrix—making the result a strong, durable, esthetic material.”

Brad Craig, PhD, senior division scientist at 3M, has developed numerous restorative dental materials in his time with the company, including their universal composites such as Filtek™ Supreme Ultra Universal Restorative and Filtek Universal Restorative; their adhesives, such as Adper™ Single Bond Plus Adhesive; resin-modified glass ionomers materials such as Ketac™ Nano Light-Curing Glass Ionomer Restorative; and bulk fills such as Filtek One Bulk Fill Restorative. His wide range of experience in chemistry includes nanotechnology, surface chemistries, composites, dental filler technologies, particle processing, hard tissue adhesives, and glass ionomer materials.

Dr Craig describes most modern restorative ceramic dental materials, such as zirconia or lithium disilicate materials usually used for crowns and bridges, as high-tech, high-performance rocks. By contrast, modern-day adhesives, such as composites, cement, sealants, glass ionomers, and the like, are polymer (plastic) or polymer/ceramic (plastic/high-performance rock) composite materials. These materials, either polymers or polymer composites, comprise precursor reactive monomers, initiator systems, and inorganic filler materials.

Also, there are preventive products that protect, reinforce, and possibly heal the tooth structure. Sometimes these products contain fluoride only, Dr Craig says, or the products incorporate fluoride with calcium and/or phosphate release as well.

Koichiro Hirata, marketing department manager at Tokuyama Dental Corporation, agrees that for resin composite, the monomer, filler, and polymerization initiator are considered essential for physical properties. In addition, Tokuyama has leveraged the performance of its filler technology to enhance its performance.

“We research and develop our filler technology so the supra-nano spherical filler used in our resin composite will have enough mechanical strength and achieve high esthetic results,” Hirata says.

How Do Restorative Materials Leverage These Chemical Processes Today?

“Not all monomers or fillers are equal,” Sedlacek says. “Monomer choice affects strength, translucency, shrinkage, viscosity, and many other properties.”

He explains that various types and blends of fillers will affect properties, including radiopacity, polishability, and elasticity. In addition, surface treatment of the filler particles can make the difference between a durable, long-lasting material and something that degrades or allows water to seep through.

“We adjust the types and ratios of resin and filler to make one product ideal for filling cavities and another for luting a crown, all while optimizing longevity, biocompatibility, and esthetics,” Sedlacek says.

In the restorative materials Dr Craig describes, specific chemical processes are leveraged in significant ways to produce properties that, to the non-chemist, might seem magical. For example, focusing on the polymer or polymer/composite materials, these start as a precursor “resin” material with reactive groups triggered by a mechanism induced by the dental practitioner, such as light activation or mixing a 2-part system. The induction mechanism starts a chemical cure or acid/base interaction between ingredients on the 2 sides mixed together.

“The light energy interacting with photoinitiators, or the 2-part chemistry, starts the reaction [that] turns the liquid ‘resin’ into a solid polymer, or plastic material, often reinforced by the inorganic fillers [that] are surface modified to wet out and react with the resin matrix, giving the material its characteristic mechanical, physical, optical, adhesive, and wear properties once cured,” Dr Craig explains. “The overall behavior of these materials is dictated by the characteristics of both the resin and filler systems that comprise their component pieces.”

Dr Craig says the relative match of the fillers’ refractive index and resins helps dictate attributes for light-curing systems. These include depth of cure, meaning how deeply the light penetrates, and much of the esthetics and shading of the composites through interactions between light, the restorative material, and the tooth structure.

Nanotechnology, one of Dr Craig’s areas of expertise, enhances dental materials’ performance. These newer filler technologies, such as nanofillers, or materials below 100 nm in size, in dental composites improve mechanical and esthetic properties and can be designed to change the opacity of bulk filling materials through manipulation of refractive index changes in the resin matrix on curing.

“These systems take advantage of these small particles’ different interaction…or lack of interaction with visible light. This allows for a bulk filling material that can cure more deeply but looks more like the adjacent dentition once fully cured,” Dr Craig says.

Adhesive and cement chemistries utilize acidic chemistries to do their jobs. These chemistries help etch and chemically bind to the more basic tooth surface through the acid-base reactions between the tooth’s adhesive and hydroxyapatite.

“Advancements in resin chemistries have enabled lower shrinkage stress composites for bulk filling materials as well as radiopaque universal dental adhesives that wet out dentin effectively and seal off the underlying tooth structure, leading to a stable interface and strong bond,” Dr Craig explains.

The filler technology has much to do with their OMNICHROMA composites’ shade-matching characteristics. Using their patented supra-nano spherical filler technology, Hirata says that Tokuyama’s team can now easily and precisely control the filler size. These fillers are the exact size and shape needed to generate red to yellow color, creating the perfect match for all 16 VITA shades.

The ability to generate color naturally is a process called structural color, Hirata says. It occurs between the interaction of light waves and microscopic structures. This concept includes how soap bubbles, oil slicks, and CDs generate a color. Hirata explains that the surface color changes depending on how the light hits the surface.

Tokuyama’s Smart Chromatic Technology, achieved by uniformly sized spherical fillers, harnesses this natural phenomenon and recreates the red to yellow color of natural teeth. Using structural color in OMNICHROMA ensures no loss in chroma or drop in the value of restoration. Hirata says this approach made a significant splash in dental materials development and continues to do so.

“Our OMNICHROMA composites serve [as] one of the most exciting developments in recent years,” he notes. “After the groundbreaking launch of OMNICHROMA universal composite in 2019, we continued to improve the innovation by offering the same shade-matching capabilities in a traditional flowable, OMNICHROMA Flow in 2021, and finally, in 2023, our bulk fill—OMNICHROMA Flow BULK.”

However, the idea behind structural color sometimes needs a little help, depending on the restoration required and the surrounding dentition. OMNICHROMA’s ability to shade match is prefaced on there being tooth structure around it to recreate, Hirata says.

To help out in these situations, Tokuyama also developed BLOCKER as a companion product for OMNICHROMA. BLOCKER has pigmented color—a generic opaque, A-range shade.

“For example, on a large class IV, there is not a lot of tooth structure, and OMNICHROMA would potentially drop in value since it is pulling the darkness from the back of the throat. Using a thin layer of BLOCKER—minimum recommendation of 0.5 mm—to create a lingual shelf, …OMNICHROMA will pull a more natural tooth shade and the adjacent tooth structure for a seamless restoration,” Hirata says.

Fred Berk is president of Pulpdent Corporation, a family-owned dental research and manufacturing company in Watertown, Massachusetts, founded by Dr Harold Berk in 1947. Berk refers to Professor John McCabe and the visionary article “Smart Materials in Dentistry,” in which McCabe and colleagues point out that most traditional dental materials are hydrophobic, designed to have a relatively “neutral” existence in the mouth.

Some might think if materials are passive and do not react with the oral environment, they will be more stable, have greater durability, and cause neither harm nor injury, Berk explains. However, McCabe et al suggest that this is an entirely negative approach and ignores the possibility that clinicians can achieve positive gains using active (“smart”) materials that behave more dynamically.

It is a fundamental principle of science that biochemistry only occurs in the presence of water, and only materials that can transport water have the potential for dynamic behavior, Berk says. Only moisture-friendly materials can release and recharge significant amounts of calcium, phosphate, and fluoride to support apatite formation and the natural remineralization process. He explains that traditional dental composites are hydrophobic and do not have this capacity.

Berk says resins that stimulate remineralization of damaged tooth structure represent both the holy grail and the future of dental restorative materials.

“Pulpdent’s development of the phosphate-rich, hydrophilic Embrace WetBond [Pit & Fissure Sealant] resin chemistry was the innovation that allowed for the development of dynamic esthetic composites. In addition, Pulpdent overcame the brittleness of traditional composites by synthesizing a patented elastomeric resin molecule that provides fracture resistance to the cured resin,” Berk says.

In 2013, Pulpdent added glass ionomer to these novel chemistries and introduced Activa BioActive materials. Berk describes the product as a breakthrough that launched a new category of esthetic bioactive materials and a new conversation about the possibilities for smart, esthetic, restorative materials for dentistry.

“A true glass ionomer reaction requires a 2-part material, and the next challenge was to create a 1-part light cure bioactive material,” Berk explains. “Pulpdent synthesized and patented a novel methacrylate-functionalized calcium phosphate molecule with highly active remineralization properties, or Crysta MCP technology, that can be added to light cure or dual-cure materials. Pulpdent has incorporated Crysta into our Activa Presto stackable low-flow composite and Lime-Lite Enhanced light cure cavity liner.

“These ‘smart’ materials play a dynamic role in the mouth,” he continues, “and meet the challenge for moisture-friendly resin-based materials that are suitable for esthetic, durable, load-bearing applications.”

Glass Hybrids Are a Different Brand of Magic

Like the materials Sedlacek describes, glass hybrids also have magical chemistry. Gaurav Joshi, PhD, BDS, FICD, product marketing manager for GC America, explains that their EQUIA Forte®, EQUIA Forte Coat, and EQUIA Forte HT are all part of their glass hybrid restorative system.

The mixtures of chemistry result in a restorative system designed to deliver exceptional physical properties and the esthetics patients want. The bulk fill introduces ultrafine and highly reactive glass particles and longer acrylic-acid chains dispersed within the conventional glass ionomer structure. The self-adhesive coat contains a highly reactive multifunctional monomer that provides high surface hardness and wear resistance.

Dr Joshi says that the products are available in a unit-dose delivery (capsule), which contains fluoro-aluminosilicate glasses and polycarboxylic acids. The chemical reaction creates a restorative material that releases chemical ions that improve the health of the tooth they restore.

“What’s special about it and why we call it a glass hybrid is [that] it’s a mixture of different sizes of glass particles. So when the glass reacts with the acid, there is a chemical reaction, and ions are released. The ions include fluoride, calcium, and strontium, which help in remineralization of teeth,” Dr Joshi explains.

There are 2 main benefits of using a mixture of glass particles, according to Dr Joshi:

It increases the strength of the material.

It improves the handling of the material, reducing the “stickiness” that can occur with restorative materials.

Another significant benefit of using these materials is the self-adhesive nature of the restorative material. Dr Joshi says the materials chemically bond to the tooth without a bonding agent. When the restorative materials harden, the calcium from the tooth forms a bond with the carboxylic acid group and matures and strengthens over time. Per Dr Joshi, one would not see secondary decay associated with these materials.

“For resin composite, the interface between the tooth and the composite resin is the weakest part, and that’s where you see secondary caries over several years,” Dr Joshi says. “But with glass hybrids, that is the strongest part. So that chemical bond matures over the period, creating a hypermineralized interdiffusion zone.”

However, when the filling has been placed, it needs protection for the first 24 hours, Dr Joshi explains. The system includes a resin coat that dentists place on top of the glass filling. The coat is a nanofilled resin with a film thickness as low as 35 to 40 μm. Dr Joshi explains that the coat provides wear resistance, protecting the glass body against acid and abrasion. When the coat wears off, the glass hybrid undergoes a unique second maturation, increasing the restoration’s hardness.

“When the initial maturation part of the chemical reaction [of the filling] is taking place, and the material is relatively weaker and developing its strength, this resin coat protects it during that initial phase,” Dr Joshi explains. “[Data from] our studies estimate the coat to stay there for about 6 months. It will wear away eventually because it’s such a thin coat, but by the time it wears out, it has done its job because we place it to give the restoration time to mature.”

Another benefit of glass hybrid chemistry is an ion exchange between the ions in mouth saliva and the restoration. Dr Joshi says their study findings show that glass hybrids can be recharged with fluoride because of this exchange.

“So if the patient is using fluoridated toothpaste or mouthwash, these materials reabsorb fluoride and rerelease fluoride into the mouth,” Dr Joshi says.

Because of the mixture of glass materials, glass hybrid technology is appropriate for stress-bearing areas, smaller Class I or smaller Class II, Class V, or occlusal areas, Dr Joshi says. The materials are also suitable as liners or small core build-ups, he notes. In addition, he sees them also as excellent materials to consider when replacing amalgams because they hold up well in occlusal areas.

Although there is some overlap in indications with resin-modified glass ionomers, glass hybrids are excellent when releasing fluoride and the compressive strength of the material is a concern. Therefore, he thinks the material you choose will depend on the situation.

Dr Joshi says another notable chemical feature of the materials is that they act as smart materials. In this instance, the fluoro-aluminosilicate glass releases more fluoride into oral environments with a low pH and higher acidity.

Based on this characteristic, Dr Joshi says these materials are excellent for compromised situations, where patients have an increased risk for caries, and for geriatric or pediatric patients, when dentists cannot isolate the tooth properly. It also works when the preparation is in an area of the mouth that is tricky to isolate.

“If you have a wiggly child in the chair and you need to get the child in and out quickly, so you don’t have time for a rubber dam or you don’t even have time to isolate, there is a high chance you will contaminate the tooth and then the restoration,” Dr Joshi says. “[As] these materials are moisture tolerant, they can bond in saliva. So even if isolation is not ideal, these materials work.”

The Work of R&D Is Where a Lot of the Magic Happens

Matthias Mehring, PhD, knowledge communication manager for VOCO GmbH, explains that research and development (R&D) plays a significant role in why the chemistry of the composites is what it is. At a basic level, all dental composite materials have filler particles and methacrylate resins. Changing characteristics about either of these things is how you play with the chemistry. For example, changing the filler material type or the size and shape changes its behavior during polymerization. Also, adding more or using less filler changes how the material behaves and the benefits it provides.

In addition, the R&D team also can play with the resin’s viscosity to get various behaviors out of the material. Resins with thinner viscosity behave differently from those with thicker ones. Playing with the thickness is one of the things that materials scientists do to get different results.

Whenever you heat something, it changes the viscosity, Dr Mehring says. Heating dental materials benefits dentists in 2 ways. First, Dr Mehring says dentists tell them the handling is easier and smoother. As preparations are not straightforward and require filling small holes and gaps, improving the handling helps, he says.

“You can compare it a little bit with butter. If you remove the butter from the fridge and want to spread it on bread, it’s hard. You can do it, but it takes some time. If it is warm, it’s easier,” Dr Mehring explains. “It’s the same thing we are doing with the restorative.”

Second, heating materials also benefits dentists. For example, VOCO’s thermo-viscous technology makes the composite flowable so it gets into the areas of the cavity that are hard to see or reach.

“To clarify, it doesn’t become soft, like the other composites. Instead we optimize the resin using specific methacrylate, which can become more liquid,” Dr Mehring says.

He explains that this chemistry does not happen accidentally or easily. The R&D team tests different resins with different fillers to get their desired effects. It took a lot of testing to find the methacrylate resin that behaved properly, not only in its conversion to a flowable composite with heat but also for strength and esthetics.

“You have to find the one that’s still maintaining all those other benefits but now can [become] flowable when it’s hot, which is very specific. And you test, test, test, test, test,” Dr Mehring says.

The R&D team also developed the nanohybrid ORMOCER restorative materials that make up the Admira Fusion line. ORMOCER stands for organically modified ceramics. The resin is mostly ceramic but with enough methacrylate to remain compatible with all the other direct restorative materials used in dentistry. Dr Mehring says the challenge is to create a material that uses this new resin but still has the esthetic and handling aspects that dentists require. However, the ORMOCER nanohybrid materials achieve that with the added benefit of higher biocompatibility than resins with more methacrylate.

Another positive effect of this composition is that it reduces the unavoidable shrinkage that occurs during polymerization. Dr Mehring explains that there is always shrinkage because single-resin monomers do not need the same amount of space they needed before, as they are now connected. However, the monomers in ORMOCER are more significant, meaning they do not shrink as much once they join.

“This, of course, ends up with benefits for the dentists. If you have low shrinkage, there isn’t any risk of gaps after curing, which in turn does not allow marginal leakage to occur,” Dr Mehring says.

Moreover, the R&D team leverages the behavior of nanohybrid technology. Nanohybrid technology allows composites to have over 80% filler in a composite.

Also, when the fillers are nanoparticle sized, they connect again to form clusters that mimic the behavior of larger particles. Moreover, the fillers chemically connect with the resin when coated with silane. This cross-linking is called functionalization, Dr Mehring says.

“This gives you, in the end, the strength that is required on the one hand because the fillers are there, because you can put more in with the nanoparticles, but at the same time, we are coating them and they have an additional connection also to the resin,” Dr Mehring says.

Additionally, the R&D team is continually modifying the properties of their resins and fillers to improve things like esthetics. For example, the Admira Fusion x-tra, VOCO’s omnichromatic, single-shade nanohybrid ORMOCER restorative material with a 4-mm depth of cure, can match the entire VITA shade range with a single universal shade.

“We want to make the dentists’ lives easier,” Dr Mehring says about the attempts to optimize materials chemistry. “Time is money, right?”

Hirata’s focus is on Tokuyama’s future development. Tokuyama’s scientists will continue improving their products in new areas where dental materials are popular.

“Our mission now is to improve the biocompatibility of our products, especially our resin composites,” Hirata says. “After the development of color compatibility with our OMNICHROMA family, Tokuyama Dental’s R&D [team] is energized and focused on continuing the development of solutions that may radically benefit the dental industry.”

Sedlacek would group development into 2 areas: first, improving performance and next, potentially adding new features.

“On one hand, we can explore new types and combinations of those monomers and fillers to push the boundaries of material performance, meaning stronger, faster, easier. Recent examples include new sintered or prepolymerized fillers to overcome composite formula barriers, amine-free reactions for color stability, and new monomer synthesis to improve bonding or reaction kinetics,” Sedlacek says.

“On the other hand,” he continues, “we can add new features, especially in the area of bioactivity. Over time, we will see more materials that can integrate with dental tissue, combat bacterial growth, and reverse demineralization. They will build on the same bedrock of resin-powder pastes, with materials added to improve the long-term quality of restorations and ultimately patient experience.”

If you don’t know what is happening, modern dental materials might seem to work like magic. We talk to experts who explain the chemistry behind them.

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