The longevity of dental restorations has long been a concern for dentists and patients alike. And it should be: research shows that more than half of US restorations each year are performed to replace those that have failed

 primarily due to the bacteria that causes secondary caries.

 thrive in acidic environments and can quickly result in infection and restoration failure. Fortunately, antimicrobial substances have been incorporated into smart biomaterials to reduce the formation of the biofilm where bacteria flourish.

“Antimicrobial restorative materials can be…put on tooth preparations to address any remaining bacteria or [on] filling materials that prevent the attachment of bacterial plaque,” says Nathaniel Lawson, DMD, PhD, director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry. “The second application, an antibacterial filling material, is the newer concept.”

Triggered by internal and external stimuli, these substances deliver on-demand care and have surpassed antibiotics in popularity because their toxicity is lower, their shelf life longer, they cause less environmental harm, and offer superior control, location selection, and dosing options, thus reducing the risk of antibiotic resistance.

Although their goal is the same, these agents come in different varieties. According to Dr Lawson, “there are antimicrobial preventative materials, like those used in mouth rinses,” including “0.12% chlorhexidine, essential oils, and CPC [Cetylpyridinium chloride],” and others that “can be applied on tooth preparations…such as 2% chlorhexidine, silver diamine fluoride, GLUMA, or liners [calcium hydroxide and calcium silicate]…[and] a new antimicrobial composite [that] contains a quaternary ammonium compound.”

Antimicrobial agents can be classified into 3 categories: polymeric biocides, biocidal polymers, and biocide-releasing polymers. Polymeric biocides consist of amino, hydroxyl, or carboxyl units that are bound to a polymer backbone. They repel microbes and thus prevent their adhesion. Biocidal polymers contain cationic moieties (like quaternary ammonium compounds [QACs], phosphonium, guanidinium, and tertiary sulfonium) that kill microbes. Biocide-releasing polymers, as their name implies, discharge molecules into the oral microbiome that kill bacteria over time.

As Dr Lawson observes, many of these agents are added to preventative materials like chitosan, triclosan, polyquaternary ammonium salts, quaternary ammonium dimethacrylate, and furanone. More frequently, however, silver nanoparticle (NAg), 12-methacryloyloxydo-decylpyridinium bromide (MDPB), chlorhexidine digluconate (CHX), and QACs are used in them.

The efficacy of NAg, researchers say, stems from its ability to deactivate bacterial enzymes and alter the replication mechanism of bacterial DNA,

 whereas MDPB damages the cytoplasmic membrane of bacteria. MDPB was first used in CLEARFIL™ SE Protect (Kuraray Dental) and is now ubiquitous.

CHX kills cells by obstructing their membrane transport systems and causing their intracellular material to leak, thus preventing bacterial formation and reducing plaque accumulation around restorations. Commonly used in such mouthwash as 3M™ Peridex™ (chlorhexidine gluconate 0.12%) and in antibacterial solutions like Consepsis™ (2% chlorhexidine) from Ultradent, CHX is likewise found in numerous products outside the operatory.

QACs are said to be one of the most effective disinfectants in resin nanocomposites. Used as monomers or micro/nanofillers, they have 1 or more methacrylate functional groups. Those with longer chain links have higher antimicrobial activity. QACs have low cytotoxicity and offer strong long-term antimicrobial benefits without leaching.

One product making waves is Infinix™ from Nobio, the first FDA-cleared restorative material to contain nonreleasing, nonleaching QACs. These particles attract bacteria electrostatically and reduce enamel demineralization and secondary caries by 68%.

The Infinix product line includes both a universal and a flowable composite and a universal bonding system with primer and bond, all of which incorporate nonleaching, nonsoluble QACs.

There are 2 ways to deliver antimicrobials. The first is contact-killing and takes place at the treatment stage via disinfectants or etchants. The second is antimicrobial agent release, which involves inserting a leachable, polymerizable, or filler particle into a dental adhesive or resin and works over time.

Contact-killing agents are immobilized within the polymer structure and able to deliver long-lasting benefits without leaching. They prevent the growth of numerous pathogens known to cause caries, periodontal disease, and endodontic infection. These nonleaching materials reduce biofilm and microbial adhesion through physisorption and/or covalent conjugation.

 However, they are ineffective against planktonic bacteria and subject to biofouling, whereby they absorb dead bacterial cells and lose potency.

This approach allows not only for delivery of antimicrobial agents to a specific site, reducing the potential for antimicrobial resistance caused by less targeted approaches, but also for continued release of embedded compounds that kill bacteria over time. However, the rate and longevity of release are difficult to establish. Because the concentration of antimicrobial agents is low, their efficacy is reduced. NAg particles are the most commonly released antimicrobials, owing to their high biocompatibility and low toxicity.

These strategies are being developed to address the drawbacks of the other approaches. Antimicrobials that can be activated and function in different ways are more efficacious. Silver, for instance, has antibacterial, antiviral, and antifungal properties, its release is easy to control, and its long-term effect easy to sustain.

 NAg has also been combined with Quaternary ammonium methacrylates [QAMs] to kill bacteria on the material’s surface and away from it.

Contact-killing and chemical-releasing approaches employ bioactive, bioresponsive antimicrobials. Bioactives with metallic and nonmetallic fillers, CHX, other cationic monomers, including MDPB, and other QACs are incorporated into a carrier like a resin, filler, or coating, to deliver antimicrobials that work on contact and sometimes also have time-release capabilities.

Bioresponsive therapies offer long-term benefits. Once activated—by light, electrical or magnetic stimuli, pH changes, and bacterial or salivary enzymes—the biomaterial in the carrier (be it a resin, an adhesive, sealant, or nanocarrier) releases antimicrobials.

A third option, still under development, is an autonomous biomaterial that can respond to different stimulus and adapt itself to address them—essentially, the compound is completely integrated into the natural biological system.

Dental resins (composites, adhesives, and primers) are common vehicles for bioactive monomers,

 which can be linked inside the polymer chain or act as a leachable compound, both unpolymerized and polymerized.

 Antimicrobials in resins are effective against a wide range of gram-positive and gram-negative pathogens.

Biofilm-related infections have risen in tandem with the proliferation of resin-based materials.

 The rate of secondary infections with these materials have reached around 60%, making the integration of antimicrobial agents into resins a priority.

One study evaluating the efficacy against 

 of quaternary ammonium polyethyleneimine (PEI) nanoparticles in resins discovered that these nanoparticles had contact-killing effects that also lasted for at least 1 month. Using a scanning electron microscope, the researchers also determined that no streptococcal chains remained within 24 hours of contact.

Because bioactive fillers are generally inorganic—most commonly made using zinc oxide, silver, titanium, diamond, glass, or polymeric compounds like quaternary ammonium PEI—they don’t contribute to antibiotic resistance and can be designed to target specific pathogens.

Antimicrobial coatings have been found to reduce peri-implant mucositis, implantitis, and implant failure by preventing biofilm formation and bacterial growth on the surfaces of implants.

 Coatings kill on contact with agents like QACs and enzymes. Although coating placement helps reduce the amount of antibacterial needed, in some instances the coating’s antimicrobial properties can compromise implant biocompatibility and osseointegration.

Given the threat of antimicrobial resistance, the long-term release of antimicrobials could be disadvantageous. Because release begins immediately upon placement, treatment duration is often limited, and little is known about long-term effects. One study found that on average, the effects of a leachable agent lasted less than 1 year and, once depleted, could not be recharged.

In addition to agent longevity, concerns have been raised about appropriate doses. Because their release is uncontrolled, antimicrobials may deploy too quickly and become depleted before therapy is complete. Finally, the inability to target specific microbes can have repercussions on the oral biome, causing an imbalance between good and bad bacteria, like S mutans.

Despite the challenges, antimicrobials have improved dramatically over the past few decades, and researchers continue to make strides in terms of dose deployment, duration, and control. In the future, clinicians can expect to see strategies that address the drawbacks of agent-release and contact-killing methodologies and more effective ways to reduce biofilm and bacteria.

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Sakaguchi RL. Review of the current status and challenges for dental posterior restorative composites: clinical, chemistry, and physical behavior considerations. 

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Chen L, Suh BI, Yang J. Antibacterial dental restorative materials: a review. 

Ramburrun P, Pringle NA, Dube A, Adam RZ, D’Souza S, Aucamp M. Recent advances in the development of antimicrobial and antifouling biocompatible materials for dental applications. 

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do Amaral GS, Negrini T, Maltz M, Arthur AR. Restorative materials containing antimicrobial agents: is there evidence for their antimicrobial and anticaries effects? A systematic review. 

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Morones JR, Elechiguerra JL, Camacho A, et al. The bactericidal effect of silver nanoparticles. 

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Makvandi P, Jamaledin R, Jabbari M, Nikfarjam N, Borzacchiello A. Antibacterial quaternary ammonium compounds in dental materials: a systematic review. 

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Mitwalli H, Alsahafi R, Balhaddad AA, Weir MD, Xu HHK, Melo MAS. Emerging contact-killing antibacterial strategies for developing anti-biofilm dental polymeric restorative materials. 

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Imazato S, Chen J, Ma S, Izutani N, Li F. Antibacterial resin monomers based on quaternary ammonium and their benefits in restorative dentistry. 

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Articles

As dental materials with antimicrobial properties become more common it’s important to be educated about how they work and the benefits and risks they can provide patients.

Understanding Antimicrobial Dental Materials

In many of my previous articles during the past 6 years, I have discussed some complex issues, including cybersecurity, Health Insurance Portability and Accountability Act (HIPAA) compliance, and artificial intelligence. What is often lost in these discussions is that you need infrastructure in place to run the software that powers these advanced systems. In this article, I want to evaluate the hardware and networking decisions you need to be making before investing in these other technologies.

As any information technology (IT) professional knows, the server is the most critical component of any dental office’s IT system. If designed properly, it should store all data, because it is much easier to back up data from 1 location than from multiple locations. To properly design a server, you must look at 4 main components: the processor, the memory (RAM), the hard drive storage, and the operating system.

For a server, consider a Xeon processor; these are much better at multitasking, which is what a server does all day long. I would start with 16 GB of RAM, but if you run a lot of programs or have more than 15 computers, then 32 GB would be better. For storage, I recommend at least 4 TB in a RAID (redundant array of independent disks) configuration. This means you have 2 or more hard drives, mirroring each other, so if one fails, you will not have any downtime and can repair or replace that failed drive later.

Finally, I highly recommend using a server operating system like Windows Server 2019 or 2022. One of the main tenets of HIPAA is that you must track, audit, and log all access to protected health data. This is far easier with a server operating system than a desktop operating system such as Windows 10 or 11. For this reason, I never recommend using a workstation as a server. Dentists should invest in a proper server to manage their practice. You and your staff should never work off a server; it is a huge security risk.

For the workstations, the specifications are not as critical unless you have a CBCT system in the office. The standard recommendation for a workstation is Windows 10 or 11, a Core i5 or Core i7 processor, and 16 GB of RAM. If you are manipulating 3D images on the workstation, then you will need a dedicated graphics card. Check with the CBCT vendor on their recommendations; most cards from NVIDIA that have at least 2 GB of video RAM will suffice.

I also recommend warranty of around 3 years. Although computers often last much longer, with regular software updates, you typically start to see slowdowns and issues around the 3- to 4-year mark. That is because as newer software requires more processing power, the computer simply cannot keep up.

Finally, you need to tie all the systems together. I highly recommend a wired network. Although wireless has gotten faster over the years, it is less secure and slower than a wired connection. Wireless networks require you to encrypt the traffic, which removes around 40% of the speed, and the network is prone to interference from walls, microwave ovens, and fluorescent lights. At a minimum, you should have category 5e cabling throughout the office. If you are adding network locations or building a new office, then category 6 is preferred.

Having proper infrastructure will ensure that you have minimal challenges when it comes to incorporating new technologies into your practice.

Although software applications get much attention, these programs cannot help a dental practice unless the right information technology infrastructure is in place.

Setting Solid Technology Foundation Is Important

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Technique Touch-Ups

Experts from across the industry share their favorite tips, tricks, and solutions to make dental care better for patients and easier for you. 

Technique Touch-Ups 2023

Good isolation is critical for restorative dentists, and patients appreciate it as well.

For one California dentist and his patients, the DryShield isolation system from Solmetex is part of the daily routine. DryShield helps keep the working area inside the patient’s mouth dry, clean, and visible, and Troy Schmedding, DDS, credits it with delivering a more productive office and happier patients.

“It really came about just as part of a 2-fold process,” says Dr Schmedding, who maintains a private practice in Walnut Creek. “We were using at one time a system without an autoclave ability and I didn’t want to have to throw away all these pieces. A little bit of my environmentalist comes out and, oh my God, that’s a lot of plastic rubber to be throwing away.”

The second factor in his thinking was wanting a reliable alternative to using a rubber dam all the time. “I do a lot of adhesive dentistry, and isolation is critical for me in terms of success,” he says. “Not everyone can tolerate a rubber dam. I don’t think DryShield is a replacement for absolutely everything, but ultimately, I found the DryShield to be able to be utilized in a large majority of my patients for quick, easy isolation in a comfortable fashion.”

Dr Schmedding has been using DryShield for about 7 years in his practice, which focuses on esthetic and functional dentistry. Clinicians can opt for the cost savings of autoclavable mouthpieces or the convenience of single-use mouthpieces.

“It really is awesome. It’s autoclavable, and then overall, just the process of delivering the isolation is critical,” Dr Schmedding says. “I can’t work in that type of environment without good isolation, and the DryShield seems to cover it with variable options in terms of sizes and matching bite blocks. The patients get great isolation and it helps us provide good dentistry.”

Every patient in his practice will have some form of isolation, and the majority of that is using the DryShield because of its convenience. It attaches directly to the high-volume evacuator and saves time during procedures.

“Rubber dam is still probably the gold standard in some instances, but ultimately rubber dams are a little bit more difficult,” he says. “DryShield is a great alternative for sure, and for patient comfort the patients tolerate it better.”

Using DryShield also reduces aerosol spread, a risk that became well known during the pandemic. “Patients are more aware of aerosols and that type of thing than ever because of COVID[-19]. So, they are more in tune with what’s going on in your dental operatory than they ever have been before,” Dr Schmedding says. “And that’s really another selling point to a lot of patients. This is great at containing a lot of aerosols, so…it does have an extra benefit. That is important. I definitely use that for a selling strategy as well for those patients [who] may be a bit on the edge. What it’s doing for you and the aerosol containment is huge.”

Increased efficiency is another plus. According to Solmetex, DryShield dentists are seeing chair time reduced by an average of 25% to 40% per procedure.

“There’s less stopping and starting…when you have some form of isolation,” explains Dr Schmedding, who uses DryShield regularly when seating crowns. “So, yes, it does help with efficiency…. It’s a [really] solid product. It checks a lot of boxes in terms of what you’re trying to accomplish.”

Why one clinician loves using the DryShield isolation system from Solmetex and how it benefits his practice and patients.

Closer Look: Reliable, Efficient Isolation Is Critical

Wouldn’t it be amazing if you could effortlessly and efficiently read CBCT images, ensure that all relevant information was added to the patient chart, and provide a second opinion and comprehensive presentation for every patient and multiple specialists? Diagnocat AI, the only artificial intelligence (AI)-powered service that can analyze 3D dental images, is making that a reality. I spent some time with the brilliant founder and CEO of Diagnocat, Alex Sanders, PhD, to find out how AI is transforming the way clinicians and specialists diagnose and collaborate.

Lou Shuman (LS): Tell me about some of your background in dentistry.

I have been in practice for about 20 years. My first private practice turned into a large dental service organization with 150 dentists. I was born in Russia, and, because of political crisis, I was forced to leave everything behind and move to Israel. As a general dentist, a PhD in prosthodontics, and a dental entrepreneur, I noticed much inefficiency in our profession. In my quest to improve quality, I went to Harvard Business School’s health care management program, where I was influenced by Professor Richard Bohmer, who greatly influenced my life with his brilliant concepts. While learning about management of processes and clinical decisions, it dawned on me that AI would be a great fit for dentistry.I was lucky to find a group of absolutely genius engineers and we created Diagnocat AI.

LS: What was your goal in creating Diagnocat AI?

Initially, my goal was to improve quality by reducing omissions and errors. From a CBCT scan, Diagnocat AI highlights anatomical areas, common findings, and previous treatments for each individual tooth, checking for over 65 conditions and then automatically generating an AI-based report. This can improve quality control, proper file documentation, and immediate presentation to the patient. After years as a clinician, I realized that some of my own errors happened because of time pressure or just because I am human. We have heard feedback that Diagnocat AI influences treatment acceptance rates dramatically by basically serving as a second opinion and helping patient communication. The radiography report is created in a few minutes, and you can share the case presentation with the patient on the screen or print it out. You can say, “Let’s talk about these things that I’m concerned about.” When I present the report to the patient, I’m not the “dentist bad guy” anymore because the unbiased AI provides a very structured and focused consultation. Now I’m the good guy!

LS: How does it work with GP and specialist collaboration?

We often need a collaborative approach. Diagnocat provides an interpretation of patients’ problems and fosters discussion within the clinical team, especially with complex cases. Based on analysis of CBCT scans, Diagnocat can generate reports specific to specialties to help plan and improve treatment flow.Also, specialist diagnostic reports can be shared with general practitioners to build partnerships.

The software can produce insights in conjunction with your practice management system. Dental charts are not always filled out properly, so we may lose information about our patient’s oral health in our practice management systems. Diagnocat AI collects and analyzes information from the 3D scans and creates a database. Diagnocat’s AI finds the patient’s problems, documents all the missing teeth, and evaluates the treatment opportunities.

LS: How is Diagnocat AI different than other AI systems?

Diagnocat AI is the only solution that works with 3D imaging to create diagnostic reports. All the others operate only in 2D. It has a much greater diagnostic value since we live in a 3D world. Dentists are buying expensive CBCT machines with complicated software, and they receive very little training. Diagnocat AI hugely reduces the learning curve because a couple of minutes after capturing a 3D scan, all the pathologies are right in front of you. AI systems (that are 2D) detect up to 8 pathologies, whereas 3D Diagnocat AI detects more than 30 pathologies, such as periapical lesions, periodontal bone loss, signs of dental caries, open margins, overhangs, impactions, and defects of previous endodontic treatment. And Diagnocat AI diagnoses on the primary dentition, which the 2D applications do not.

Diagnocat AI certainly increases confidence. The report is easy to read, and everything is documented for the medical record. Some dentists may still want to send the scans to an oral radiologist. In some Canadian provinces, an oral radiologist reading is mandated by law. Interestingly, some oral radiologists are actually using Diagnocat AI for the exact same efficiency reasons that dentists use it.

In the future, we are creating a new sister company called Segmentron. While Diagnocat AI is about diagnostics, Segmentron will be about treatment planning. It combines 3D images, intraoral scans, and digital photographs and creates a virtual patient. It can also be used for patient presentations as well as treatment planning for orthodontics, oral surgery, and implants. Segmentron Implant can determine an implant of the right size, put it in position, and generate a surgical guide. Segmentron Ortho will create an orthodontic setup, virtually straighten the teeth, and even locate the roots at the end of the treatment. With the click of a button, you will generate a setup that can be used for aligner manufacturing. It is still in development but will soon be available as an institutional review board (IRB) in the United States.

Right now, Diagnocat AI is available in Canada, and as an investigational device IRB in the United States. United States clinicians who want Diagnocat AI now can contact us, and we can add them to the IRB after a bit of paperwork.

We expect to introduce Diagnocat AI to the United States [commercial] market later this year. We are integrating Diagnocat AI with a number of practice management systems and intraoral scanners for a seamless approach. We’re constantly working on the precision of the algorithms, new user-friendly software designs, even an app that is soon to be released.

This new artificial intelligence-powered image analysis platform will provide dental professionals with a second look at CBCT scans, intraoral imaging, and 3D images. 

Taking the Clinical Experience to a New Reality With Diagnocat AI

® have decided to devote ourselves to helping readers understand the “what I wish I knew before becoming a dentist.” This is a great idea because many things fall into that category. It does not matter how long you have been in practice; there are always things to learn. Some might seem basic, but if you happen to be unaware of them, then they are not so basic, are they?

I know an oral surgeon who has a great way of explaining the odds of complications. When he discusses the potential for complications with patients, he tells them, “I could quote you all kinds of statistics, but it does not matter what those percentages are if it happens to you. If it should happen to you, the odds are 100%.”

That same philosophy applies to knowledge. If you do not know a “common” fact, then that fact is not so common.

For this column, I thought about making a list of the things I wish I knew before I became a dentist. Then it occurred to me that if I wrote down the things I did know, the list would be much shorter.

All kidding aside, certain things are important to know no matter where you are in your career. What I have decided to do for this issue is to answer some of the questions many doctors have asked me during my career. However, instead of doing a Q&A, I have decided to break things down into concepts and expand upon them. Hopefully, there will be some information here that you can apply to your situation, no matter how long you have been practicing.

I will begin with a bit of advice about bringing in or upgrading technology. I love the old expression, “You do not eat an elephant in 1 bite. You eat an elephant 1 bite at a time.” This means start slow and steady when bringing a new piece of technology into your workflow.

Everything takes time to learn, so learning the basics of a system is where you want to start. Anytime I bring a new technique into my workflow, I always work “on the bench” before I “go live” with patients. I want to make sure I have things figured out before I incorporate it into my normal routine. Whether it is a new endodontic file or anything else, it pays to have some experience with it.

That applies just as well to your team. Getting them proper training and/or experience with something really helps when the moment comes to be in front of patients. Human beings are creatures of habit and we also do not want to look foolish or unsure of ourselves. If someone starts to struggle in front of a patient, the first inclination is to go back to the “old way” because that is where the comfort is. By giving them a comfort level with something new, you help ensure their success.

The other part of this equation is to bring in new things gradually. Trying to change more than 1 workflow or process at a time is confusing. Keeping things simple pays off.

For a journey to be accomplished, it is important for everyone to know what the destination is and how they are going to get there. Unless you agree on where you are heading, you will never reach your destination. That means you need agreement, cohesion, and teamwork.

I have been told numerous times of situations where a doctor decided to initiate a change in the office and chose not to include the staff in the decision. I have heard many versions of this story, but never one that turned out well. The decisions the doctor makes almost universally affect the team. If the team does not have some type of input, implementation is going to be dicey at best.

The doctor wants to make a change. There is a staff meeting involving the team members this change will affect. The change is discussed in a civil, conversational manner. Potential problems are discussed and solved.

The point is that the staff leaves the meeting with a positive feeling about the change. They feel included and respected because they are part of the decision-making. That means that when there are snags (and there almost always will be), the team will work through them diligently and with few complaints. That is simply because it was “their idea” too.

The concept of “we’re all in this together” goes a long way in fostering success.

I absolutely love tried and true verbal expressions. I use them all the time. One of my favorites is, “People don’t care how much you know; they want to know how much you care.” That expression is incredibly true and there may be no area where it applies better than health care.

As I have said here before (many times), one of my first technology purchases was an intraoral camera. The camera allowed me to show patients the inside of their mouths, which then allowed me to explain what needed attention. The first patients examined using the camera were in awe of what I could show them. The part that amazed me was that most of them were more impressed with the technology than with seeing their mouth.

By today’s standards, the system was primitive, but what it provided was nothing short of groundbreaking. It allowed me to show the patient the problem and, most importantly, allowed them to understand the problem. Once that happened, almost everyone wanted to know the best solution and how quickly the problem could be rectified. The result was amazing. The big lesson was that patients appreciate communication, and communication helps build success.

Once I learned that lesson, I devoted a lot of my time and resources to communication. The high-tech environment we all work in today has many benefits and helps us provide better care for patients. However, one of the secondary benefits to things like digital radiography, artificial intelligence, and even digital impressions is the communication it provides with patients. Being able to text and email patients is a tremendous benefit of communication, but when patients can see things in the office with their own eyes, they understand.

The other upside of communication is when your patients have exposure to the high-tech tools in your office, and then communicate their experiences to friends. It is amazing to me how technology markets itself.

Our office does not do much external marketing. However, we do invest in the best high-tech tools available. By doing that, patients come into the office and, when they experience the technology, they often tell coworkers, family, and friends about that experience. Word of mouth from friends and loved ones is the best form of marketing available.

That heading probably seems silly to some of you, but it is so true. I tell my high school patients figuring out their futures that it does not matter what they do, as long as they love it. Another old expression I believe in is, “Love what you do, and you will never work.”

Without telling the entire story here, I wanted to become a dentist when I was 3. Here I am, all these years later. The profession has allowed me to develop relationships with thousands of individuals. I get to help others, change lives, and determine my own destiny.

Do not get me wrong—there are some days when I probably would prefer to own a bait shop, but those days are rare. We have a fair number of young adults come to our office to shadow doctors and hygienists. I encourage anyone with an interest to explore the profession and, if they feel it is the right choice for them, to go for it.

By loving what you do, you help your patients to relax and to have less stressful visits. There is no greater compliment I can receive than to have a patient say, “You really seem to love what you do.” I always tell them, I do—and part of that is helping individuals like themselves.

As I look back on what I have written here, I noticed that I did not really mention much about the clinical side of things. I tend to feel that the intangibles drive the tangibles. For me, the patients are the most important part. Once they are comfortable and understand the need for treatment, then we can focus on the hands-on part of the profession.

Maybe I will do a column some day on the technique side of things I wished I had known much earlier. Of course, the way our profession changes on a regular basis, that column might be outdated by the time we get it into print.

In addition to treating patients, I also love writing and I love communicating with all of you in every issue. Thanks for reading and thanks for being a part of dentistry. What you do changes patients for the better, and that changes the world for the better.

Chief Dental & Technology Editor John Flucke, DDS, shares what he has learned and why he is so passionate about this profession. 

What I Wish I Knew Before I Became a Dentist

Restoring damaged or missing teeth is an essential aspect of modern dentistry. Advances in materials and techniques have improved dentists’ ability to achieve predictable, long-lasting outcomes. One such advance is the use of chairside esthetic zirconia crowns, which provide excellent strength and durability without compromising esthetics. 

This case report discusses the use of chairside esthetic zirconia crowns as a viable option for restoring the patient’s smile, highlighting the clinical and technical aspects and the rationale behind selection of materials and techniques used in the procedure.

Kuraray Technique

The patient expressed his gratitude and appreciation for the appearance of his new smile. When placed adjacent to all-ceramic lithium disilicate crowns, the clinician will note comparable esthetics and translucency.

With the help of Kuraray Noritake’s powerful material, this clinician helps patients achieve the smiles they want without sacrificing the durability they need. 

How to Deliver Strength With Chairside Esthetic Zirconia 

Esthetics is key in restorative dentistry. Although mechanical function is paramount in successful restorations, the primary concern for many patients is esthetics. As important as texture and contour are, color is perhaps the most critical aspect in achieving impeccable esthetics.

“In the past, esthetics of dental restoration were not as achievable as they are today,” says Amelia Triplett, junior research scientist at products and materials manufacturer BISCO. “Esthetics took a back seat to the important mechanical properties required of a dental restoration. Now, science and technology have advanced enough to ensure the strength [required] of a restorative material using chemistry, and we are able to have greater focus on the esthetics.”

With the strength issues handled, esthetics can take center stage. There are strong materials easily customizable for color and opacity, allowing for more natural-looking restorations. In addition to these chemical advancements, Triplett says, clinicians now have the tools of color science and technology, such as spectrophotometry and light control, to aid in the shading process.

“We’ve got the physical strength requirements taken care of,” Triplett says. “Now the artistry of restorative dentistry can shine through.”

A big component of this artistry is color. Although we were all introduced to the color wheel in kindergarten, color theory in dentistry is a little more complex than the old childhood mnemonic ROYGBIV.

At its most basic level, light is the key to color. To make a color, light is reflected from a surface or filtered through something translucent. For example, according to subtractive color theory, blue only appears that way because it absorbs the colors that are not blue (red and green) but reflects blue light.

According to the Munsell color system, color is described by hue, value, and chroma. Developed in the early 1900s by Albert H. Munsell, the system was the first to separate color into the 3 dimensions and apply a numeric value to colors.

In this context, hue is defined as “the dominant range of wavelengths in the visible spectrum that yields the perceived color, even though the exact wavelength of the perceived color may not be present.”1 In plain language, the hue is the color. Value is the quantity of light that is returned from a material; essentially, the lightness of the color, or how dark the color falls on a black-to-white scale. Chroma refers to the saturation or intensity of the hue and is inversely linked to value.

Although hue, value, and chroma play a large role in coloration, the opacity of a material also affects the appearance of color. Materials that are transparent allow light to pass through with minimal interference, simplifying color matching. In comparison, opaque materials reflect and absorb light.

However, things get complicated when it comes to translucency. Translucent or semitranslucent materials (such as a tooth’s surface) scatter, absorb, and transmit light, affecting how the material interacts with light. This makes it much more difficult to determine shade. For example, in crowns, higher translucency means less light is reflected, lowering the crown’s value.

“Depending on the thickness of the material, translucency allows the underlying color to show through in varying degrees,” says Shotaro Matsubara, CEO of Tokuyama Dental America. “It will affect the value and chroma of the final shade.”

In short, the more translucent the material, the less light is scattered within it, and the more its color will be affected by the surrounding colors.

“Translucent materials will take on the color of the background, as the light reflected from more colorful/opaque background objects will be able to pass right though a translucent object easily,” Triplett says. “The thickness in which the material is used also has a more pronounced effect on the perceived color of translucent materials than it does on the perceived color of opaque materials.”

Fluorescence also plays a role in restoration color. Fluorescence is the emission of light from a material that has absorbed light, most often emitted in a longer wavelength. In natural teeth, fluorescence usually occurs in dentin, as it is highly organic. To mimic this, fluorescent powders are often added to restorations to bolster the amount of light returned, masking discolorations and decreasing the chroma—particularly beneficial in high-value shades where it can increase value without hurting translucency.

Triplett notes that dental materials are also affected by molecules within that interact with visible light wavelengths. The color of a material can be affected by the light in which it is viewed, because if the light does not have a specific wavelength band, the material cannot reflect it.

Regarding dentistry, Triplett says, one of the molecules involved in light-curable materials is camphorquinone. This material absorbs the near-UV visible light from curing lights and initiates free radical polymerization.

“Because camphorquinone absorbs near-UV visible light, which to us appears bluish in color, camphorquinone reflects the other wavelengths of light, resulting in this chemical appearing yellow to us,” Triplett explains. “If camphorquinone is not optimized in a dental restorative material, it can possibly cause an unesthetic yellow color.”

When it comes to color in dental materials, colorants (pigments or dyes responsible for the chromatic reflection of light with the material) are employed to create certain shades. The chemical composition of a particular colorant absorbs certain sections of the visible spectrum.

“Most dental materials get their color from adding chemical color—pigments and dyes to achieve the various shades and opacity needed to blend with natural dentition,” Matsubara says.

These pigments and dyes, Triplett clarifies, are used in small amounts labeled Generally Recognized as Safe or approved under the Federal Food, Drug, & Cosmetic Act (FD&C) or by the United States Food and Drug Administration. They include titanium dioxide and FD&C Red No. 40. However, in recent years, alternatives to colorants have emerged.

“The assumption that we have to use chemical color, pigments, and dyes to achieve shade matching in resin composites has really had a paradigm shift in the [past] few years,” Matsubara says. “In 2019, an alternative option launched with the release of OMNICHROMA. The resin composite relies on structural color—the interaction between structure and light to create color—to shade match to surrounding tooth structure.”

This concept of structural color was a novel development for resin composites. A 1-shade universal composite, OMNICHROMA employs supranano spherical fillers that can shade match any color from A1 to D4. In one study, conventional A2-shade resin composites (composed of 5-50–nm fused silica fillers and 100-nm spherical fillers) were compared with structural color composites. Researchers determined that the structural color composite (comprised of 260-nm spherical fillers) exhibited lower color differences between natural tooth and restored areas and a higher color adjustment potential.

“When OMNICHROMA was first launched, there was a bit of hesitation since the concept of structural color was never considered viable for resin composites,” Matsubara says. “Structural color is a natural way to see color and has been studied for practical application in many industries due to its long-term stability and environmentally friendly properties.”

Another unique benefit of OMNICHROMA is its ability to shade match post bleaching, or as teeth change color over time. “This is a big benefit for esthetic dentistry, because patients who need anterior restorative work no longer have to decide immediately [whether] they plan to whiten their teeth,” Matsubara explains. “OMNICHROMA gives them the freedom to decide when and how much they want to brighten their smiles in the future.”

When it comes to choosing a material, there are several things to keep in mind that can affect color, particularly in the long run. “A hydrophilic material will take on water over time, which can affect the perceived color of the restoration. Additionally, a high monomer percentage in a material’s composition can lead to higher water sorption. It is important to ensure these materials are properly cured, which can increase a material’s hydrophobicity,” Triplett says.

We take a deep dive into the science behind the colors of restorative materials, expanding on why they perform as they do and how to optimize them for esthetics that patients desire. 

Dental Products Report June 2023