Focus on peri-implantitis has increased in recent years, due to an escalation in reported incidence. This has not been due to growing case numbers, but to more frequent identification of this pathological process as practitioners come to understand the signs and symptoms.

Peri-implantitis is a pathological process that occurs at the bone surrounding dental implants and is characterized by inflammation of the soft and hard tissues adjacent to the implant, which leads to progressive loss of bone supporting the implant. It may appear as mucositis early in the life of an implant or many years after restoration of the implant, and may progress slowly or in an accelerated manner depending on the causative factor and the patient’s immune system.

Peri-implant disease is classified as either peri-implant mucositis or peri-implantitis. Peri-implant mucositis is classified as inflammation found only around the soft tissues adjacent to the implant, with no bone loss evident. Peri-implant mucositis is a precursor to peri-implantitis and may be successfully treated to prevent progression to peri-implantitis when identified early enough. With peri-implantitis, the gingival inflammation has progressed to the underlying bone, leading to deterioration of osseous support of the implant. Treatment of peri-implantitis typically requires surgical intervention to stop progression and repair the lost hard tissues.

The clinical conditions leading to the conversion from gingival inflammation to peri-implantitis are not completely understood.

 Evidence suggests that progressive crestal bone loss around implants in the absence of clinical signs of soft-tissue inflammation is rare.2 Peri-implant mucositis is a relatively benign, reversible condition, yet can progress to peri-implantitis.

 Some patients, particularly smokers or those with a history of chronic periodontitis or diabetes, are more susceptible to peri-implant diseases.

So, where can bacteria originate before leading to peri-implant mucositis and potentially peri-implantitis? The oral cavity is filled with bacteria and other microorganisms. Historically the focus has been on poor home care as a major factor in peri-implant disease, but other sources of microorganisms in the oral cavity need to be considered. Research has demonstrated that bacteria in the oral biofilm can be harbored between the implant and the restorative parts connected to it at the implant platform.

The Implant Connection as a Potential Source of Bacteria

When implant abutments and other parts that connect to the implant at its platform are manufactured, large volumes of product are machined, and what is referred to as “slop” is designed into the process to allow for tolerance variables and product parts that fit. This is so that any abutment will seat into any implant when manufactured. The result is a microgap between the implant and abutment at the connector. This also pertains to the abutment screw that will thread into the channel in the implant (

). That microgap is not visible to the eye, but only under the scanning electronic microscope; however, it is large enough for bacteria that are much smaller to exist in the microgap. These bacteria then have the potential to percolate out, leading to inflammatory conditions in the surrounding gingival tissue and potentially spreading to the crestal bone.

A study reported microgap sizes ranging from 2 to 7 µm at the implant-abutment connector, whereas another reported a variation in microgap size ranging from 10 µm to 1.72 mm, which is wider than the bacteria found in the oral environment.

 Biofilm has an adhesive nature, sticking to all surfaces in the mouth including titanium and zirconia, from which implants are fabricated.

Additionally, micromovements during occlusal function can lead to wear at the implant connector,increasing the microgap sizes.

This can lead to a pumping effect, pushing bacteria in the connector in and out of the connection and being a further source that may lead to gingival inflammation.

Whether the restoration will be retained with a screw or be an abutment with overlaying cemented restoration, a screw is utilized to fixate something to the implant at the platform. A pliable material is required to not occlude the hex or square on the fixation screw so that it can be engaged to either remove the screw or tighten it when required. Traditionally, this was accomplished with a piece of a cotton pellet that in the case of a screw-retained restoration was then sealed at the crown’s surface with a composite resin.

A shift occurred some years ago to utilizing a piece of polytetrafluoroethylene (PTFE [plumbers’ tape]) to overcome the bacteria and odor noted when the composite was removed from over the plugging material or in the case of a cemented restoration when the abutment was exposed to access the screw. Studies have reported high levels of streptococci and fungi were found in those cotton pellets, with less noted when PTFE plugs were used.

 But, being an inert material, PTFE does have the potential to allow bacterial biofilm to exist in those sealed areas. So, we can seal the area over the fixation screw, but with micromovements between the restoration and implant at the connector due to the microgap, how do we prevent bacteria from growing in those areas and prevent potential peri-implantitis?

Silver nanoparticles have been demonstrated to be a potent and broad-spectrum antimicrobial agent. This has no cytotoxic effect on the metabolic activity of the host cells and is an effective broad-spectrum bactericidal agent, regardless of the antibiotic resistance of the bacteria.

 These particles are smaller than the microorganisms, diffusing into the pathological cells, rupturing their cell walls with no negative effect to the host’s cells.

 Studies have reported that utilization at the implants connector that oral microbiological organisms are inactivated that could be found in the oral biofilm.

 These silver particles do not have a life span and their antibacterial properties remain as long as the particles remain within the area.

SilverPlug® (SilverPlugUSA) was developed utilizing silver zeolite, a naturally occurring substance, in a pliable polymer material to allow adaptation to the area over the fixation screw, adapting to the geometry of the space as it is placed (

). The material has been utilized in the European Union for more than 10 years and has certification as Class IIA material with medical device regulation. SilverPlugwas granted FDA approval in 2022. The SilverPlug does not release silver particles and kills microorganisms that come into contact with it. The silver particles are incorporated into the silver zeolite contained into the medical polymer and do not migrate away from the plug material. Thus, with a dramatic reduction of bacteria present in the area in and around the abutment/implant platform gaps and screw access tunnel, no odor is noted that would be commonly reported when cotton pellets or PTFE are used.

Placement when a screw-retained restoration is being used consists of carrying the SilverPlug to the screw access opening and determining the width needed at that site (

). Length is then determined that will allow 2 mm of composite to be placed over it and be flush with the restoration’s surface; the plug is cut with scissors (

). The piece of cut plug is then carried to the access hole with an explorer or perio probe and inserted into the access hole (

). Cotton pliers can be utilized to hold the plug in the restoration as the explorer/probe is withdrawn. A restorative plugger can be utilized to push the SilverPlug into the access space until it is 2 mm apical to the restoration’s surface (

As the material is pliable, excess can be removed with the edges of the plugger or a diamond bur in a highspeed handpiece so that no material is in contact with the access opening circumferentially in that 2-mm area apical to the restoration’s surface. Similarly, if a cemented restoration is being utilized, the SilverPlug is placed to the superior aspect of the abutment (

Should the fixation screw need to be accessed, removal of the SilverPlug is easy. After exposing the SilverPlug following removal of the overlaying composite or—in the case of a cemented restoration—removal of the restoration, the plug is ready to remove to access the screw. As the material remains pliable, an instrument is inserted into the SilverPlug and it is pulled out of the access area (

If the instrument is having trouble removing the plug, a large (size 45 or larger) endodontic file can be threaded into the plug and pulled out of the area. Removal is easier than removal of a cotton pellet that may leave fibers in the area over the fixation screw’s head or PTFE. The removed SilverPlug can be reused on that same patient should the screw need retightening, or if the restoration is being reinserted at the same appointment.

How to Prevent Peri-Implantitis With Elimination of Cotton Plugs or PTFE

Oral biofilm has a strong connection with peri-implantitis, and those bacteria can be present between the implant and restoration at the connector or over the fixation screw. Utilization of a material that has antibacterial properties, which are present with nanosilver, aids in prevention of active microorganisms in those areas between the implant and restoration that are not accessible with home care. SilverPlug is an easy-to-use material to fill the area over the fixation screw and provide long-term prevention of the issues that contribute to peri-implantitis without affecting host tissues or their normal functions. Its pliable nature allows retrieval should the fixation screw need to be accessed.

Bianco LL, Montevecchi M, Ostanello M, Checchi V. Recognition and treatment of peri-implant mucositis: do we have the right perception? a structured review. 

2021;58(4):545-554. doi:10.17219/dmp/136359

Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. 

. 2018;89(suppl 1):S267-S290. doi:10.1002/JPER.16-0350

Daubert DM, Weinstein BF, Bordin S, Leroux BG, Flemming TF. Prevalence and predictive factors for peri-implant disease and implant failure: a cross-sectional analysis. 

. 2015;86(3):337-347. doi:10.1902/jop.2014.140438

Esposito M, Grusovin MG, Worthington HV. Treatment of peri-implantitis: what interventions are effective? a Cochrane systematic review. 

Hwang G, Blatz MB, Wolff MS, Steier L. Diagnosis of biofilm-associated peri-implant disease using a fluorescence-based approach. 

Lopes PA, Carreiro AFP, Nascimento RM, Vahey BR, Henriques B, Souza JCM. Physicochemical and microscopic characterization of implant-abutment joints. 

. 2018;12(1):100-104. doi:10.4103/ejd.ejd_3_17

Zupnik J, Kim SW, Ravens D, Karimbux N, Guze K. Factors associated with dental implant survival: a 4-year retrospective analysis. 

. 2011;82(10):1390-1395. doi:10.1902/jop.2011.100685

Raab P, Alamanos C, Hahnel S, Papavasileiou D, Behr M, Rosentritt M. Dental materials and their performance for the management of screw access channels in implant-supported restorations. 

. 2017;36(2):123-128. doi:10.4012/dmj.2016-049

Ramidan JC, de Mendonça E Bertolini M, Júnior MRM, Portela MB, Lourenço EJV, de Moraes Telles D. Filling materials efficacy on preventing biofilm formation inside screw access channels of implant abutments. 

. 2022;48(6):573-577. doi:10.1563/aaid-joi-D-20-00191

Ptasiewicz M, Chałas R, Idaszek J, et al. In vitro effects of silver nanoparticles on pathogenic bacteria and on metabolic activity and viability of human mesenchymal stem cells. 

. 2024;72(1). doi:10.2478/aite-2024-0007.

Siddiqi KS, Husen A, Rao RAK. A review on biosynthesis of silver nanoparticles and their biocidal properties.

. 2018;16(1):14. doi:10.1186/s12951-018-0334-5

Matsubara VH, Igai F, Tamaki R, Tortamano Neto P, Nakamae AE, Mori M. Use of silver nanoparticles reduces internal contamination of external hexagon implants by Candida albicans. 

. 2015;26(5):458-462. doi:10.1590/0103-644020130087

Articles

A powerful material aids in the fight against peri-implantitis. Read on to learn how to effectively harness this tool.

With new and innovative approaches to dental treatment and practice management being introduced all the time, dental professionals face a challenge when it comes to trying everything and staying up to date. Fortunately, no dental professional faces this challenge on their own. Learn and stay on top of the latest in dentistry with this annual collection of advice from across the industry.

Smooth Transitions

A New Twist on an Established Material

Use Tints to Elevate Single-Shade Composites to High Esthetics

No more “Watch & Wait” with Silver Diamine Fluoride

How best to advance care for treatment of dental hypersensitivity and promote dental health

A New Adjunct Treatment for Periodontal Infections

Achieving Optimal Marginal Integrity With a New Lithium Disilicate Block

Increase Clinical Efficiency With Two Instruments in One Hand

Point-of-Care Testing for Personalized Patient Care

What I Wish Every Dental Professional Knew About Whitening

Unlock Workflow Efficiency by Optimizing Suction Line Health

Making X-ray Aiming Easy

Enhance Your Oral Health Assessments With Fluorescence Technology

Esthetic Enameloplasty With Clear Aligner Treatment

Streamlining Care Through Wireless Innovation

Revolutionizing Case Acceptance and Financial Management in Dental Practices

Instrumental Precision Redefined

Invest in Cutting-Edge Dental Management Software to Transform Your Dental Practice

Increasing Restoration Accuracy With Chairside Milling

Automate Your Front Desk Workflows and Improve Efficiency

Finding the Perfect Mix to Help Perio Patients at Home

Technique Touch-Ups 2024

Dental professionals throughout the industry share their favorite new workflows, technologies, materials, and more.

As a systems integrator in the dental field for more than 25 years, I often tell clients that I have “seen it all,” and this is true. In this modern era of identity theft, ransomware, and tons of other pitfalls, I feel genuine concern for my colleagues as the need to protect and secure your data has never been higher. As I mentioned in my previous column, these next few articles are going to focus on the infrastructure that every office needs in place.

One area where I have “seen it all” is in operatory design. I am always amazed that, considering the amount of time most dentists spend in such a small space, many people have not taken the steps to properly plan their operatories for function and efficiency.

It is often not enough to choose a computer based on processor speed or hard drive. Other issues that must be evaluated are the need for DVD players, CD-RW drives, and video cards. Just as important, although often overlooked, is the size and shape of the computer cases. Many offices have cabinets at the 12 o’clock position where an area has been designated for placement of a computer. However, these spaces will not fit all computers, and the dimensions of this space should be evaluated before purchasing the system. Although it would be easy to say offices should simply purchase the smallest case, there are trade-offs that are part of this decision. Many add-on cards, such as those used for video capture and some CBCT systems, will not fit into these smaller cases and therefore will affect which case is chosen. Dentists may also elect to mount their computer systems on a wall or cabinet, although they should understand how much space is required to do this.

The positioning of the monitors is crucial to get the most out of the digital systems in the operatory. The first decision is whether to have 1 monitor or 2 (or more) in the operatory. Many offices are electing to have 2 monitors: one in front of the patient to show digital images, patient education, streaming, or TV, and another behind the patient that can be used to show Health Insurance Portability and Accountability Act–sensitive information, such as the schedule or financial information.

To properly design this, there are certain decisions to make. First, the exact location of the monitor is chosen. In many cases, an articulating arm, such as those from ICW or Ergotron, is used to give the monitor positioning some flexibility. Most offices will mount monitors to the ceiling, light pole, or wall. If mounting to a wall, the location and type of the wall studs will determine how the monitor is mounted. Secondly, there is the concern over cables and cords. Each monitor requires at least a video cable to be run to the computer, and each requires electricity. Because most dentists do not want to see multiple cables snaking across the floor and walls, it is often a challenge to determine the best way to run these cables and end up with a visually pleasing solution.

Although touch screens are an option, their cost often makes them prohibitive for dental offices, so most dentists still prefer to have a mouse and keyboard to input data. Wireless devices are almost mandatory in the operatory, but the positioning remains important. If the dentist or staff member must twist their body to use the devices, back and shoulder problems can develop rapidly.

Although the digital dental operatory is evolving, dentists should understand that many minor issues need to be addressed in the planning stages to get the most benefit from their new systems.

Dental operatories are the heart of the practice, so it is vital that key details and technologies are implemented to ensure efficiency and function.

Optimizing Operatory  Design for Efficiency

Photobiomodulation (PBM) has been used clinically in treating the temporomandibular (TMD) joint for more than 30 years. PBM has been increasingly used in other countries but is not as widely used in the US for TMD joint pain. PBM uses light energy to repair damaged areas for a patient.

PBM is like photosynthesis in plants but uses certain wavelengths of light in the red and infrared spectrum (the ideal range is 660-840 nm). PBM causes intracellular photochemical changes that lead to a cascade of downstream intracellular photochemical, extracellular, and physiological changes. The mitochondria within the cell wall are particularly receptive to this process. At the cellular level, visible red and near-infrared light energy is absorbed by mitochondria, which produce cellular energy called adenosine triphosphate (ATP).

PBM’s use in treating the existing TMD joint and/or pain and dysfunction in masticatory muscles impacts the biological process, especially inflammation, and is considered an adjunct treatment modality in TMD cases.

This article will focus on the use of PBM to aid in the dysfunction of the TMD joint. PBM will aid in decreasing inflammation in the joint, increasing endorphins associated with masseter muscle, and the stimulation of acupuncture points (an Eastern medicine). PBM can stimulate the acupuncture areas; this is called photoacupuncture (combination of 

). The World Association for Photobiomodulation Therapy defines 

 as “photonic stimulation of acupuncture points and areas to initiate therapeutic effects like that of needle acupuncture and related therapies together, with added benefits of PBM.” Photoacupuncture helps to repair the physical dysfunction, relieves pain, and aids in the comfort of the patient.

When treating patients, the first procedure is to document the maximum opening without pain (

). You can use this device or your fingers to measure the opening from the maxillary incisors to the mandibular incisors (

). The patient should be able to open to 3 fingers’ width. The mean opening in a study done by Zawawi et al was around 48 mm.

Next, use photography to document the area in the masseter that creates the most pain (

). By documenting this area, auxiliaries will be able to make quick reference to the site of the masseter that creates a trigger spot for pain during function just by touch. During the first session you will want to overstimulate the site to get pain relief (release the body’s endorphins). This site is normally treated with 12 to 15 J of energy as shown with a 1-minute duration using a 25-mm extraoral device (Ultradent Products’ Gemini 810 + 980 diode laser with PBM attachment; 

. Cell physiologists have shown that use of 4 to 6 J of energy produces healing amounts of light energy, whereas using more than 12 J overstimulates the pain receptors.

As discussed earlier, stimulation of photoacupuncture points also stimulates the area around the ear (

), but this is done with 4 to 6 J of energy to each site. These areas need to be treated at each visit with the same 4 to 6 J of energy.

The other stimulation sites are the lymphatic sites in the head and neck areas. TMD creates inflammation in the joint, so by treating the lymphatic system, you can reduce inflammation in the head and neck area.

Treatment of the submandibular and the subclavicular lymphatic ducts with 4 to 6 J of energy at each site will need to be done during each visit (

). Using this regimen every 4 to 5 days between sessions brings the most optimal results, with the only change being to stimulate the trigger point in the masseter with 4 to 6 J of energy after the first session.

Using Photobiomodulation to Ease Temporomandibular Pain

The treatment is not a one-and-done procedure, as it must be done for 1 session after the patient states they have significant reduction of pain and mobility to allow normal opening of the mouth without pain (6-8 sessions). The patient may have several months of relief until stress creeps back into their life and they begin overfunctioning and stressing the TMD area.

Many insurance companies cover the expense of this treatment, which we charge at the first session and do not charge anything further to prevent patients from stopping treatments early due to concerns about cost. Insurance codes used are D7899 (unspecified TMD therapy, by report) and D9130 TMD (noninvasive physical therapy). Another dental code that can be used is D9110 (palliative emergency treatment of dental pain). Unfortunately, insurances rarely pay using this code. For medical coding, use 97032 (electric stimulation, manual, each 15 minutes) if you have the capability to submit by these means.

Following this treatment plan works well but requires patient adherence to the number of visits needed for success. Let patients know up front that you cannot guarantee success, but the resolution of limited opening and related discomfort should be possible—especially if the patient changes habits, such as refraining from chewing gum and eating chewy foods like submarine sandwiches or bagels that put stress on TMD joints.

Some may still consider this hocus-pocus dentistry, but it does work and there are numerous articles in PubMed showing PBM makes a significant difference.

 One great resource for learning more about PBM treatment is the Academy of Laser Dentistry. PBM does work and has many uses in dentistry and in medicine.

Clinical images courtesy of Dr Edward Kusek. 

Azeemi STY, Rafiq HM, Ismail I, Kazmi SR, Azeemi A. The mechanistic basis of chromotherapy: current knowledge and future perspectives. 

2019;46:217-222. doi:10.1016/j.ctim.2019.08.025

Sun G. Photoacupuncture: combining Eastern and Western medicine for integrative healing. Academy of Laser Dentistry. November 2023. Accessed May 6, 2024. https://www.laserdentistry.org/index.php?option=com_dailyplanetblog&view=entry&year=2022&month=11&day=22&id=36:photoacupuncture-combining-eastern-and-western-medicine-for-integrative-healing

Zawawi KH, Al-Badawi EA, Lobo SL, Melis M, Mehta NR. An index for the measurement of normal maximum mouth opening. 

Madani A, Ahrari F, Fallahrastegar A, Daghestani N. A randomized clinical trial comparing the efficacy of low-level laser therapy (LLLT) and laser acupuncture therapy (LAT) in patients with temporomandibular disorders.

 2020;35(1):181-192. doi:10.1007/s10103-019-02837-x

Xu GZ, Jia J, Jin L, Li JH, Wang ZY, Cao DY. Low-level laser therapy for temporomandibular disorders: a systematic review with meta-analysis. 

. 2018;2018:4230583. doi:10.1155/2018/4230583

Photobiomodulation and light have a variety of uses, including for temporomandibular joint pain that many patients experience.  

Using Photobiomodulation to Ease Temporomandibular Pain 

Kintegra Health is a federally qualified health center. Specifically, we are a community-sponsored, family health–centered health care organization that offers treatment, education, and preventive services regardless of a patient’s ability to pay. More than half of our patients are under Medicaid, and the rest are self-pay and private insurance patients.

Kintegra’s origins go back to 1989 in Gastonia, North Carolina—the result of the formation of a local task force of concerned citizens, business leaders, and representatives from our local hospital. The task force was formed to address the concern that our town’s growing uninsured population was frequently using the local hospital’s emergency department to obtain primary medical and dental care. This task force was the catalyst for the formation of Gaston Family Health Services (GFHS).

In 1992, we saw our first medical patient, and then we added dental services in 1996. Our current services are much more holistic and include adult and pediatric primary care, behavioral health, pharmacy services, chiropractic, and podiatry. We will be adding optometry to our school-based programs in 2024.

In April 2020, we rebranded GFHS as Kintegra Health. We made the change to better represent our growth in multiple counties outside of Gaston and our expanded comprehensive and integrated health care services.

When the COVID-19 pandemic struck in the middle of our rebrand, we did not know what to expect or how we were going to continue caring for the underserved community that had been depending on us for health care services. We certainly did not want to see a return to the situation that prompted our formation in 1992—overwhelming the local emergency department. We knew we had to be innovative once again.

After much thought, we decided to take a virtual patient care approach and implement digital imaging and teledentistry. Within the first few months of the pandemic, we equipped the public health hygienists on our mobile dental units with teledentistry-enabled MouthWatch intraoral cameras and never looked back.

We standardized MouthWatch cameras because they came highly recommended by Kintegra Health Dental Director Bill Donigan, DDS, MPH, who had been using them in his private practice for years. It had been his idea to equip Kintegra’s medical providers with intraoral cameras.

MouthWatch has its own award-winning teledentistry software named TeleDent, but its intraoral cameras integrate well with about any teledentistry platform. Because most of our providers were already familiar with Microsoft Teams, we integrated the cameras with that platform to fast-track the teledentistry program during the pandemic and ensure its widespread adoption among our dental and medical providers.

Kintegra Health has its medical and dental providers and its front office personnel as part of our workflow, so having the ability to close the medical-dental loop very quickly when patients seek care is a great advantage. By using the MouthWatch camera with Microsoft Teams, we were able to easily integrate intraoral images into our existing medical-dental collaborative workflow. Here is the medical-dental referral process:

If a patient complains of pain or has oral health concerns, the medical provider will request that their medical assistant take intraoral photos with the MouthWatch camera.

The medical assistant then makes a dental referral in their electronic records (which is Epic to dental), and the intraoral images are uploaded into a transfer file that the medical and dental teams can access.

The medical assistant then sends a Teams message to the dental provider, who will respond with a patient urgency-of-care assessment of level 1, level 2, or level 3.

Level 1 signifies that the patient needs to be seen within 24 to 48 hours and that the patient is expressing a pain level of 9 or 10 (the dental provider includes this in a report shared with medical).

Level 2 indicates the patient could wait to be seen within a week.

Level 3 means the patient’s dental appointment can be pushed out further, within 2 weeks.

This process is similar but reversed as the referral is from medical to dental in these cases.

Since we adopted this workflow, the feedback from our medical providers has been positive. They are frequently surprised by how quickly we can get their patients’ intraoral images reviewed by our dental providers and scheduled for treatment if necessary.

This quick collaboration is made possible with teledentistry, whereby we conduct an initial evaluation and create a treatment plan that we can present when the patient or patient and guardian come to the clinic. Very often when the medical and dental teams work in the same location, we can start dental treatment the same day, which is not only convenient for the patient but quickly closes the loop with our medical providers.

We had a 5-week-old being seen in one of our pediatric offices. The pediatric medical team sent an intraoral photo of an eruption cyst to one of our pediatric dental providers in the same building. She was able to walk to the medical office within minutes and give that mom peace of mind by letting her know that the eruption cyst would dissolve on its own and there was nothing to worry about.

A child with lymphadenitis had an abscess associated with the stainless steel crown on a primary molar. Medical and dental teams agreed to send this patient to the emergency department immediately so he could receive intravenous antibiotics. He returned to the dental clinic a week later for extraction of that abscessed primary tooth. This was an example of optimal care for that patient because we were able to agree to send him to the emergency department right away and not waste time having him come to the dental clinic first.

In another instance, our pediatric medical facility forwarded a photograph to our dental team. Nearly every tooth in this child’s mouth had decay. Although the original photo was just a broad-spectrum picture of the mouth, the dental team took more photos to demonstrate how bad the patient’s oral health was. In addition, this child had a cardiac episode. Thanks to teledentistry and our patient navigator, we were able to virtually refer that child from the pediatric medical clinic to a pediatric dentist who looked at the data and responded within a half-hour. The good news was the child never had to leave the medical clinic for the dental evaluation, and the cardiac referral received top priority and was processed the same day.

Some cases are more troubling. Our dental team recently received an intraoral photo taken at one of our schools, and the child had a papilloma on his palate. Coincidentally, our dental team had recently attended a lecture regarding how to identify the signs of child abuse during oral examinations. We immediately turned this case over to our Department of Social Services. If we were not taking intraoral photos in the schools, this incident would have been missed and that child would still be enduring sexual abuse. Thanks to digital imaging and teledentistry, Kintegra Health can be an active advocate for child safety in every community we serve.

When we started the medical-dental integration program, we were not sure how it was going to unfold or what the response among our medical and dental providers would be. Fortunately, our medical and dental teams have been very receptive. I was not surprised about the support among dental providers, as they are taught in dental school to touch every single tooth.

I was, however, pleasantly surprised when some of the medical providers said to me, “Hey, we never really referred to dental because we never knew if our patients were actually seen.” Once we were able to get our medical providers excited, Kintegra Health was well on its way to delivering whole-person care and establishing a higher level of clinical excellence for our patients—and we are keeping them out of the emergency department.

With the help of MouthWatch, Kintegra Health is working to close the gap between medical and dental care and has collaboration success stories that show how it is keeping patients out of the emergency department. 

Deep Dive: Establishing Better Physician-Dentist Collaboration With Technology

In my years of being Technology Evangelist, I have gotten to work with some amazing products and collaborate with some amazing people. As an industry, we are lucky to have these individuals in the world of research and development. We count on them to deliver us state-of-the-art tools, supplies, and materials that allow us to do better in helping patients.

Dentistry is a huge industry. Because of that, we benefit immensely from all types of companies that support us. Large multinational companies, medium-sized operations, and smaller companies provide us with things we use every day that improve the lives of our patients. As a tech lover, I see and use the benefits of all types of their hard work. This month, I would like to highlight one of those smaller companies that gives us big benefits. That company is AdDent in Danbury, Connecticut.

The company was founded by Josh Friedman, DDS. He is one of those individuals who quietly work behind the scenes, but we all benefit from what he has created. I do not remember the first time I met him, but what I do remember was realizing he is an “outside the box” thinker.

One of his great advantages is that he is a dentist. That allows him to understand the unique things we face clinically every day. However, he is not just a dentist. This bright individual is also an electrical engineer with a bachelor’s in electrical engineering that he earned at City College of New York in 1959. After earning his degree, he embarked on a career that spanned working on intercontinental ballistic missile (ICBM) guidance systems, being a research scientist at the New York University College of Dentistry, and founding 3 companies: Demetron Research Corp, the first company to introduce an efficient handheld curing light; Electro-Lite Corp, a manufacturer of powerful UV lighting systems for industrial use; and his current company, AdDent.

Those of you practicing in the late 1990s probably remember the Demetron curing lights that were incredibly popular then. After selling Demetron to a large dental manufacturing company in the early 2000s, Dr Friedman’s next dental manufacturing company was AdDent, which he continues to run today.

I mentioned that he is an “outside the box” thinker and that is borne out by the fact that he hasover 30 patents with more pending. He has also been given the moniker “the da Vinci of dentistry” due to his creative problem-solving. He has a real knack for developing “better mousetraps” for the profession.

I recently asked him about his time working on missiles, and this is what he had to say: “My first job out of engineering school was with a company that made the guidance system for the Atlas ICBM…precursor to the Minuteman missile. These missiles are in silos throughout the West and Midwest. I was then faced with an urgent and unusual challenge—to find out why the guidance memory was defective. In the event of a launch, the ICBMs could go anywhere. It turned out that the epoxy coating on the memory boards was shrinking during polymerization and causing critical components to crack. As I reflect on that experience, I think of how directly it relates to dentistry in the way we formulate and manage composite filling materials to reduce shrinkage.”

After solving the problem with polymerization shrinkage on missile guidance systems, he applied those lessons learned and his problem-solving skills toward the issues with composite shrinkage in dentistry. That led him to become a leading advocate of warming composite before placement and curing to help reduce polymerization shrinkage. When the curing light is applied, composite has a natural tendency to shrink, which can lead to cracks in the healthy tooth structure as well as gaps in the restorative margin. This leads to recurrent caries. Studies have shownwarm composite has fewer voids and less marginal gap formation.

Under his guidance, AdDent developed the Calset Composite Warmer. This is a device that uses alternating current power to warm the material before placement. It consists of a base that creates heat as well as a variety of trays that can be placed on top of the base to warm things such as composite compules, composite syringes, operative instruments, anesthetic cartridges, and even veneers and crowns (to warm them before final cementation).

Not resting on the laurels of Calset, AdDent decided to take composite warming to the next level and recently created the Compex HD, a composite-dispensing gun. Most companies sell composite-dispensing guns, but they are usually throw-in products made of inexpensive plastic that do not work very well.

AdDent’s Compex HD has a warming unit built into the barrel that heats the composite compule in the gun. You place the compule in the gun, push the “on” button, and in 30 seconds the compule is heated to 155 °F. The heating element is under the compule and well insulated so that any part that touches the patient stays cool. Once activated, the device continues to warm the composite for 10 minutes before automatically shutting off. It has a rechargeable battery that allows use with 100 compules before needing a recharge.

I use total etch as my go-to technique, so in my workflow, we activate the Compex HD as I begin to place the etchant. By the time I get ready to deliver the restorative, the material is warmed and ready. In addition to less shrinkage, warm composite is easier to place, condense, and sculpt. This device is intrinsic to how I work and is now something I cannot do without.

The latest creation from the mind of Dr Friedman is another interesting and “better mousetrap” problem-solver. In clinical dentistry we are often faced with handling and manipulating small objects that require a sturdy grip as we place them. Veneers and crowns can be small and delicate. When you factor in the luting materials, these can be difficult to hold and place.

In the past I would tell patients, “If, God forbid, I drop this in your mouth, don’t be polite. Spit this out and don’t worry about my reaction. Even if it hits the floor, we can clean it, but if you swallow it, we aren’t going to go looking for it.” That usually elicits a chuckle, so I explain, “The glue we use works incredibly well, but it has the viscosity of maple syrup and the coefficient of friction of baby oil. If I happen to get some on my glove, these things get really slippery, and it may slip out of my fingers.” Although it is a decent way of letting patients know not to swallow anything, it is also a conversation I would rather not have.

To the rescue comes the Vac-Tak. It is a small handle with a suction cup that attaches to it. The suction cup is moistened and used to pick up the prosthesis. Once attached, the luting material is placed, then the Vac-Tak is used to deliver the prosthesis onto the tooth. Once the prosthesis is seated, it is tack-cured and the Vac-Tak removed.

The process is quick, simple, and efficient. The device has 2 sizes of silicone suction cups and I have not come across a crown or veneer that I cannot attach. Both the handle and the suction cups are autoclavable.

Placing a crown on a maxillary second molar is one of the trickiest things I must do. Despite my best efforts, I often get a tiny bit of the luting material on a finger and suddenly the crown is sliding around in my grip like a wet marble. The Vac-Tak has solved that problem as well as the stress that comes with it.

AdDent makes much more than the products I have mentioned here. The company sells a variety of products, including a very good oral cancer screening light called the Bio/Screen. To see all their products, visit www.addent.com.

In a letter to scientist Robert Hooke in 1675, Sir Isaac Newton wrote: “If I have seen further, it is by standing on the shoulders of giants.” As a profession, we in dentistry stand on the shoulders of many giants. We are lucky to have “outside the box” thinkers in our industry.

In my time as Technology Evangelist, I have been lucky enough to meet many of them. As clinicians in the trenches every day, we often do not realize the contributions that many of our own have given us. We truly see farther because of them. I am excited to see what Dr Friedman comes up with next.

The industry is fortunate to have many great minds developing products and techniques that help clinicians perform better dentistry.

AdDent Keeps Delivering “Better Mousetraps”

In 2016, one of my patients—a frustrated mom who was about the same age as me—humorlessly asked me, “Isn’t there, like, a magic coating you can put on my teeth so I don’t get any more cavities?”

If I could sum up everything I learned in dental school in 1 sentence, it would be this: Blood ruins everything.

Sadly, blood is here to stay. Even the most talented and extraordinary periodontist in history would have to admit that a significant percentage of his or her patient population comes in regularly with the type of gums that just ooze.



Having graduated dental school 20 years ago, I was taught 2 effective strategies to mitigate the headaches that blood causes:

The second one is easy and liberating. My dental work is difficult, and I can just blame the patient for their horrible home care.

The first one, sadly, is difficult and does not always work. If I were to survey every general dentist in the US about whether they enjoy packing cord, I am quite confident that the majority would mark the “no” checkbox. Not only is packing cord difficult, time-consuming, and painful (for the patient and the dentist), it does not always work. This is made worse in the presence of copious gingival hemorrhage. One of the worst of all clinical incidents is the rare occasion when a handpiece bur gets entangled with a stray fiber from a poorly packed cord. Blood and the remaining cord rotate like a helicopter around the shank of the handpiece. Not only does this ruin the procedure, but it also ruins lunch, it might ruin your white coat, and quite possibly might ruin your day. How ironic—we pack cord in attempts to gain control over blood, but it is the blood that can also make cord packing more difficult and less predictable.

The good news is that I graduated dental school 20 years ago, before iPhones,Amazon, and smartwatches were ubiquitous. Technology was very different. It would stand to reason that, although other areas of our lives have benefited greatly from the exponential increase in technological development, our work as dentists should benefit as well. The good news is that it has.

Several dental technologies and innovations have made the most difficult aspects of general dentistry easier, more predictable, and more patient friendly. Listed below are several incredibly easy and innovative agents to mitigate and often eliminate the presence of blood during difficult dental procedures, all of which I had never learned about in the early 2000s as I progressed through my dental education.

HybenX from EPIEN Medical and PerioDT from Young Specialties:

 These nonantibiotic chemical desiccants kill subgingival bacteria and desiccate the treated gingival tissue. They have not been marketed as agents designed to limit gingival bleeding but, in my experience, have been quite effective.

 These allow for incision, excision, tissue modulation, and cauterization. Lasers are incredibly effective at eliminating gingival bleeding, but drawbacks include the following:

Time-consuming to set up and activate compared with the other listed options

Postoperative pain can be expected in the affected areas

ViscoStat or Astringedent X from Ultradent Products:

 These are topical ferric solutions that, when scrubbed onto the affected gingiva, result in excellent hemostasis. Sadly, this does not result in any gingival retraction.

This solution was introduced to my clinical repertoire most recently and will be the focus for much of the remainder of this article. This is an aluminum chloride-based astringent paste.

It is both an astringent and retraction agent. Designed as a 2-stage formula, it allows precise application without injury to the gingiva, and then offers increased stability in the sulcus, leading to effective temporary widening.

VOCO Retraction Paste is dispensed from an incredibly thin plastic tip, allowing maximum depth into the sulcus, and is packaged in a single-dose blister pack at 0.3 g per cap. This provides enough material for about 3 crown preps.

What differentiates it from the options summarized above is its ability to progress from phase 1 (dispensing) to phase 2 (increased viscosity). It is easily dispensed using a composite placement gun, and comes packaged in a single-use compule. Upon dispensation, the material quickly becomes more rigid, achieving gingival retraction as cord might. This transformation happens in 2 minutes or less.

After the more rigid phase of the retraction paste has created displacement of the gingiva away from the tooth prep, the material is rinsed off with a combination of air, water, and occasionally cotton, resulting in dry, highly visible margins. It has a bright turquoise color, so there is never any doubt about whether I have rinsed off all of the material.

Although there are clinical scenarios that require use of all the hemostatic and retraction options above, my preference usually is the VOCO Retraction Paste. It is inexpensive, user-friendly, and incredibly effective.

Not only does it work well with crown impression and/or scanning, but I have found myself using it in any restorative instances in which I need to control bleeding and achieve gingival retraction. This includes class V composites, class II composites, crown cementation, and endodontic procedures. Although plenty of clinical scenarios require packing cord, I have found that, even in those infrequent and inconvenient cases, I will still use the VOCO Retraction Paste to complement the cord.

Most clinical cases are traditional crown preps, just prior to taking an impression or scan. During this procedure, the material is dispensed around the entire gingival margin through a thin tip designed to allow material to extrude into the gingival sulcus.

I then place a cotton compression cap over the tooth (not required) and have the patient bite, causing more gingival displacement as the material transitions into more viscous phase 2. This process allows me to leave the operatory and see a patient in another room. Upon returning, the material is thoroughly removed, and I can have confidence in taking an excellent scan or impression.

VOCO Retraction Paste helps clinicians deal with blood and, in most cases, cut the cord.

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