Dental Assistant

by Ray M. Becker, DDS
Private Practice, Ellicott City, Maryland; International Certifying Instructor for Total BioPak and Biometric Technologies Featured Speaker at the 2009 BioRESEARCH Annual Conference

Every dentist recognizes the importance of occlusion for clinical success in dentistry, yet very few take the necessary steps to understand and control its impact objectively in everyday practice. Most dentists are aware of the ongoing debate over whether it is more important to treat just the teeth, the muscles, or the joint as the Rosetta stone of occlusion. However while dentists acknowledge that they need to know more, it is hard to know where to start. This article outlines a strategy to address occlusion using biometrics. Biometrics is the gathering of objective data from the patient’s stomatognathic system. Biometrics is used widely throughout all fields of medicine. The term refers to the gathering of recordable, measurable, and reproducible data from the patient. Blood pressure, cholesterol levels, and blood chemistry are only a few examples of recordable biometric data that physicians routinely gather to evaluate, diagnose, and treat patients. The significance of being able to record data for analysis, comparison, and archiving cannot be overstated. This is what elevates occlusal analysis to a true science as compared with subjective analytical methods.

Generating recordable data is important, and recordable, objective data points cannot be obtained with articulating paper. Historically, articulating paper has been used as the sole instrument for gathering data from the patient’s occlusion. However, it is impossible to use articulating paper to obtain specific defined data to measure, archive, compare, and study occlusion. This fact alone prevents research to obtain parameters to analyze, study, and therefore, standardize the use of articulating paper. In contrast, using biometrics in dentistry does provide objective data that has been studied, researched, and evaluated for more than 40 years. Research has defined specific pathologies related to the objective data obtained from biometrics. Therefore, a clear and objective understanding of the interrelationships that exist with the teeth, muscles, and joints of the patient is now possible with a high degree of accuracy. This data and its accuracy provide practitioners with the ability to evaluate, diagnose, and treat occlusion as never before.

Biometrics has three distinct relevancies with regard to occlusion: diagnosis, treatment, and reevaluation. With a more accurate diagnosis, the dentist can define the current state of the patient’s stomatognathic system, and therefore, treatment plan with greater clarity and purpose. The subsequent treatment is guided by the objective data and feedback from biometrics. Finally, the dentist has a very powerful tool to reassess the outcome and determine with objectivity whether the intended treatment goals were obtained. These data help the dentist clearly diagnose and understand the patient’s occlusion.

THE BIOMETRIC APPROACH

The approach described in this article is simple for patients to understand and accept, straightforward for the office to implement into its busy workflow, and easily performed by auxiliaries, increasing productivity of the practice. This model encompasses all three aspects of the stomatognathic system including the teeth, muscles, and joints, which interrelate and define a patient’s occlusion. This approach overcomes the difficulty often encountered helping patients to realize their condition and the complex nature of occlusion. Additionally, it is easily accessible, and can be applied purposefully to all dental patients. When used proactively, clinicians can catch potential problems early, often preventing many overlooked and debilitating conditions. This approach also provides for scalable treatment that is driven by patients and built on objective data and findings, not a subjective belief system, which unfortunately is necessary when diagnosing in the absence of data.

Step One

A biometrics approach begins with joint vibration analysis (JVA). The BioJVA™–Quick test (BioResearch Associates Inc, Milwaukee, WI) is a computer-assisted vibration analysis of the patterns of friction and vibration, which should be performed routinely on every dental patient. JVA has been shown to be 98% sensitive and 98% specific in the diagnosis of joint pathology.^1,2 Simply stated, this means it has the ability to show both the true presence and absence of disease. Further, a JVA is easy to replicate and allows different practitioners the ability to obtain the same diagnosis 98% of the time. This is in contrast to 14% and 48% consistency of diagnosis with the respective use of a stethoscope or Doppler ultrasonography.^3-5The ability to diagnose the condition of the joint easily and accurately is significant because, as early as 1984, an American Dental Association committee stated in its findings that dentists should be the primary source of evaluation and treatment of temporomandibular disorders (TMDs).⁶ Since then, various researchers, committees, and organizations have echoed these sentiments to the dental profession. Yet, overwhelmingly, most practitioners continue to provide little if any assays or treatment for joint-based diseases and occlusion. In less than 2 minutes, a wealth of information can be obtained with the BioJVA–Quick test. The BioJVA–Quick test uses industry-unique and patented accelerometers that are arranged as a very simple headset.

Using a JVA recording device provides the practice with a tool for better patient understanding of occlusion through heuristics. The power of heuristics is well understood through the research of ethologists, scientists who study human behavior. According to Cohen,⁷ individuals in a busy society, such as United States, are so overwhelmed with stimuli and information that they often take shortcuts, even to many very personally relevant daily decisions. This could be one reason many practices find it difficult, if not impossible, to help patients understand (let alone treat) occlusalbased issues. The BioJVA–Quick test provides patients with information and objectivity that allows self-discovery and makes the connections so critical for codiagnosis. This happens because of heuristics where patients see objective and accurate data on the computer screen and easily recognize and understand their condition. It has been shown that involving patients and providing objective data, as opposed to hearing only the subjective perspective of the provider, are powerful triggers that help patients decide on the relevancy of information received and act on a particular topic.⁸

The specific triggers that the BioJVA–Quick test provides are consistency of application, involvement and commitment, integrity and authority, proof of value, and allowance for objection-raising within a noncommittal environment.⁹ More specifically, when patients recognize that the provider uses and consistently applies these technologies for every patient, it helps them understand the value it potentially holds for their care. Being able to give patients objective data that illustrates and quantifies an issue that is often overlooked consequently builds patient confidence in the dentist’s abilities to potentially treat these conditions. With this information, there is often a flood of questions previously withheld regarding these issues, allowing patients the opportunity to explore, raise questions or objections, and codiagnose these issues without bias. These psychological triggers provide patients with information they easily and comfortably accept, and then act upon.

Step Two

If the patient and practitioner further decide to explore and possibly treat a positive finding from the JVA, full biometric testing is recommended. Full biometric testing provides the dentist with accurate data regarding the interrelationships of the teeth, muscles, and joints. These data allow the dentist to understand how these elements of occlusion influence and affect each other within the individual’s stomatognathic system and treatment plan accordingly. Full biometric testing can be performed by the support staff and be reviewed later by the dentist. This allows auxiliaries to become more productive assets within the practice. Full biometric testing is also invaluable to reevaluate the patient after the proposed treatment to assess the outcome or success of therapy objectively and quantitatively.

Based on the findings of the biometric testing, the clinician can determine the state of health of the patient’s stomatognathic system accurately. By diagnosing and isolating any discrepancies of the teeth, muscles, or joints, the practitioner can guide the appropriate treatment for that patient. Whether a single-unit or a full-reconstruction case, biometric testing offers dentists the ability of assaying for degenerative joint disease before treatment, which may influence the clinician’s and patient’s ultimate decisions. Additionally, with this data the dentist can become proactive with treatment planning to help stabilize the patient’s stomatognathic system, potentially preventing difficult-totreat degenerative conditions from occurring.

FURTHER BIOMETRIC TESTING

If it is determined that full biometric testing is required, the clinician can examine objectively the timing and force of individual tooth contacts by using the T-Scan^® III (Tekscan Inc, South Boston, MA), a USB computerized scanning device. The clinician also can record craniofacial muscle activity in both rest and function by using the BioEMG™ II (BioResearch Associates Inc). Then, through the use of T-Scan/BioEMG Link software (Tekscan Inc/BioResearch Associates technology partnership), the clinician can determine the specific activity of the muscles of mastication timed exactly with the individual contact forces.

THE BENEFITS OF SCIENTIFIC ACCURACY

Almost universally dentists use articulating paper and centric occlusion as their basis for performing, analyzing, and delivering dentistry. With biometric testing, dentists can obtain objective and concise results that help diagnose, treat, and reevaluate a patient’s occlusion and stomatognathic system.

The use of articulating paper alone for occlusion fails to follow the basic tenets of the scientific method on which all research and modern advancements are based. The definition of the scientific method from the Encyclopedia Britannica reveals that for a hypothesis to be tested, one needs to collect objective, recordable, reproducible data. This allows for a process called “full disclosure,” which is critical so that others may replicate the same results for additional analysis at different times and locations.¹⁰ Imagine how difficult it is to describe and subsequently share in a quantitative, objective manner the markings made with articulating paper to a colleague in a different state or country.

Unfortunately, there are no studies to verify or show how articulating paper alone can provide for these specific requirements of the scientific method. Kerstein et al¹¹ have shown there is a very poor correlation of the actual marks made with articulating paper and the specific force creating them. Even more disturbing was their finding that higher forces often paradoxically leave less ink markings on the tooth surface. This author, as well as other dentists, has noted with use of the T-Scan III that often areas of greater force indicated with the device appear less densely marked with articulating paper. This is noted routinely with a wide variety of papers and articulating films. This phenomenon and direct comparison is easily noted by users of the T-Scan III device because it is necessary to use articulating paper in conjunction with the device, whose mylar sensor does not make any physical markings on the tooth surface during its use. Articulating paper is necessary after a scan to indicate the actual force and timing events noted with the
T-Scan III.

Case 1: Scientific Articulation

The following case illustrates the concerns about using articulating paper alone for occlusion. The patient had an all-ceramic restoration placed to fix a previously fractured tooth. This case initially was completed before using an objective scanning device for occlusion analysis. The allceramic crown failed shortly after placement. Figure 1 shows the subsequent replacement crown immediately after milling and before characterization, glazing, and final insertion. Checking the occlusion with 20-_m articulating paper produced what appeared to be very light contact on tooth No. 31. Figure 2 shows the subsequent T-Scan III analysis of the same patient.

The computerized analysis showed that even with very light articulating paper markings there were excessive forces being placed on the area around tooth No. 31. The 3D graph showed the exact area that needed to be adjusted for this discrepancy. Because this area of concern was previously undetectable with articulating paper alone, it may be the cause of the initial failure of the patient’s tooth. The new all-ceramic crown placed after using T-Scan III analysis and adjusting the occlusion based on the finding solved this problem. Whereas the original restoration fractured within 1 month, the subsequent replacement, as of this writing, has lasted for more than 2 years without failure.

Often material choice alone is considered the primary factor to take into account with fracturing or occlusionbased issues. If clinicians simply attempt to repair damage with a material they believe less likely to fracture again, they can overlook the possible cause of the failure. While that approach may seem to solve the fractured tooth concern initially, occlusal forces could displace as problems to other teeth, muscles, and/or joint of patients. Biometrics allows clinicians the ability to analyze occlusion objectively and address the cause instead of just treating the effect. These tools allow dentists to practice comprehensively on the entire stomatognathic system instead of simply repairing damage. This allows delivery of biologically based, instead of just spatial, dentistry. Occlusion is not influenced solely by the restoration material used in the previous example; therefore, the failure of the initial crown should not be attributed to the inherent qualities of all-ceramic crowns versus porcelain-fused-to-metal (PFM) crowns or gold crowns. The properties of current ceramic materials often closely match the original properties of natural enamel.¹² An intrinsic characteristic and property of ceramics is that they are brittle, much like a natural tooth, whereas gold or metal is ductile and not as prone to failure by fracture. Therefore, ceramics are likely to fail by fracturing whereas an all-gold restoration, or the metal framework of a PFM, is unlikely to fail immediately. Unfortunately, merely masking the occlusal discrepancies does not remove these forces. Therefore, if a clinician overcomes the fracturing through material choice, he or she is ignoring these forces.

Occlusal force discrepancies often show up as issues elsewhere in the stomatognathic system. The many benefits of using all-ceramic materials can be realized when biometrics are used to address the forces of occlusion. Simply changing materials might eliminate a chronic fracturing problem, but without an objective analysis the new restoration may create an uncomfortable tooth, muscles of mastication, etc. Grinding the tooth further out of occlusion can solve this problem only for the short term because eruption likely will cause the discrepancies to return.

Case 2: Full Occlusal Rehabilitation

The following case illustrates how the biometric approach can be used along with the tenets of both popular schools of thought regarding occlusion. In this example coordinating the timing and activity of individual muscles, as well as a canine-protected occlusion, will be used simultaneously to improve a patient’s overall occlusion.

A direct feedback loop exists with proprioception of teeth and the elevator muscles of mastication.¹³ The more teeth that contact, the higher the muscle contraction in that area increases. Group function, therefore, causes more muscle firing than single-tooth canine rise. Hyperactivity of these muscles can lead to a variety of clinical pathologies including headaches, muscle fatigue, joint dysfunction, bruxism, and tooth wear.¹⁴ After recording the timing and force of tooth contacts with the T-Scan III, and the muscle activity with the BioEMG II, the clinician can use the linking software (T-Scan/ BioEMG Link) to observe the disocclusion of teeth from centric occlusion toward lateral excursions. Lessening the otherwise difficult-to-isolate interferences during this transition creates harmony in the occlusion.¹⁴ The software allows the clinician to confirm muscle activity, synergy, and symmetry as it changes from altering tooth contacts. Reducing the number of teeth contacting during this transition reduces unnecessary muscle contraction. Lessening the amount of muscle activity can be the difference between comfortable occlusion and a potential trigger for any of the previously mentioned muscle-based pathologies.¹⁴

Preadjustment, the patient experienced a left excursive from centric occlusion (Figure 3). After some initial adjustments, the software confirmed that the patient finally achieved canine rise after group function, and the elevator activity decreased accordingly (Figure 4). Then, the working and nonworking interferences were adjusted to make the transition from centric occlusion to canine rise as efficient as possible. The results of the final adjustments were confirmed with the software (Figure 5).

Computer analysis allowed the clinician to assess accurately and adjust concisely in less time only those interferences that disrupted the disocclusion of teeth from group function into canine rise. This was possible because the software showed the exact timing and specific tooth contacts and loads in conjunction with muscle activity. Reducing disocclusion time from group function to canine rise reduced interferences that disrupted the harmony of the teeth, muscles, and joint
complex.

CONCLUSION

The role of occlusion is often overlooked, minimized, or ignored in many dental practices. Many dentists find it difficult to understand occlusal concepts, or perhaps cannot fathom where or how to begin to incorporate occlusal technologies into their busy practices. Implementing an easy-to-learn and easy-to-use biometric approach gives clinicians a powerful tool for incorporating occlusal analysis into their practices. Through heuristics, the BioJVA–Quick test enables the patients to make the necessary connections between occlusion and the benefits of potential treatment. Further, the biometric approach provides recordable and reproducible objective data, which can lead to improved clinical results and fewer failures. Requiring far less clinical chair time, the biometric approach gives dentists the critical information they need to create harmony of the teeth, muscles, and joint complex.

DISCLOSURE

The author has received honorariums for lecturing at conferences, including BioResearch Associates Inc’s annual conference. Additionally, BioResearch Associates Inc has paid the author to test/teach/certify dentists in proficiency (after their purchase) of Total BioPAK. All articles written by the author (including this one) have been without renumeration.
REFERENCES

1. Ishigaki S, Bessette RW, Maruyama T. Vibration analysis of the temporomandibular joints with degenerative joint disease. Cranio. 1993;11(4):276-283.

2. Ishigaki S, Bessette RW, Maruyama T. Vibration of the temporomandibular joints with normal radiographic imagings: comparison between asymptomatic volunteers and symptomatic patients. Cranio. 1993;11(2):88-94.

3. Hardison JD, Okeson JP. Comparison of three clinical techniques for evaluating joint sounds. Cranio. 1990;8(4):307-311.

4. Paesani D, Westesson PL, Hatala MP, et al. Accuracy of clinical diagnosis for TMJ internal derangement and arthrosis. Oral Surg Oral Med Oral Pathol. 1992;73(3):360-363.

5. Puri P, Kambylafkas P, Kyrkanides S, et al. Comparison of Doppler sonography to magnetic resonance imaging and clinical examination for disc displacement. Angle Orthod. 2006;76(5):824-829.

6. Griffiths R. Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders. J Am Dent Assoc. 1983;106(1):75-77.

7. Cohen S. Environmental load and the allocation of attention. In: Baum A, Singer JE, Valins S, eds. Advances in Environmental Psychology. Vol. 1: The Urban Environment. New York, NY: Halstead Press; 1978.

8. Chaiken S, Trope Y, eds. Dual-Process Theories in Social Psychology. New York, NY: Guilford; 1999.

9. Cialdini R. Influence: Science and Practice. 4th ed. Boston, MA: Allyn & Bacon; 2001.

10.Baconian method. Encylopedia Britannica. 2008. Available at: http://www.britannica.com/eb/article-9011665. Accessed Jun 11, 2008.

11.Carey J, Craig M, Kerstein R, et al. Determining a relationship between applied occlusal load and articulating paper mark area. The Open Dentistry Journal. 2007;1:1-7.

12.Giordano R. Vita machinable ceramics. 2008. Available from: Vident, Brea, CA: http://www.vident.com/assets/downloads_cloak/Vitablocs_2008_Giordano.pdf. Accessed Jul 2, 2008.

13.Huang X, Zhang G, Herring SW. Effects of oral sensory afferents on mastication in the miniature pig. J Dent Res. 1993;72 (6):980-986.

14.Kerstein RB. Disocclusion time-reduction therapy with immediate complete anterior guidance development to treat chronic myofascial pain-dysfunction syndrome. Quintessence Int .1992; 23(11):735-747

by Shannon Pace Brinker, CDA CDD

About 10 years ago, a dental assistant wearing magnification or using surgical telescopes was unheard of. With the demand for clinical excellence in all realms of dentistry, assistants now more than ever need to see more clearly, decrease eyestrain, and have a supported balance in the musculoskeletal ergonomics.

Eyesight

The eye is a complex sensory organ. It allows us to see and interpret shapes, colors, and dimensions of objects by processing the light they reflect or produce. The eye is able to see in bright light or dim light, but it cannot see objects when light is absent.¹ The iris adjusts to incoming light to maximize the quality of images. Under bright light, the pupil diameter quickly varies from about 1 to 3 mm as the light level changes. This means the eye can easily control the amount of light entering by a factor of 10.² The increase in pupil diameter increases the eye’s resolution capability, as a camera does. The resolution capability usually diminishes at around 2 to 3 mm because the human eye is not a perfect lens. Brighter illumination can improve the depth of field because the diameter of the eye lens decreases, resulting in better resolution over a longer working range.

Magnification Power

Loupes or surgical telescopes of a 1.7 to 2.5× magnification (Figure 1) are recommended for dental assistants for most dental procedures, especially if magnification has never been experienced before. More than this amount will greatly reduce depth of field (Figures 2 – 4). For endodontics, oral surgery, and periodontics, a stationary fixed microscope may be required for greater magnification. If more than 5× magnification is used in either spectaclesmounted or headband-mounted systems, it can be difficult to stabilize the field of vision. Longer working distances require higher magnification powers to achieve the same visual perception. Make sure to verify the true magnification power with your vendor. Optical performance will vary depending on the precision of optical alignments and the quality of lens coatings. Optical misalignments reduce the binocular image quality and often create double images, eyestrain, and headaches. High quality coatings will enhancethe light transmission.

Figure 1. Retracted postoperative frontal view: 2.5°.

Figure 2. The degree of magnification can be increased or decreased when trimming and polishing provisional restorations.

Magnification Scotoma (Blind Spot)

Magnification scotoma is the on-field/off-field blind spot created by your surgical magnification system. Because surgical magnification systems magnify only a portion of the total field of vision, a blind spot occurs whenever an object is carried from the peripheral unmagnified field toward the magnified center of the field—the greater the power of magnification, the greater the absolute size and proportion of the blind spot. A large blind spot may encourage the operator to turn his/her head sharply to one side to eliminate its effects during instrument movements or exchanges.³ The greatest distress related to magnification scotoma is the risk of poor control when instruments are being moved into or out of the magnified field of view. The assistant must be aware of the dangers to the dentist, the patient, and themselves as instruments are passed through this blind spot. The assistant can learn to compensate by guiding the instrument to the dentist’s operating site with any sharp points or edges guarded with a gloved finger until the instrument is under visual control and in the magnified field of view.

Figure 3. By using magnification allows the image to be close enough so the hygienist can see exactly where to place the prophy angle.

Figure 4

Types of Magnification

There are 4 categories of surgical magnifications to choose from. Those categories are and have the following characteristics:

Stationary/Fixed Microscopes

• Wall or ceiling mounted

• High magnification (6 to 20×)

• Confined field at high magnification

• Limited depth of field at high magnification

Low Magnification Multilens Systems

• Spectacles-mounted or headband-mounted telescopes

• Very portable and convenient

• Low to medium magnification range (2 to 5×)

Single-Lens Loupes and Magnifiers

• Headband-mounted or clip-on spectacles

• Low magnification

• Limited depth of field and working distance

Prescription Lenses and Reading Glasses

• Low magnification

• Limited depth of field and working distance

Selecting the Appropriate Magnification

Optical Declination Angle

The dental assistant needs to select a system that meets his/her optical declination angle, which is the angle to which the eyes are lowered when positioned in the working position. If the declination angle is not matched to the musculoskeletal needs, eyestrain and or muscle strain of the head, neck, and back can occur.

Working Distance

The working distance refers to the distance between the dental assistant’s eyes and the working site. The working distance of telescopes should match the assistant’s working distance (Figures 5a, 5b and 5c). Telescopes having the same magnification power and working distance will have significantly different depths of field, depending on what design criteria were used. A representative of the manufacturer should customize the telescope, to center the depth of field to each assistant’s personal working distance.

Figure 5a

Figure 5b

Figure 5c

Depth of Field 

Depth of field is the range over which one is able to achieve visual resolution.³ It is determined by the combination of vision and the surgical magnification system. It is recorded in terms of the nearest and farthest extremes of distance from the surface of the eye to the object observed (depth of field average from 13 to 18.5 in). A well-centered depth of field of 3 in is the minimum sufficient for visualization of structures from the nearest point (central incisors) to the farthest (a reflected view of a distal molar) in the average adult mouth. Less depth of field will certainly require the assistant to tip his/her head forward or backward to visualize some area of the oral cavity.

Reflectance

Reflectance is defined as how well the teeth reflect light. The lower the reflectance is, the better the visual acuity and depth of field given the same magnification and illumination. This is mostly accomplished by nonreflecting coating on the lenses. Most manufacturers coat lens with magnesium fluoride, silica, zirconium dioxide, or titanium dioxide.

Light Systems 

Adequate light must be present for the human eye.² As the amount of room light increases, the visibility of objects also increases. Excessive light obscures details of the object and presents glare problems. The reduced pupil size resulting from the excessive light will increase the depth of field but will in turn decrease the eye’s resolution capability. Dental manufacturers are turning much attention to the development of low profile, lightweight light sources that provide ideal lighting for dental and surgical needs. Co-axial illumination light systems come in 2 types: lights mounted to headbands and lights mounted directly to the surgical telescope-mounting fixture. The separate headband mounting light is generally heavy and cumbersome. With light that is directly clipped onto the telescope, the illumination direction always stays in line with the telescope and therefore the user’s line of sight.

Loupes

There are 2 types of loupes available for uses in the dental practice. The first type is the flip-up loupe, which is mounted on a bracket and attached to the frame of the eyeglasses. The attachment may be either a single hinge or a vertical attachment hinge. Both hinges will allow the assistant to flip up the microscope when it is not needed. The eyeglasses themselves may or may not have corrective lens. The second type is through-the-lens (TTL) loupes, which are less bulky and more esthetically pleasing. TTL loupes are also referred to as fixed telescopes.

Advantages of Flip-Up Loupes

• They can be worn at all times (simply flip out of the field of vision when necessary).

• Other team members can use them.

• Flip-up loupes are less likely to interfere with the use of intraoral or digital photography.

• Because the declination angle is adjustable, flip-up loupes promote better ergonomics.

• They can be repaired faster than custom systems.

Disadvantages of Flip-Up Loupes

• They weigh more than TTL loupes.

• Because they are adjustable, the screws may get loose and striped causing them to flip down at inappropriate times.

Advantages of TTL Loupes

• They are lighter than flip-up loupes.

• They will not get out of adjustment because they are custom designed for each assistant.

• Because the telescopes are closer to the eyes, the field of view is larger.

Disadvantages of TTL Loupes 

• They must be removed if you want to leave the field of view, for instance, to talk to the patient or another team member.

• They are harder to clean.

• They cannot be shared by another team member because they are custom designed.

• If a vision prescription changes, they have to be sent back to the manufacturer to replace the lenses.

• Because the declination angle is limited, the assistant may have to bend his or her back and neck slightly.

Microscopes

Dental professionals increasingly use microscopes for treatment. Some advantages to using a microscope are:

Advantages of Microscopes

• They feature the widest articulation range.

• They have adjustable eyecups that can be fully adjusted.

• Maneuvering handles can be adjusted to the user’s preferred position.

• The fine focus feature allows for easy adjustment.

• Lens range of 20 mm allows for easy focus adjustment without moving the microscope.

• Optimal magnification range of 2.1 to 19.2×.

• They allow for comfortable positioning, reducing or eliminating neck and back pain.

• They will accommodate upgrades and retrogrades without high costs.

Disadvantages to Microscopes

• The feeling of disorientation and loss of field perspective. Because the field can be magnified from 2.1 to

9.2×, it may take the assistant a little longer to get use to.

• It is harder to communicate to the patient with the microscope over their face. Communication must be done before the microscope is in place.

• Difficult to see the expressions of the patient. Asking the patient to raise their hand or use a clicker to make the dentist and the assistant aware of any discomfort.

• Passing of instruments must be practiced because of field perspective.

Conclusion

Magnification allows the assistant to check margins of an impression more accurately.⁴ Provisionals can be fabricated with a more defined margin. Temporary cement removal and cord packing procedures can be enhanced by magnification. As with any new piece of dental equipment, frequent use of a surgical magnification system requires techniques that must be learned and practiced. The higher the magnification of the system, the more difficult the transition will be.

Acknowledgment 

The author would like to thank Robert Lowe, DDS, and Ross Nash, DDS, for their help with the images in this article.

References

1. Chang BJ. Ergonomic benefits of surgical telescope systems: selection guidelines. CDA Journal. 2002; 30(2):161-169.

2. Driscoll WG, Vaughan W, eds. Optical Society of America. Handbook of Optics. Section 12. New York: McGraw-Hill, 1978.

3. Murphy DC. Ergonomics and the Dental Care Worker. Washington, DC: American Public Health Association,1998.

4. Samaras CD. Loupes de loupes: magnification systems for the everyday dental practice. Contemporary Esthetics and Restorative Practice. 2004; 8(7):40-42.

By Shannon Pace Brinker, CDA CDD 

With so many whitening materials on the market today, it is really hard to determine which product to use and why. As dental assistants, we are not trained to decide what is the best percentage of bleach; what is safest for a particular patient; and, most importantly, whether to use an in-office or at-home treatment (or both). Most of the time we draw upon our own experience and our patients’ responses. In this article, we used several different systems from Heraeus and SDI. We chose patients of varying ages and used differing methods for predictable results.

 HOW DOES WHITENING WORK?

The peroxide in the whitening solution breaks down into water and oxygen ions. The oxygen ions enter the enamel and dentin and are attracted to the staining molecules. The oxygen ions attack and destroy the double bonds, leaving shorter stain molecules. Double bonds create discoloration and, once broken, the discoloration and the compounds are removed.

WHAT ARE THE DIFFERENCES BETWEEN HYDROGEN AND CARBAMIDE PEROXIDE WHITENING?

Hydrogen is used for most in-office procedures and can cause more sensitivity. Hydrogen is usually activated by light and is stronger and faster than carbamide peroxide. It is easier for the patient because the dental team does all the work. Carbamide peroxide is recommended for whitening tray wear and can be used day or night. Carbamide causes less sensitivity and has more effect on dark stains but must be worn longer for more effective results.

 COMPREHENSIVE ORAL EXAM AND RECORDS

The dentist must first make an assessment as to whether the patient is an ideal candidate for whitening. We suggest that the patient first undergo a thorough dental hygiene visit to remove extrinsic stain, calculus, and plaque. During this initial visit, we can provide dental X-rays, periodontal charting, digital photography, and pre-operative study models for home-trays if needed. Make sure to take pre-operative photos with and without a shade guide to prove shade change.

 WHO IS A CANDIDATE?

Teeth that are yellowish-brown (a shade range) and typically stained from aging tend to whiten more rapidly than teeth that range from gray to grayish-brown. Patients who consume large quantities of dark soft drinks, tea, coffee, grape juice, red wine, and/or use tobacco will achieve greater success with the in-office procedure as compared with an at-home whitening procedure. White stains do not go away and may even get lighter during the whitening process. Teeth with tetracycline stains, decalcifications, traumatic injuries, or root canal therapy may require additional visits and possible home tray alliance to achieve optimal results. Please note that whitening is not recommended for women who are pregnant or breast-feeding.

WHAT ARE THE MAIN CAUSES OF SENSITIVITY?

Most of the time, sensitivity is caused from recession, abrasion, erosion, and dehydration. During the first 24 hours of treatment after in-office whitening some patients may experience some tooth sensitivity or pain. Normally that goes away after 24 hours, but in rare cases can persist for longer periods of time. Most offices will recommend sodium fluoride (Remin Pro Voco) (MI Paste GC America) be placed in the tray for 30 minutes before or after the whitening process.

PRODUCT TYPES

There are three basic types of whitening procedures our office offers; they are:

• In-Office (one-hour whitening) with take-home trays

• Take-Home (custom tray whitening) Day or Evening wear

• Pre-Filled (disposable whitening trays)

PRE-FILLED, DISPOSABLE WHITENING TRAYS

The Venus White Ultra by Heraeus is a disposable tray that is pre-filled with an 11.2% mint-flavored hydrogen peroxide gel that is worn for 30-45 minutes a day for up to seven days. Each set comes with an upper and lower tray that self-adheres to the tooth arches with just a pinch. This pre-filled tray is ideal for teenagers and young adults who are looking for a lighter, brighter smile.

Figures

Figure 1. Venus White Ultra 11.2%.	Figure 2. Dry teeth with a cloth or paper towel before placement of the Venus White Ultra. Remove from packaging and place tray on upper teeth.
Figure 3. Mold the Venus White Ultra pre-filled tray to the arch form of the upper arch.	Figure 4. Mold the Venus White Ultra pre-filled tray to the arch form of the lower arch.
Figure 5. Retracted view of the Venus White Ultra in place on the maxillary and mandibular arches.	Figure 6. Patient is instructed to wear for 30-45 minutes everyday for 7 days. Patient is then instructed to return for a follow-up visit and shade check with photos.
Figure 7. Preoperative 15 yr old patient post ortho treatment Shade A3.	Figure 8. Post Op Shade B1 after 1 week use of Venus White Ultra.

FABRICATION FOR WHITENING TRAYS

There are several materials to choose from when it comes to the impressions for the whitening trays. In my practice we use both polyvinyl and alginate. What is very important is the detail that is captured in that impression. The whitening tray must seat and fit properly. Over the years, I have been asked to block out my model when fabricating a whitening tray. Is it necessary to cut the papilla to minimize tissue irritation? From my own experience in performing over 400 whitening  procedures within the last 2 years, it has made no difference whether the block out or papilla has been removed from the tray. The choice is really up to the patient. We offer several types of whitening in our practice. When discussing compliance with the patient, it is very important to help the patient to understand that this is an investment and we do not want to waste their time if they are not going to follow-up. In our practice we have nighttime wear and daytime wear. We allow the patient to choose, which makes them accountable. Poladay by SDI home-tray whitening gives the patient the option of a 30-minute whitening at 9.5%. We also offer the patient a polanight that is an overnight wear carbamide peroxide gel at 10%. Teeth-whitening gel will only whiten natural teeth.

Figures

Figure 1. SDI Poladay 9.5% hydrogen peroxide.	Figure 2. Impressions for Whitening Trays with Flextime Putty and Correct Flow Wash by Heraeus.
Figure 3. Remove syringe from case and load the tray with SDI Poladay 9.5%, depress the plunger and fill each tooth in the tray with a pearl of gel.	Figure 4. One syringe can be used for two days of whitening or two applications for top and bottom. Do not press too hard only enough to seat on teeth. Wear tray for 30 minutes a day for 10 to 14 days.
Figure 5. Pre Op Full Face.	Figure 6. Post Op Full Face.
Figure 7. Pre Op Shade A1.	Figure 8. Post Op Shade BL4 on Chromoscope Shade Guide.

IN-OFFICE WHITENING

In-office whitening provides the quickest way to whiten teeth. Venus White Max is an in-office whitening treatment that consist of a 38% hydrogen peroxide gel that is applied for 4 (15) minute sessions without the use of a light. The patient is instructed after the in-office whitening to follow up the treatment with 2 weeks of take-home whitening (One hour a day for 14 days or the patient may choose to have another in-office whitening procedure.).

Figures

Figure 1. Venus White Max by Heraeus.	Figure 2. Mix the Venus White Max 38% hydrogen peroxide gel. Apply 1 mm of Venus White Max gel to facials of teeth for 15 minutes, after applying lip/cheek retractors and bite block.
Figure 3. After 15 minutes, suction off whitening agent and re-apply for another 15 minute session. Repeat 1-2 more times.	Figure 4. Suction Venus White Max off teeth and rinse. Remove the gingival barrier and retractor. Take a final photo and instruct patient how to use the take home trays.
Figure 5. Pre Op Shade Tab D3. Patient’s teeth have been pumiced. Retractor and Gingival barrier have been placed	Figure 6. Final Post Op with Shade Tab A1.’
Figure 7. Full Face Pre-Operative Photo.	Figure 8. Final Full Face Photo.

RESOURCES:

References

1. Haywood VB. Tooth Whitening: Indications and outcomes of Nightguard Vital Bleaching. Hanover Park, Il: Quintessence Publishing Company Inc; 2007.

2. Matis BA. Tray whitening: what the evidence shows. Compend Contin Educ Dent. 2003; 24(4A):354–362.

3. Gottardi MS, Brackett MG, Haywood VB. Number of in-office light-activated bleaching treatments needed to achieve patient satisfaction. Quintessence Int. 2006;37(2): 115–120.

4. Browning WD, Swift EJ. Critical appraisal: comparison of the effectiveness and safety of carbamide peroxide whitening agents at different concentrations. J Esthet Restor Dent. 2007;19(5):289–296.

5. Cooper JS, Bokmeyer TJ, Bowles WH. Penetration of the pulp chamber by carbamide peroxide bleaching agents. J Endod. 1992; 18:315–317.

6. McCaslin AJ, Haywood VB, Potter BJ, et al. Assessing dentin color changes from nightguard vital bleaching. J Am Dent Assoc. 1999;130:1485–1490.

7. Hall DA. Should etching be performed as a parta of a vital bleaching technique? Quintessence Int. 1991;22:679–686.

8. Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2006;26(9):11–20.

9. Leonard RH, Haywood VB, Phillips C. Risk factors for developing tooth sensitivity and gingival irritation associated with nightguard vital bleaching. Quintessence Int. 1997;28: 527–534.

10. McKamie A. Deep bleaching: one practice’s protocol for enhanced patient satisfaction. Contemporary Esthetics. 2007;10:12–19.

by Trish Jones, RDH, BS, Sr. Clinical Trainer, Align Technology, Inc

Dentistry is in a constant state of evolution. New items are coming out all the time. They can add to the profitability, they can add to patient value and add to patient comfort. Advances in technology should be reviewed on a regular basis in regards to what it can add to your hygiene practice and patient satisfaction.

Restoration choices:

We are in the era where more and more offices are offering metal free options to patients. The Registered Dental Hygienist should be informed what is offered and why. Why would you need to know this? It makes you more of a comprehensive hygienist in regards to discussing restorative options with the patient. Also, the hygienist can be better informed to make homecare product recommendations customized to the restorations in the patient’s mouth, as well, as utilizing the appropriate polishing agents during the patient’s re-care appointment.

All porcelain restorations require special care as the surface is glazed, and the restoration itself it bonded to the tooth with a resin. Sometimes this margin may be subgingival, but often times, it is supragingival. What restorative porcelain materials does your office recommend and why? For example, lithium disilicate is porcelain that can be made thin, yet very lifelike or zirconia options are milled, and are very strong as they are great for patients who may have para functional habits such as bruxism. There are many options available today, and it is the hygiene department’s benefit to sit down with the dentist(s), and discuss what is currently offered to the patients of the practice. The hygienist can customize care and treatment to the cosmetically restored patient.

The longevity and integrity of esthetic restorations can be maintained by keeping the surfaces smooth. Smooth surfaces decrease the potential for stains and plaque retention, and well as minimizing surface and margin deterioration.

Recommending the appropriate home care choices to the patient shows you care about the long term appearance and function of the patient’s smile.

Homecare Choices

There are many choices in toothpastes OTC today in stores. Are you recommending one that is appropriate for your restored patient?  Toothpastes that have been approved by the FDA also have been tested to the abrasive value. RDA/REA (Relative Dentin Abrasion/Relative Enamel Abrasion) is a way to score or index the abrasiveness to dentin and enamel. Values rank from 0 to 250. The ADA recommended limit is 250. The more stain removal or more whitening the higher the RDA value since it is indicated to remove extrinsic stains.  Ideally, a cosmetically restored patient does not need to use whitening toothpaste because it will not change the color of the porcelain. One thing to consider is the possibility of it dulling or micro-scratching the glazed surface. This can lead to providing a rough surface for plaque and stain to be retained. It is to the patient’s benefit and the practices to review toothpaste selection with cosmetically restored patient.

Figure 2

Polishing

Not all polishing pastes are indicated for all patients. There is not just one polishing paste that fits “all”. Although, it is often only one type is used or found in a dental office. Polishing pastes contain abrasives that differ in particle size and particle harness, i.e. grit. The finer the abrasive is, the smaller the scratches that are created on the tooth surface. The goal of polishing involves creating the smoothest surface possible while retaining a glossy or lustrous shine whether on a restoration or the natural tooth structure. The hygienist may even deem selective polishing as an option for the patient. When polishing a cosmetically restored patient, review the polish paste indications. If it does not reflect an indication for porcelain, don’t use that one. Use a polishing paste that is indicated as safe for cosmetic restorations. An example is Soft Shine by Water Pik. It contains white sapphire micron particles that won’t scratch restored surfaces. Another to review for your hygiene department is Proxyt by Ivoclar. It contains silicon dioxide which is safe to use on porcelain and composite restorations. As more patients are electing to have all porcelain restorations placed in their mouths, companies are recognizing the need for cosmetic polishing agents. Research and find one that fits your practice philosophy and customize your polishing protocol specific to your patients’ needs.

Figure 3

Technology

Technology in dentistry has grown tremendously. No longer is this the same type of dentistry our Grandparents received! In the era of cell phones and high definition television, dentistry has become high tech as well. There are a few advances in dental hygiene that have promoted better care and can even save lives!

Oral Cancer Screening Devices:

Oral cancer screening devices and tools has led to a quick and easier way to detect oral cancer. It has been a growing trend to stress overall health in conjunction with oral health. In office use of the VELscope^®Vx can assess the patient while in the chair for a host of diseases. Using natural tissue fluorescence it can discover a wide range of abnormalities. This device can be incorporated into a regular soft tissue exam as it only takes 1-2 minutes. Not much time when you consider it can detect abnormalities sooner rather than later.

Other companies have taken oral cancer detection to the next step with taking salvia samples to assess the patient’s risk of developing oral cancer or periodontal disease.  For more information, check out OralDNA Labs, Inc.

Figure 4

Cordless Hand pieces

A premier advancement in dental hygiene has been the introduction of cordless hand pieces. It can be an issue to the hygienist if the hand piece is too heavy as it can compromise ergonomics and accessibility to the oral cavity. Cordless hand pieces are a lightweight option without bulky cords and offer easy infection control, as well as increased accessibility. The goal in mind is to reduce hand fatigue such as in prolonged prophylaxis procedures. DENTSPLY currently offers the Midwest RDH Freedom. If it is something you may be interested in, contact a local representative which may let you take it for test drive before you make an investment in the hand piece.

Keeping up

With all the advances in dentistry and dental hygiene today, it can be a challenge to stay ahead of the game. As a hygienist, you should be continually researching and evaluating new trends and technologies that become available.  Patients are savvy and often even do their own research before visiting the dental office. With all the technologies available, it doesn’t mean your office has to offer them all, but this gives you an opportunity to evaluate the ones that your office feels would enhance the patient’s quality of care while at the same time increase the benefits to the office. There are a plethora of choices available these days, just being aware of what’s out there keep you informed, knowledgeable, and capable of making an educated decision.

References:

1. Barnes C. Care and maintenance of aesthetic restorations. J Practical Hygiene. 2004;13(4):19-22.
2. Stookey GK, Schemehorn BR. A method for assessing the relative abrasion of prophylaxis materials. J Dent Res. 1979;58:588-592.
3. Wilkins EM, Wyche C. Clinical Practice of the Dental Hygienist. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2008:724-740.
4. Huff KD et al: A novel, minimally invasive approach to managing mild epithelial dysplasia. Gen Dent. 2010 Mar-Apr;58(2):126-9.
5. Williams PW et al: Evaluation of a suspicious oral mucosal lesion. J Can Dent Assoc. 2008; 74(3): 275-80.
6. Guignon AN, Celebrating polishing. RDH. Vol; 13:10.  Accessed online Mar 18, 2012.

by Edwin Porter, DDS

Tissue management is certainly on of the most important factors in ensuring a high quality impression and in turn, a properly fitting restoration. This article will discuss various retraction techniques and the advantages and disadvantages of each, as well as the importance of achieving excellent hemostasis prior to taking the final impression

Methods of Retraction

It is important to recognize that retraction and hemostasis are actually two different objectives. Although it may be possible to accomplish both tasks with a single treatment modality, this is not always the case. Retraction is the temporary displacement of the gingival tissue away from the surface of he tooth to expose a subgingival margin and to make room for impression material to record it. Retraction can also be used prior to preparing the tooth. In this case, retraction serves as a visual aid in establishing an ideal subgingival location to place a preparation margin. This may help prevent iatrogenic injury to the gingival crevicular tissues, and facilitates preservation of periodontal health and the biologic width.

Depending on case requirements, there are four types of retraction techniques in general use
today.

1. Cord Techniques
2. Electrosurgey
3. Soft tissue laser
4. Paste retraction

The retraction method you choose may be influenced by your familiarity with the technique; the location, quality and condition of the soft tissue; your personal ski level or the complexity of the case at hand.

Cord Techniques

The cord-packing technique is the most poplar method of retraction and is done using a twisted, knitted, woven or braided cord. There are a variety of natural and synthetic fiber types used in making gingival retraction cords, including wool yarn, cotton and silk. The cords are commercially available in plain versions and impregnated, or pretreated with hemostatic medicaments. When using a cord packing technique, an appropriately-sized cord is gently placed into the gingival sulcus with the intent of mechanically displacing the soft tissues from the tooth and margin of the preparation. In general, it’s best to use the smallest cord possible since larger cords can sometimes tear delicate gingival tissue, increase hemorrhage and damage the sulcular epithelium. Fortunately, the newer impression materials can capture excellent marginal detail within relatively small gingival spaces. Typically, retraction cords are placed after the tooth preparation is completed and then removed immediately before the impression tray is seated. Cords are packed with many different types offhand instruments. The specific instrument that works best often depends on the type of cord. Ultrapak (Figure 1a) by Ultradent is an instrument that we prefer in our office that works best with firmer cords and the tightly knitted or braided varieties. The smooth-tipped packers tend to work better with loosely twisted or braided varieties since they are less likely to catch on the fibers and separate them. Cords should always be packed by angling the instrument tip toward the starting point of the cord. Packing away from the starting point tends to dislodge or pull the cord out of the sulcus.

Figure 1a. Dux Shortcut. Shortcut cord placed with the ultrapaker by Ultradent before placement of direct composite.

Single-Cord technique

The single-cord technique is by far the most popular and commonly used. In this technique, the dentist prepares the tooth completely and then packs a single cord into the gingival sulcas to achieve retraction.The packed cord is removed just prior to taking the final impression. The single cord can be wrapped once around the circumference of the preparation, or it can be wrapped multiple times. A single wrap (Figure 1b, Dux Shortcut)  is acceptable when the depth of the sulcus is nearly identical to the diameter of the cord. However, a single wrap with a single cord may not produce adequate retraction when the cord diameter is significantly smaller than the depth of the sulcus. This tends to produce a teardrop-shaped retraction, which allows the tissue to collapse over the top of the cord or allow a very thin margin of impression material, which can easily tear on removal. In this case, wrapping the cord multiple times may help achieve proper retraction and compensate for an undersized cord. An excellent, through less popular, alternative to the single-cord technique is the double-cord technique.

Figure 1b. Dux Shortcut.

Double-Cord Technique

This technique is especially good for impression where there is a deeper gingival sulcus present. As its name implies, two cords are used.  The first of the two cords is usually smaller and packed into the bottom of the sulcus. It is generally used to help control fluids and hemorrhage, and can be packed before the bottom of the sulcus. It is generally used to help control fluids and hemorrhage, and can be packed before the preparation is completed or after. The first cord may be left in during the impression or removed right before it is taken. If left in, it must be located below the margin of the preparation. The second of the two cords is larger and packed directly on top of the smaller first cord (Figure 2). This tends to produce a V-shaped retraction, which allows better access for the impression material and permits the impression margin with greater bulk.

Figure 2. Double cord technique.

With all cord techniques, it is extremely important for the dentist to carefully check that all cords, stray fibers, and impression material remnants are completely removed from the gingival sulcus before the patient is dismissed. Residual materials will be treated by the body as a foreign object and can lead to infection, inflammation and other periodontal problems. As withal retraction methods, you should always try to expose 0.5 – 1.0 mm of tooth structure creating a restoration with a proper emergence profile.

Electosurgery

Electrosurgical retraction – or electrosurgery – works by surgically removing a small portion of the epithelial lining of the gingival sulcus to create room for the impression material. Typically, a thin wire electrode is inserted into the sulcus and an alternating electrical current above 100 kHz is passed through the tip, which simultaneously removes the desired layer of tissue and cauterizes the surgical site.  When properly utilized, electrosurgery furnishes excellent retraction, as well as hemostasis, and the epithelial tissues will rapidly heal. Electrosurgery can also be a valuable adjunctive treatment modality when retraction cords alone do not seem to be effective. However, it is somewhat technique sensitive. Some of the significant risks of improper usage include dentinal and cementum burns, and damage to the periodontal attachment. This can ultimately lead to the formation of periodontal defects and gingival recession, which can compromise the aesthetics and longevity of the final restoration.

To reduce the risks, electrosurgery should ideally be avoided in deep gingival areas where visibility is poor and risk of injury to the tooth or other tissues is high.  More recently, units operating at frequencies higher than 2500 kHz (radio frequencies) have been found to be more efficient and safer. These are referred to as radiosurgery devices and should be distinguished from the older electrosurgery units, which operate at lower artificial pacemakers, or when gaseous anesthetics are employed for these reasons, electrosurgery remains a less popular method of retraction.

Soft Tissue Laser

Soft tissue lasers create surgical retraction in much the dame way as electrosurgery. Lasers are generally considered safer than electrosugery because they use a high intensity form of light instead of electrical current to remove the tissue. The laser light typically is delivered into the surgical area via a thin gloss fiber or fiberoptic bundle. Lasers tend to produce a more shallow cellular necrotic burn in the tissues adjacent to the epithelial layer, so healing is faster (Figure 3)and more predictable than with electrosurgery. Though lasers can also cause burn damage to the dentinal, cemental and attachment tissues, the risks are lower. Lasers are also safe for patients with pacemakers or when gaseous anesthetics are in use. Depending on the type and wavelength of the laser, they may be either useful or totally ineffective in assisting with hemostasis. Lasers are most often recommended in cases where margins are unexpectedly deep or when there is excessive bleeding.

Figure 3. Soft Tissue laser used on 7 and 10.

Paste Retraction

A recent addition to the variety of retraction techniques is best referred to as paste retraction. In this technique, retraction paste material is placed directly into the sulcus and left for a period of one to two minutes.  The paste is then removed before taking the final impression. Centrix Access Edge (Figure 4), which is a paste that physically displaces the tissue, creating space between the tooth and the tissue, much like a retraction cord. Aluminum chloride astringent has been added to help with hemostasis and fluid control. Since the paste is applies with little or no pressure (Figure 5) there appears to be reduced potential for damage to wither the epithelial lining of the sulcus or rupturing of the periodontal attachment. The manufacturer of these product states that is also may be used prior to placing direct dental fillings or the cementation of crowns and veneers.

Figure 4. AccessEdge tube by Centrix which is a paste retraction.

Figure 5. AccessEdge placed before impression.

Overview of Hemostasis

In dentistry we define hemostasis as the stopping go undesirable bleeding or blood flow. Related to this is the seepage of blood products, such as gingival crevicular fluids, that also can significantly impair impression taking.  Although hemostasis may be related to retraction, this is not always the case. Therefore, retraction and hemostasis should generally be considered as two different tasks.

While some hemostasis can result just from the pressure of a retraction cord within the gingival sulcus, chemical agents area most often used to improve the hamostatic effects. Likewise, some of the astringent chemicals used for hemostasis will also help in achieving effective retraction. In most cases the application of chemical hemostatic agents is through the use of retraction cords that are impregnated with the medicament. However, cords can also be purchased plain and treated chairside with different medicaments right before they are used. The use of impregnated cords may be slightly more expensive, but also assures a more exact dosing, or concentration, of chemical.  (Table)

As with the use of any medication in the body, you should be familiar with the risks and benefits of each medicament It also is essential to take a good medical history, including a history of any past allergic or adverse reactions to any of the chemical agents or materials. For example, epinephrine should be avoided with patients who report previous sensitivity or may have extensively lacerated tissues. For these patients, use of epinephrine may result in excessive systemic uptake and lead to an adverse syncopal-like reaction called epinephrine syndrome.

Certain medicaments also may have an impact on the setting reaction of the impression material. For example, it ahs been reported that the presence of sulfer in aluminum and ferric sulfate can inhibit the setting of some addition-reaction silicone (A-silicone) impression materials. Exceeding the recommended treatment times of any hemostatic agent should be avoided since it can lead to delayed tissue healing, as well as damage to the periodontal attachment.

Mixing of different agents can be synergistic in some cases. This is usually accomplished by dipping a cord impregnated with one medicament into another type of liquid medicament before it is packed. However, epinephrine and ferric sulfate should never be combined because they generate a dark precipitate that is extremely difficult to remove form the preparation. In addition to being beneficial in retraction, electrosurgery and lasers can also assist in achieving hemostasis when medicaments may be contraindicated.

Remember, through an effective hemostasis is an important part of preparing for an impression since blood and moisture can negatively affect the performance of most impression materials, resulting in a compromised impression.

by Trish Jones, RDH, BS, Sr. Clinical Trainer, Align Technology, Inc

As dentistry becomes more high tech, it is often the success of an office incorporating digital technology dependent on the dental team’s support. This not only includes the assistants but hygienists as well.

One of the newer technologies that dental offices have seen rapid growth is digital impression taking. What exactly is this? How can the office and patient benefit from it? What all does it entail and how team members use it? Read more

by Linda Zdanowicz, CDA

“To enjoy the things we ought and to hate the things we ought has the greatest bearing on excellence of character.” ~Aristotle~

Have you ever felt that there must be more? More joy, more satisfaction, more passion, more desire to get up in the morning and go to work? Have you ever wished that the people you work with every day had more of that, too? I’m here to tell you that you can have it all and more. You can have the practice of your dreams, a team you can admire, and patients that will tell everyone that they have found something special. The “E” word I’m talking about is ethics. You may be thinking that ethics sounds like an old-fashioned, stuffy subject. The kind of thing you might assume that everyone learned in kindergarten and if they didn’t, it’s too late now. But you know what? It’s never too late to become what you are capable of becoming. It’s never too late to make your practice what you’ve always wished it could be. Imagine what life would be like if the foundation of your practice could rest on ethics and your management style reflected the ethical base of your practice. I was once talking to a friend of mine who is a business consultant. He specializes in business ethics, and he surprised me when he said “Don’t talk about character too much, it turns people off.” I thought, “Wait a minute, isn’t that what your work is centered around? How can you tell managers and business owners not to talk about character, when you believe it’s so important that you base your life’s work on it?” We talked a while longer and I realized that if you really want to build the culture of your practice on strong ethical beliefs and behaviors, you have to lead people to discussions that will turn into examinations of how good character traits and ethics benefit them in their work and life, but you can’t shame them or intimidate them with the negative results of unethical behavior or character deficiencies. That’s an important thing to remember, approach all discussions of ethics and character from a positive direction, not from a negative angle. Building a strong culture based on values and vision is one of the greatest gifts a manager can give in return for the honor of trust that is being shown by the dentist in allowing you to run their practice, and by the staff in their willingness to follow your lead. Read more

by Phillip Kemp, D.D.S.

With Christmas behind us, I know there are a lot of people who are holding those new cameras ready to capture images in the dental world and in their personal life. Though you may think it is different, capturing dental images is not any more difficult than capturing images in life.  The most important thing is to know your equipment and how it works. Understanding just the basics of your DSLR camera will put you light years ahead of most people when it comes to the type of images they capture.

I want to share with you a basic intro to DSLR photography. If you have a DSLR camera and are nervous to take it out of auto mode, a quick tutorial is all you need to have the confidence to have control over you images. You may have heard words like Aperture, ISO, and Shutter Speed and wondered just how on earth they come together to give you a better photo. Once you understand what some people call the “Exposure Triangle” there is no photography situation you can’t handle.  This brief introduction on what each part of the exposure triangle means and how they affect your photos can make the difference between your images turning out too bright, too dark, too blurry or being AMAZING.  This guide will show you how to get the most out of your DSLR camera and give you confidence to take it out of auto mode in no time! (Figure 1)

All DSLR cameras have auto settings that allow the user to take better images without knowing every aspect of the camera’s operation.  These settings are fully Auto, Program mode, Aperture Priority mode and Shutter Priority.  On a Canon, the settings are a Green Square, AV, P. or TV. On a Nikon, this are green Auto, A, P or S.

Figure 2

Our goal for this tutorial is to take each of you from the fully Auto mode to be able to use Manual mode with confidence. By learning each of the auto modes, you will slowly gain the confidence to take images in the fully Manual mode in no time. (Figure 2) Read more

By Robert Shaffer, AIA, CID, LEED AP

The latest spark in the world marketplace is sustainability and everything “green.” Now that spark includes even dental practices. Green dentistry has become a focus of many clinics around the country and is serving them well as an approach to social conscience, environmental stewardship, reduction of everyday expenses, and potential tax incentives. Years ago, who would have thought that green would be a positive thing to call a dental practice? With all of the options available today, green dentistry is quickly becoming the standard.

Green means different things to different people in different circumstances. There are different shades of green: different degrees to which you can green your dental practice. Whichever shade you choose—whether greening your current practice, planning a new green clinic in an existing building, or designing a new green clinic building all your own—you are climbing aboard one of the strongest marketing waves to sweep modern businesses since the Internet. Your LEED AP (Leadership in Energy and Environmental Design Accredited Professional) architect can help you choose the level of green that makes the most sense for your dental practice as you ride this green wave. Read more

by Linda Zdanowicz, CDA

It’s All in the Presentation First things first, understand your patient. What do they want? What do they care about? Is it the perception others have of them, or their own comfort and health? What is their understanding of oral health? What can they afford, and what are they willing to spend? How can you show them what they need in a way to make them want it, and how can you show them how to afford it? This all starts in the pre-clinical interview so don’t cut corners here. It’s very tempting to rush the pre-clinical interview if you’re running behind, or if the patient seems like an impatient person who wants to control the way the appointment is going to go. But, don’t do it, take your time and get in there with them. Find a way to get past their defenses and get them to open up. You go first; tell them why you do what you do in your office, before to try to tell them why they should buy it.

Once you have a good idea of what is important to your patient and you’ve gathered all your clinical information with the dentist, sit down and discuss the patient’s treatment plan with the dentist. First listen as a dental professional and make sure you understand the rationale for the treatment. Then put yourself in as close to your patient’s frame of mind as you can and ask the questions you think they’d ask. Finally, come up with 3 treatment plans; good, better and best. (Sears used to do that years ago and who really wanted to go home with the good blouse if they could pay a little more and get the best quality one?) Also, find out if there is any treatment the dentist absolutely won’t suggest or provide. Now you’re ready to put your treatment plan presentation together.

Read more