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Inside Dentistry
July 2014
Volume 10, Issue 7

The 5th Annual Tech Issue

Click on a section to read more from our experts:

Digital Radiography | CAD/CAM | Digital Impressioning | Bioactive Materials | Lasers | Endodontics | Practice Management | Implant Guidance | Caries Detection


Digital Imaging Options

Paul Feuerstein, DMD

Developer and fixer are becoming terms like rotary dial phones—antiquated. Digital radiography has been proven to be more accurate than film and using accompanying software as well as large images on a computer screen allows for detailed visualizations of small areas for even better diagnosis. As early as 2011 in a CR Foundation study1, the findings were that caries diagnosis was superior with sensors and the recommendation was to “go digital” as soon as possible.

Making the Investment

The main stopping point to “going digital” still seems to be the initial cost of the installation. This includes setting up an office with computers in each treatment room and networking them together to be able to file the images in a way that they can be easily retrieved for each patient. There are a couple workarounds, including using a laptop with a sensor and moving it around the office. This becomes unwieldy as well as an infection control nightmare. One company, MyRay ( offers a sensor with a little portable screen similar to an iPod, aptly named X-Pod. But these are just stalling points to get to the truly useable complete system. Here is where the real confusion begins.

At last count, there were almost 30 different sensors in the marketplace with a price spread of thousands of dollars. There are a few “major” players, but part of that is their visibility due to the size of the companies and, to be honest, their advertising budgets. We often hear complaints from dentists who ask, “How could this little electronic device cost so much?” Part of the answer is related to the fact that these are not mass-produced electronics, like digital cameras. The companies will not sell thousands a year. To pay for research and development, toll-free support, and other services, these expenses become part of the sensor cost. Dentistry is a very small “vertical marketplace,” and because of that many of the more complex products that we use are higher cost to allow for enough profit to keep the companies in business.

Having said that, there are a number of smaller, independent sensor companies that sell direct or through limited partnerships with dealers, which allows them to keep the prices and profit margins lower. When looking at a system, one has to keep all of this in mind. At this time, all of the sensors available will give you diagnostic images equal to or superior to film. The differences are related to things like size and shape of the sensors, position of the wire, raw image quality, proprietary software, and features such as replaceable wires, WiFi, Bluetooth, and more, as well as support and stability of the manufacturer or retailer. One hidden issue to new users is the fact that many offices are using older x-ray heads with older controls for exposure time and KvP controls. To get the most out of your sensor, newer x-ray heads using electronic timers are able to tweak the images and allow easy changes for different areas of the mouth or patient sizes.

Easing Integration

There are a number of practitioners who have been using film for years who feel that they will have trouble adjusting to sensors and like the ease of use of film. For these people, there are several “phosphor plate” systems. These use sensors that look and feel like traditional film. Newer upgrades of the actual sensors and the scanners have enhanced their resolution. The images are taken with the same “old” technique and these plates have to be digitally developed. The newer developers (called scanners) can get a film on the screen in less than 5 seconds. The plates are between $20 and $30 and the smaller scanners are well under $10,000. Due to the lower cost and ease of use, many larger offices find that the use of phosphor plates for routine bitewings or full-mouth series can be complemented with fewer wired sensors for other tasks. A number of endodontists find that the plates are easier to fit under a rubber dam and clamp during treatment. Some notes of caution: although they are somewhat flexible, the plates cannot be bent or rolled to the extent that film can. Cracks will occur and they will have to be replaced. Scratches are also detrimental, although replacing a plate is not as devastating as replacing a wired sensor.

If your office has a film panoramic system, there are digital pan-sized phosphor plates that can be used in these instead of film. This requires larger scanner, which is a slightly higher cost, but the “pans” go into the digital workflow. Keep in mind, though, that these images are not the same as a newer digital pan. The mechanics of the machine are still analog, so you will still get the fadeout in the center of the scan.

New digital pans are available for less than $25,000, but can cost more depending on features. One company in fact allows the practitioner to install a unit for $3,000 and pay a fee for each image taken, softening the initial investment. There are some at higher cost that have more features, including extraoral bitewings or computer-generated 3D renderings. Others allow retrofitting/upgrading to 3D cone-beam, allowing a lower introductory cost to this new modality, although the process is not inexpensive.

Looking Ahead

The explosion of cone-beam units, software, and developing technology is surely the future of digital radiography. These have gone from the original “full-volume” units, which encompassed an area well beyond the dental structures, to more precise and defined fields of view. This allows the practitioner to concentrate on the area of interest, using less radiation and depending on the ultimate requirements—a smaller, less expensive unit. New software allows “stitching” of the smaller volumes to create larger ones if necessary. And companies are now allowing shorter scans with (slightly) lower resolution that use a fraction of the radiation of the earlier units, even on full volumes. Evolving software enhances diagnosis and treatment planning in many areas, including implants, and by merging with digital impression scans, it has opened up enormous restorative options. 3D printing or milling directly from these scans can also create appliances such as surgical implant guides and even sleep apnea appliances. SICAT (, a division of Sirona, is pushing these limits with their “Function” software, for example, allowing virtual articulation of a case using the patient’s own condyles.

With digital radiography, the future is unlimited, and with the new graduates who have grown up in a digital world, we have no idea where all of this is going to go. What a great time to be in dentistry.


About the Author

Paul Feuerstein, DMD, is in private practice in North Billerica, Massachusetts.

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Update on Bioactivity

Gerard Kugel, DMD, MS, PhD

It was in 1969 that the concept of a bioactive material was first recognized. Since then, the area of bioactive materials has expanded enormously in both medicine and dentistry. The concept of bioactivity was defined this way: “A bioactive material is one that elicits a specific biological response at the interface of the material which results in the formation of a bond between the tissues and the material.”2

In dentistry, the most commonly used bioactive materials are the glass ionomer cements (GICs), resin-modified glass ionomers (RMGIs), mineral trioxide aggregate (MTA), bioactive glass (for treatment of periodontal defects), and calcium hydroxide.

Clinical Benefits

The use of bioactive materials should result in a long-lasting restoration. In theory, it should also help to repair damaged dentin while decreasing the chance for recurrent caries. Clinical features of bioactive materials include:

Bioactive restoratives have a remineralization and strengthening effect on human hard tissue. This is valuable for the treatment of acid-caused tooth enamel erosion.

The mineral enrichment efficacy leads to an immediate and long-lasting increase of the pH level. This will help to protect the tooth structure from the detrimental effects of all types of acids.

These materials chemically bond to the dentin. This property will also help decrease sensitivity often caused by bonding technique errors.

When activated with water, these materials release the ions from their composition, forming a mineral matrix equivalent to that of natural hydroxy apatite.

GICs have shown to be effective in the reduction of MMP formation, and thereby reducing, if not eliminating, the collagen breakdown commonly found in many resin–dentin bonding procedures.

Bioactive glass is effective as an adjunct to conventional surgery in the treatment of intrabony defects.

How to Integrate

Many dentists are already integrating bioactive materials into their dental practice. The use of glass ionomer liners, calcium hydroxide, and MTA are nothing new to our profession. We are now seeing new and improved RMGI restoratives as well as new bioactive filling materials that are based on glass ionomer chemistry. MTA has recently been introduced in a more user-friendly light-activated form. This light-cured bioactive material is used to seal and protect the dentin–pulp complex. Some are considering this a new class of internal pulpal protectant materials resin- modified calcium silicates (RMCS). It is yet to be seen if this new class of RMCS materials are clinically effective.

Training and ROI

The area of bioactive dental materials requires a re-education as to the value of these types of materials as well as their benefits, particularly for high-risk patients. These materials should be incorporated in hands-on direct placement courses and educators need to review material options as well as the evidence for or against their use. At this year’s American Association for Dental Research meeting, I was surprised at the number of research papers on this class of materials.

Return on investment (ROI) with this “new” technology seems apparent. These materials should decrease recurrent caries, remineralize dentin, decrease sensitivity, help maintain better long-term bonded restorations, repair intrabony defects, create an apical plug during apexification, and help repair root perforations and improve the results for direct pulp caps.

This new class of materials offers many benefits to both patient and provider without a high cost.


About the Author

Gerard Kugel, DMD, MS, PhD, is dean for research, department of prosthodontics and operative dentistry at Tufts University School of Dental Medicine. He is also in private practice in Boston, Massachusetts.

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Address the 3 Common Challenges with Going Paperless

Dayna Johnson

I remember when I was working in a dental office, I had been encouraging my doctor to go chartless, but he just wasn’t ready. He would always change the subject whenever I brought it up and I knew to leave it alone. One day, however, he came up to the front office, pulled a paper chart from the file cabinet, and started reviewing it. This patient had a long list of unscheduled treatments, and there were no notes in the paper chart that I had followed up with the patient. Seeing this, I pulled up the computer chart where I had been managing all the patients with unscheduled treatments, and showed the doctor my tracking system. It was at that point he knew it was going to be okay to go chartless.

What I’ve found from working with hundreds of offices on going chartless over the past 6 years is that the clinical team has some very good reasons for holding up the transition, and if you don’t take time to address them, you will never get them on board. Here are three common challenges facing the clinical team, and how you can get them on your side.

Stay on Schedule

No one wants to run late with his or her next patient, into lunch, and especially at the end of the day. The clinical teams, especially the hygienists, have a very small window to treat their patients, write up the chart, document the treatment plan, and turn over the room for the next patient. Now you’re asking them to enter it all in the computer, and they are worried about how long it will take them to get everything done. Research your practice management software and learn how to create customized, super-efficient templates. Using template information for documentation will help your team eliminate a lot of typing.

Find What You Need

Searching for information is another common problem when you change over from a paper chart to a digital record. The consistency of making notes is critical when you use a computer. If you can’t find information, frustration will reach an all-time high. Create a spreadsheet for your team that maps all the information you document for a patient, where it was located in the paper chart, and where it is located in the digital chart. Then hand one out to every team member. This will be their reference sheet if they need to be reminded where to find the patient’s medication list or the letter from the specialist. If you want a sample worksheet, you can e-mail me at

Keep it Secure

HIPAA security and backup is one of the most overlooked and undermanaged elements of going chartless. The doctor is worried about running late, finding patient information, and tracking patients, but security is always in the back of his or her mind. Put the doctor at peace by implementing an automated, secure, and documented backup system. Put together a step-by-step instruction sheet for your team so everyone knows when the backup runs, how often, who is responsible for looking at the logs, and what to do if an error comes up. On this same sheet, list specific instructions on what to do in case of a computer crash or data loss so everyone on the team knows what to do.

The team that plans a strategy together will stay together. When you create systems to address these common challenges, you will have a much more successful transition to paperless.


About the Author

Dayna Johnson is a trusted consultant in the Pacific Northwest who has helped dental offices around the country transition to paperless. She can be reached at 425-238-3699,, or via her website,

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Advantages of Intraoral Scanning

Andrew Koenigsberg, DDS

Over the past 25 years, we have witnessed a change from analog to digital in the way data are captured and stored in many aspects of our lives, including communications, banking, entertainment, and more. In dentistry, we have experienced the transition to digital technologies in our shift to paperless practice management systems and digital radiography. The transformation of dental lab work from analog to digital has been extremely rapid. In just 10 years, the percentage of restorations that have a digital component in their manufacturing has jumped from less than 5% to more than 50%, and that number continues to rise. New restorative materials are being introduced and improved that are manufactured exclusively through the digital workflow. These materials—zirconium, lithium disilicate, and nano-ceramics—often eliminate the need for metal substructures and, in the case of implants, can significantly lower production costs.

Historically, intraoral scanning has been challenging compared to extraoral scanning of models. Most dentists avoided intraoral scanners because of the expense, cumbersome workflow, and steep learning curve. Labs chose to scan conventional models to introduce them into their digital workflow. However, the past 3 years has seen an explosion of new, chairside optical scanners that are finally up to the task of routinely capturing the intraoral environment in a rapid, easy, and economical way.

Benefits and ROI

The paramount advantage of digital scanning is the ability to deliver better dentistry on a consistent basis. Although both impression material and optical scanning are theoretically capable of producing accurate models, the clinical reality is often different. A 2005 Lab Management Today survey found that 59% of impressions did not convey the information that labs needed to make an ideal restoration.2 This is not related to the accuracy of the impression material but rather to the challenge of impression making in a wet environment, on the difficulties of working with a moving patient, and the difficulty in evaluating the impression chairside. It is often difficult to tell if the margin has been fully captured or if a “pull” is significant when looking at the “negative” in an impression. Remaking impressions is time consuming, expensive, and disliked by patients. Often, it is not possible to fully assess the quality of the impression until the model has been poured. By that time, the patient is long gone and there is additional inconvenience and expense involved in remaking the impression. In contrast, optical impressions are easy to evaluate immediately as the dentist can view an enlarged 3D virtual model. With many systems, space for restorative material and occlusal clearance can also be assessed while the patient is in the chair. Making corrections to the preparation and impression is free and often just part of the optical scan needs to be retaken. The patient benefits by having a better restoration in fewer visits along with a better experience while the dentist saves time and minimizes patient dissatisfaction. Financially, eliminating expensive impression material, saving chair time and reduced lab fees, make optical impressions an economic plus for the office.

As new scanners have entered the market, the price has declined while new features have been added. Several of the scanners no longer require a reflective powder, greatly simplifying the impression process and reducing the learning curve. Some labs offer a discount of up to 20% for digital impressions. A number of manufacturers offer the ability to plug the optical scanner into a laptop, making the process easier in tight, clinical spaces.


When choosing a system, there are additional considerations that should be taken into account. The ability to upgrade the optical scanner so that restorations can be designed and milled in the office is not available on all systems. Even when that option is available, it may mean dealing with multiple manufacturers as opposed to a single company with an integrated system. While many dentists may initially only be interested in the optical scanning segment of the workflow, there is a good chance that as design and milling improves, more dentists will choose to incorporate this part of the digital workflow. The dentist also needs to know if his or her lab can accept scans from their optical scanner.

Integration with CBCT is now available on some systems, which allows for the rapid and inexpensive making of precision surgical guides in the office. Dentists should have an idea about their future needs when choosing a system. Support is also an important consideration, as some systems are sold by large distributors with extensive service departments and others come from small, local distributors. In general, the major manufacturers are the first to have additional features and are distributed by the major supply houses.

Incorporating optical scanning into a practice’s workflow has become simple and economical. The advantages to both the patient and dentist make this technology the future of dental impressions.


About the Author

Andrew Koenigsberg, DDS, is a partner at Gallery57 Dental in New York, New York, and cofounder of CAD/CAM Excellence.

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21st Century Laser Dentistry

Anthony R. Cardoza, DDS

Over the past 29 years, I have witnessed many technological advances in dentistry. Some of these advances have included computers throughout the office, digital x-rays, digital intraoral photography, loupe and microscope magnification, and CAD/CAM technology, just to name a few. One of the most significant technological advances has been the evolution of the dental laser, and it’s this technology that is really firing my passion for dentistry.

Choose Wisely

Lasers have been used in dentistry for decades, but in the past 5 years they have become widely accepted; now tens of thousands of dentists in the United States and around the world have implemented lasers. Market acceptance of dental lasers is rapidly growing at a level where digital imaging was 5 to 7 years ago.

In my practice, we have several lasers for both hard and soft tissue applications that are used for a wide range of procedures. It is well established that different procedures require different laser wavelengths. Wavelength is important because specific body tissues (chromophores) interact in different ways depending on the laser source. Therefore, it is important to use the proper wavelength that is tissue specific for the procedure.

Clinician & Patient Benefits

Following are just a few of the laser procedures performed in our office every day and the clinical advantages they offer our practice and, most importantly, our patients.

The 1064XLase™ (Fotona, 1064-nm diode laser has become my laser of choice for hygiene. It is very effective for procedures such as laser bacterial reduction (LBR) and laser depitheliazation during scaling and root planing. Additionally, because of the 1064-nm wavelength and the ability to micropulse, the 1064XLase is excellent for soft tissue surgical procedures such as frenectomies, gingivectomies, fibroma removals, and gingival retraction for crown and bridge impressions.

The most versatile laser I have is a dual-wavelength Er:YAG (2940 nm) and Nd:YAG (1064 nm) all-tissue laser, the LightWalker AT (Fotona). Practically all laser-assisted dental treatments can be performed with either the most highly absorbed Er:YAG or the selectively absorbed, deeper penetrating Nd:YAG laser wavelength. I use my LightWalker several times a day for no-shot, no-drill cavity preps. My patients love being able to avoid having shots and postoperative numbness. This laser gives me the ability to quickly and effectively remove decay and often these restorations had not been scheduled but are discovered during hygiene examinations. We are able to complete these procedures in one appointment and avoid the inconvenience of rescheduling the patient. With my LightWalker laser, I am able to perform these procedures fast and often without anesthesia.

Upgrading Your Offerings

Lasers have allowed me to expand the procedures I perform and one of the most important areas is endodontics. With our LightWalker we routinely perform even complicated molar endodontic cases using an effective, fast, and easy procedure called PIPS™. PIPS is an advanced, patented method using the LightWalker for cleaning and debriding the entire root canal system. It has been shown to greatly reduce the bacteria found within the canal system. PIPS has allowed me to reduce the treatment time for molar endo by about 30% and reduce retreatments.

The combination of these two proven wavelengths in one system has enabled our practice to perform not only single wavelength but also dual-wavelength treatments. Using both wavelengths in many treatments makes optimum use of the unique laser-tissue interaction characteristics of each wavelength. When combined, they can dramatically improve the outcome of laser-assisted treatments.

The decision is no longer whether to add a laser to your practice, it is just a matter of which laser will best fulfill your needs.


About the Author

Anthony R. Cardoza, DDS, is in private practice in Santee, California.

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CAD/CAM for Implant Planning

David P. Sarment, DDS, MS

Dental implant guidance methods are defined as aids to surgical placement using predefined planning. It implies a diagnosis using computed tomography (CT) and software to plan the position and dimension of implants. Transfer to surgery is accomplished using two methods.

The first method uses an intraoperative navigation apparatus where cameras track the patient and surgical instruments. Although real-time, setup is complex and line-of-sight is a limiting factor. As a result, navigation has so far not been successful in implantology. The second method of transfer uses CAD/CAM to print accurate surgical guides in three dimensions. Typically, the clinician owns the implant planning software. However, several third-party services offer remote assistance because cost, learning curve, and time for planning can be prohibitive to low-volume users.

Clinical Benefits

There are several benefits to using CAD/CAM surgical guides. Surgical precision is enhanced while decision-making is eliminated and procedure time is decreased. Furthermore, careful planning takes place at an early stage, improving communication between surgical and restorative colleagues and positively impacting the outcome. When depth-controlled guides are used, osteotomies close to critical anatomic landmarks (eg, sinus floor, mandibular nerve) are safer. Another benefit is the option to perform a “surgery” on a study model and prepare a provisional restoration in advance when immediate temporization is anticipated. When presented to the patient, such sophisticated yet explicit preparation conveys a high degree of professionalism. Finally, chair time is reduced and postoperative pain tends to be diminished.

Integration, Training, & ROI

Integration of CAD/CAM guidance to the office workflow requires minor adaptation and is somewhat easier with an in-office cone-beam computed tomography (CBCT) scanner. A dedicated computer station with appropriate software and rapid processing is best because files are large and graphics are demanding. When using a third-party planning assistant, allow for a phone meeting with simultaneous website access, also at the office, to review and discuss the plan. Once approved, provide ample time for the guides to be printed and shipped. If depth-controlled guides are ordered, dedicated surgical kits must be purchased too.

With regard to training and education, there are two critical elements. First, CT images must be interpreted, keeping in mind that incidental pathological finding must be diagnosed. To that end, maxillofacial radiologists using teleradiology are available. The second aspect of training is essentially software related: tools and options need to be well understood for best performance. The use of the guides themselves is simple, with some access limitations in posterior areas, in particular when using depth-controlled guides.

The return on investment (ROI) is unlike most other added dental procedures. In this case, fees are like those for regular surgical guides, but the added costs of software, training, and preparation time are not easily transferrable. Therefore, increased costs must be built in customary surgical fees. It is interesting to consider time factors as well—additional preparation time is offset by less surgical time and potential improved outcome.

CAD/CAM surgical guides have become, over the past 10 years, relatively simple. With increased presence of in-office CBCT and digital dentistry, CAD/CAM guides are a natural fit with a bright future.


About the Author

David P. Sarment, DDS, MS, is in private practice in Alexandria, Virginia.

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Allen Ali Nasseh, DDS, MMSC

Ultrasonic technology has proven to be an integral part of dentistry for half a century. The origin of the dental application of ultrasonic energy goes back to its use in surgical and nonsurgical periodontal therapy and dental prophylaxis procedures in the 1950s. However, the evolution of this technology from the original magneto-restrictive units to the current piezoelectric units helped catapult these devices into their current position of significance in clinical dentistry.

Clinical Applications

The piezoelectric technology allowed ultrasonic devices to be more than mere tools for removing stains and calculus from teeth and helped shape them into effective, and highly efficient, methods of dentin removal, root canal irrigation, and canal instrumentation. Today, piezoelectric ultrasonics are significant players in periodontal, endodontic, and restorative procedures and extend their use from nonsurgical to surgical care.

In endodontic therapy, ultrasonics can be used to trough dentin conservatively and with more control. This, along with enhanced visualization of the site of action around the thin ultrasonic tip (compared to a thick rotary handpiece), helps the clinician find hidden canals during the access preparation, and efficiently remove pulp stones, canal obstructions such as posts, broken instruments, and hard cements. Ultrasonics can also be used for preparing deep retro preparations during surgical apicoectomy procedures, something that was not previously possible using a rotary hand piece. In conjunction with the use of endodontic files, these devices can greatly improve the efficacy of cleaning and shaping procedures during root canal therapy.

Today, my clinical endodontic practice revolves around the use of ultrasonics. In fact, I use ultrasonics, in one form or another, in every surgical and nonsurgical case. Nonsurgically, the use of ultrasonics is during the early phase of the treatment in a conventional root canal is very helpful in finding additional canals or finding dystrophically calcified canal orifices and removing debris efficiently. During retreatment procedures, ultrasonic energy is used to vibrate, loosen, and remove posts and other canal obstructions that impede access to the root canal.

Once access is made and obstructions are removed, ultrasonic energy can help as a catalyst for enhanced irrigation due to its ability to increase the rate of reactions through cavitation, agitation, and acoustic streaming, as well as the increased fluid temperature resulting from these actions. More importantly, ultrasonic energy itself has been shown to disrupt biofilm, aiding in successful dismantling and decontamination of this tenacious cause of root canal failure.

After final canal instrumentation is complete using rotary files, an ultrasonically activated thin file that has been extended to the full working length can further help expedite decontamination of the root canal surfaces and removal of the smear layer. A 30- to 60-second agitation per canal using a size 15 ultrasonically activated file will dramatically improve the quality of cleaning and shaping following rotary canal instrumentation.

Lastly, the newer and superior bioceramic cements used in endodontic therapy are readily cleaned and removed using ultrasonic energy and water.

Ultrasonic devices are critical for improving clinical care in endodontic therapy and belong in every operatory where these procedures are performed.


About the Author

Allen Ali Nasseh, DDS, MMSc, is president of RealWorldEndo™ ( and clinical instructor in the department of restorative dentistry and biomaterial sciences at Harvard University School of Dental Medicine, and maintains a private practice in Boston, Massachusetts.

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Digital Dentistry... Are We There Yet?

Parag R. Kachalia, DDS

Technology is influencing the world around us and dentistry is by no means immune to this trend. One area of particular note is the recent explosion of the CAD/CAM marketplace. For nearly 30 years, Sirona’s CEREC® ( platform was the only player in this arena and if a practitioner chose to enter this world they were forced to jump in with both feet. The landscape over the past few years has changed drastically, with many more competitors entering the market, and practitioners today have the flexibility to enter this digital world in any way they believe is appropriate for their practice. This entry point can range from simply digital impressioning all the way through essentially creating a digital lab in one’s office.

Today’s Options

Most individuals would agree that the traditional workflow for crown and bridge restorations is fraught with error and many stars must align for a restoration to be truly successful. In addition, most would agree that a patient would prefer not have a tray full of impression material placed in their mouth for 3 to 5 minutes, wear a provisional crown for 2 to 3 weeks, and return for a restoration on second appointment. In an ideal world, a highly accurate digital impression would be captured and a restoration would be designed and fabricated in office for delivery on the same appointment. Although this would be ideal, this workflow requires the clinician or trained staff member to take on the responsibility that previously fell with the laboratory. If an office chooses to enter this world in total, the practitioner now has the ability to choose a system from Sirona (CEREC), Planmeca/E4D Technologies (PlanScan,, Carestream (CS Solutions,, and many others will come to market as time goes on. Each of these systems has a combination of a digital impressioning unit, design software, and an in-office mill.

If, on the other hand, a practitioner would like to enter the digital path incrementally, they can do this by simply starting with a digital impressioning unit that has the ability to grow as time goes on. These units can capture highly accurate digital impressions when proper soft-tissue management is implemented and the captured digital data can then be sent to a dental laboratory for restoration fabrication. Many systems, including 3Shape’s Trios® (, Align’s iTero® (, Planmeca/E4D’s PlanScan, and 3M ESPE’s 3M™ True Definition Scanner ( now have the ability to export data in an open architecture standpoint (open STL file) to essentially any dental laboratory, whereas other systems (Sirona’s CEREC) have a closed data set that can only be used by partner laboratories. If in the future the practitioner chooses to pursue in office milling, a milling system can simply be added. Over the past few years, more and more systems are adopting an open architecture format and multiple milling systems can now work with different digital scanners. This allows the practitioner to choose the setup that is right for them.

Considering ROI

In addition, new services are available where a practitioner may actually have both a digital impression system and a milling system in office; however, they can outsource the design phase to a third party for a relatively small costs and not have to be intimately involved with this phase.

From a business standpoint, the return on investment (ROI) can be both simple and difficult to calculate. If one decides to fabricate the restoration in office, a simple ROI essentially takes into account the savings in laboratory cost and a small portion of chair time relative to the monthly payment over a period of time. This ROI is a very tangible number. On the other hand, if one chooses to enter the digital impression route only, the numbers become a little softer. The investment in the system is offset by a reduction in laboratory fees (many labs discount charges when a digital impression is sent), decrease in material costs related to traditional impressions, faster laboratory turnaround times, and potential increase in patient flow.

As time goes on, our technologically savvy patients will seek out practices with this technology because they perceive the digital process as patient friendly. In addition, internal referrals are likely to increase as well when patients have positive experiences.

True success with any technology implementation comes when the entire practice is on the same page. Time and energy must be spent on training all members of the dental team so that they understand the benefits of digital technology and they can properly execute a successful workflow.


About the Author

Parag R. Kachalia, DDS, is an associate professor and vice chair of simulation, technology, and research at University of the Pacific’s Arthur A. Dugoni School of Dentistry and is in private practice in San Ramon, California.

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1. Do dental radiographs show incipient carious lesions? Clinicians Report. 2011;4(3).

2. LMT Communications, Inc. Trends 2005. website. Accessed March 24, 2014.

3. Hench, LL, Splinter, RJ, Allen WC, Greenlee TK Jr. Bonding mechanisms at the interface of ceramic prosthetic materials. J Biomed Muter Res. 1971;5(6):117-141.


Unlocking the Mystery of Disease-Causing Bacteria

Working in conjunction with Oak Ridge National Laboratory, Clifford Beall, PhD, research assistant professor of oral biology at The Ohio State University and lead author of a study published in the journal PLOS ONE, collected 12 individual cells from the healthy mouth of one individual to begin sequencing the genome of the Tannerella BU063 bacterium. BU063, which has not been successfully cultured, is closely related to Tannerella forsythia, one of multiple bacteria linked to periodontal disease. The DNA of the BU063 genome has been identified by the federal Human Microbiome Project as one of the “most wanted” genomes for sequencing. Unlike its “cousin” T forsythia, BU063 is in healthy gingiva.

At present no antibiotics or other drugs are effective against diseases such as periodontitis because of the multiple bacterial complexes involved. The current treatment modality involves surgery or deep cleaning to remove the bacterial infection from the pockets around the gingiva. Beall hopes his research and that of others will lead to methods to combat the disease on a molecular level. “There are many of us working on similar projects focused on solving periodontitis,” he says. “Unraveling the complexity of the oral microbiome will take many years but should result in important breakthroughs.”


Caries Detection

Many general practitioners are moving beyond low-tech options such as the explorer and seeking more consistent and predictable ways to identify caries. Generally simple to use and easily integrated into existing patient examination protocol, the following technologies combined with a strong understanding of CAMBRA (caries management by risk assessment) can take preventive care and treatment to the next level.


By hugging the tooth and bathing it in safe, near-infrared light, CariVu’s transillumination technology makes the enamel appear transparent while porous lesions trap and absorb the light. This allows the clinician to see through the tooth exposing its structure and the actual structure of any carious lesions with very high accuracy. There is no need to clean the tooth of bacteria, calibrate the device, or become versed in the meaning of multiple color codes or numeric indicators.

The Canary System® Quantum Dental Technologies

The Canary uses a low-power, pulsating laser light to scan teeth for the presence of dental caries or tooth decay. It can detect decay on smooth enamel surfaces, root surfaces, biting surfaces, between teeth, and around existing amalgam or composite fillings.


DIAGNOdent operates at a wavelength of 655 nm, at which clean, healthy tooth structure exhibits little or no fluorescence. Carious tooth structure will exhibit fluorescence proportionate to the degree of caries, resulting in elevated scale readings. An audio signal allows the operator to hear changes in scale values.

SOPROCARE® Acteon North America

SOPROCARE is a high-performance intraoral camera that illuminates dental tissue with a specific wavelength of light between 440 and 680 nm to detect biofilm, inflammation, tartar, plaque, and occlusal caries. It features 3 modes: PERIO, DAYLIGHT, and CARIO.

Spectra® Caries Detection Aid Air Techniques

Spectra uses fluorescence to detect caries in fissures and smooth surfaces that may go unnoticed in x-ray images. After capturing the image within existing imaging software, the extent of the decay will be interpolated and indicated by color coding and with a numerical indicator.

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