New Directions in Dentistry

Based on my activities with Clinical Research Associates as senior consul-tant, my educational projects with Practical Clinical Courses, and my experiences on the lecture circuit, I will make observations on the state-of-the-art developments and imminent potential changes that I see coming in the future for dentistry. I will mention numerous products and companies in this article. For those interested in more information, I recommend contacting the respective companies or researching the subjects further on the Internet.

DIAGNOSIS AND TREATMENT PLANNING

 

Much of dental treatment is now elective. It has been estimated that elective procedures such as veneers, PFM crowns, bleaching, amalgam replacement, etc, generate as much as 50% of a typical general dentist's income.  Currently, some practices are overwhelmed with patients and have far more treatment than they can do, while others are desperately looking for patients. One of the major keys to a busy practice is thorough patient education. In spite of constant education by the lay press and professional sources, patients do not know what dental practitioners can do. They do not know the procedures that can upgrade their facial appearance and their overall self-esteem. As a result, the dentist who does only superficial examinations, avoids patient education during the diagnosis and treatment planning appointment, and treats only the obvious broken or carious teeth will have difficulty fully realizing the potential of his or her practice.

I highly recommend using one of the several electronic patient education concepts available today. CAESY (A Patterson Company) has a beautiful interactive patient education series; Practical Clinical Courses has a well-organized, easy-to-use, concise DVD series that is oriented toward assisting with patient informed consent; and MedVisor is an interactive patient education system just coming on the market. These types of educational programs are making a significant difference in practices, where they are used at the diagnosis and treatment planning appointment as well as during subsequent treatment. When a patient has a few mandatory procedures that are needed immediately, most patients will accept the treatment after it is explained to them. If elective procedures are discussed and demonstrated during the same initial encounter as when the mandatory treatment is explained, it has been my experience that patients will accept the elective procedures after the mandatory treatment has been completed. This suggestion does not infer encouraging patients to accept more treatment than necessary, only to educate patients to the treatment possibilities available and help them make their own decisions based on the education provided.

ENDODONTICS

 

Automated endodontic therapy has made a major impact in dentistry in the past 10 years, but many dentists are still using the concepts they were taught in school years ago. As with any new technique, the initiation of rotary endodontic therapy was met with criticism and skepticism, since one of the originators of the concept was a rebel in endodontics and was the initiator of Sargenti paste in root canals. Nevertheless, the introduction of numerous excellent rotary endodontic devices has made this concept clearly superior to conventional endodontic therapy. It is anticipated that dentists will continue to change to rotary endodontics and the so-called "crown-down" endodontic procedure.

Gutta-percha has been the mainstay in endodontics forever and is still the major material used as root canal filler. However, new products are being investigated, used, and promoted by dentists, manufacturers, and lecturers. The most promising of these  potential gutta-percha replacements is Resilon (Epiphany [Pentron]) and similar products from other companies. This material is a polymer of polyester that looks and feels similar to gutta-percha. It plasticizes at a slightly lower temperature than gutta-percha, doesn't become brittle like gutta-percha does, and is bonded into root canals, unlike gutta-percha.

Because of the aging population and increased retention of natural teeth, there is no question that endodontic therapy will continue to be one of the most active and income-producing areas in dentistry.

AESTHETIC DENTISTRY

 

The king of dental therapy continues to lead both in activity and income in the profession. As an indication of the importance of this area, veneer fabrication now comprises about one third of the gross dollar production of the American dental laboratory industry. I anticipate that the major emphasis of the public and the profession toward aesthetic dentistry will not stop, or even slow down, in the foreseeable future.

As a past president of the American Academy of Esthetic Dentistry, an American Board of Prosthodontics diplomate, and one who stimulated the movement toward this area of dentistry, I have some major concerns. The challenges are not oriented toward technical or material subjects. The challenges are ethical! The most frustrating challenges in aesthetic dentistry are clear. How much of the current aesthetic dentistry therapy has been explained to patients with proper, signed,  informed consent? Do patients really know that some of these procedures have a finite lifetime, even if they are accomplished at a high-quality level? Are patients being treated by practitioners who are educated to accomplish the procedures? Is the national "hype" on lay TV and in published commercial advertisements factual and informative or just for financial gain? Are the "degrees" or special designations some aesthetically oriented general practitioners promote legitimate?

It is evident from discussions with leaders in the profession, concerned practitioners, and mistreated, uninformed patients that aesthetic/cosmetic dentistry, a potential blessing to patients and the profession, is rapidly becoming a curse as well. It is time to do something about it!

On the positive side, aesthetic dentistry has been the profession's salvation. If this emphasis had not come along,  then the volume of dentistry in the United States would be about 50% of what it now is. More dental schools would have probably closed. Aesthetic dentistry has made this profession much more creative, interesting, satisfying to patients and dentists, and, of course, financially rewarding. However, the negative signals are evident. If we let the current trend toward dollars and selfish motives run unabated, we will have enormous public outcry. Over the past 10 years, dentistry has fallen from the top of the Gallup poll on public esteem to the middle of the scale. Let's stop that downward movement!

IMPLANT SURGERY

 

If there is one area of dentistry that has had fantastic innovation over the past few years, it is implant surgery. Implants are now the standard of care for many situations. Try placing a 3-unit fixed prosthesis between 2 virgin teeth and see how you will be treated in a court of law. If adequate bone is present, implants are state-of-the-art for everything from 1 missing tooth to an edentulous arch. I promote to patients at least 2 implants and an overdenture for edentulous mandibles as the primary treatment plan instead of a typical complete denture.

Root-form implants are now in 3 general size categories–mini implants (~2 mm in diameter), standard implants (~3.75 mm in diameter), and wide implants (~6 mm in diameter)–with sizes in between the 3 categories. Many patients do not have enough bone for a standard implant and do not want significant grafting. The mini implant has been accepted rapidly, as it has filled a significant need when adequate facial-lingual bone is not present. Imtec has actively promoted mini implants. I have placed mini implants in bone as thin as 3 mm from a facial-lingual dimension.  However, at least 10 mm of bone must be present from an apical-occlusal dimension for successful use of mini implants. The mini implants are proving themselves for retention of both removable partial dentures and fixed prostheses, and for resistance to chewing and retention when placed under complete dentures. I have personally used them for several years with remarkable success.

The wide, short implants are especially valuable when grafting is not desired in areas over the inferior alveolar canal or under the maxillary sinus, where the bone is wide facial-lingually (6 mm or more), but minimal occlusal-apically (~7 mm).

After proper education, more general practitioners should become involved with implant surgery in healthy patients who have adequate bone. Currently, most oral surgeons and periodontists, some prosthodontists, a few endodontists, and ~5% of general dentists place implants. To serve the American public well and in adequate quantities of treatment, many more practitioners should take the time and spend the money to become educated adequately in this area. I belong to 3 organizations that will excite and educate you about implant dentistry, and I encourage you to look into joining one of them. Call for information: (1) The Academy of Osseointegration at (800) 656-7736; (2) The Interna-tional Congress of Oral Implan-tologists at (888) 449-4264; and (3) The American Academy of Implant Dentistry at (312) 335-1550.

IMPLANT PROSTHODONTICS

 

Wonderful changes are taking place in implant prosthodontics. From recent surveys, nearly all general practitioners and all prosthodontists are accomplishing this area of dentistry. Manufacturers have simplified their systems significantly, and continuing education has enhanced the level of quality in this area. The result is that most practitioners do not hesitate to practice implant prosthodontics on a routine basis. Advances over the past few years have made this area predictable and gratifying to patients and to dentists.

Laboratory fees are still a problem. They appear to be too high in many areas. If the dentist has adequately placed an implant abutment at the impression appointment, there appears to be no reason why the abutment crown should cost the dentist and patient more than a standard crown plus the cost of the abutment. Placing the abutment takes about the same time as preparing a tooth. If the laboratory technician has made a custom abutment for a fee to the dentist, again, there appears to be no reason that the crown should cost the patient more than a standard crown plus the cost of the abutment. How long does it take to screw the abutment onto the implant? If costs are held to an affordable level, then both patients and dentists will benefit, because more implants will be placed.

It is evident that the trend toward more implant prosthodontics will continue, the quality of these prostheses will increase, and this treatment will be as common as a crown on a tooth is today.

OCCLUSION

 

I feel that occlusion is the most neglected area of dentistry. In my opinion, the reported 30% or more of the population that has bruxism and clenching and the enormous number of people who have TMD need our help. Fortunately, we are seeing more interest in making occlusal splints for those who need them. I encourage you to educate interested staff persons to make occlusal splints. They may be conventional, hard, full-arch splints, or the popular NTI (nociceptive trigeminal inhibition tension suppression system; Access Dental), or the Best-Bite. Both the NTI and Best-Bite devices are partial occlusal splints placed in the anterior portion of the mouth to reduce masticatory muscle activity significantly and thus reduce or eliminate bruxism, clenching, and TMD.

Learning a simple method and rationale for occlusal equilibration is also mandatory for optimum occlusal treatment, and it is doubtful if you received that information in your predoctoral education.

The resurgence of so-called neuromuscular occlusion is evident. Although this concept and mechanism has been around for more than 50 years, it has found a home and is being highly promoted commercially. This trend will continue. After many years of active involvement in occlusion, I find that the various "religions" of occlusion are diverse and that there is some truth in each group. The important point is that we as practitioners must select the occlusal concept that is best for each of our specific patients, even if it combines concepts from more than one "belief" in occlusion.

If occlusal splints were made for the estimated one third of your patients who need them, consider the significant service you have rendered to the public, and don't underestimate the major income source that splint placement is to your practice. There are now lawsuits indicting dentists who have watched patients grind their teeth for years without suggesting or making occlusal splints. It is time for us to be proactive in suggesting and providing occlusal splints for our bruxing and clenching patients.

I see more interest in occlusion and potentially more activity in this important area, and I encourage you and your staff to become more educated and involved in this area.

OPERATIVE DENTISTRY

 

This area was supposed to die. Did it? No. It continues to increase in need because of the aging population and the retention of natural teeth. Resin-based composites have made some operative dentistry procedures relatively easy, predictable, and highly gratifying to patients and dentists. New restorative resins with lower polymerization shrinkage are coming. More nanofill resins are coming. Amalgam continues to be used at least some of the time by more than 50% of practitioners, and its use seems to be somewhat stabilized in quantity. Two new, 5-second-cure LED lights are now available from both  Kerr/Demetron and Ivoclar Vivadent. Electric handpieces are now a viable choice for routine tooth preparation. Nevertheless, operative dentistry remains the lowest income area of dentistry on a time-use basis. Learn how to accomplish it rapidly, well, and with significant staff help. Operative dentistry is enjoyable, highly service oriented, relatively simple, and when done correctly, nonthreatening to you because of minimal complaints from patients.

ORAL AND MAXILLOFACIAL RADIOLOGY

 

Is there any question about change in this subject? Digital radiography for periapical and bite-wing radiographs is rapidly becoming the norm. You can't wait much longer. It is expensive and still in the developing stage, but it is wonderful, and when it is incorporated into practice, you wonder how you got along without it. About 5 major companies can easily be identified by your local dealers. Ask your local dealer which is providing the most adequate support and which brand has been the most reliable in your area. Then go for it! Plan on upgrading your system as the technology continues to develop. At the present time, the concept is great, but there is still a long way to go, and you must expect change. Don't wait.

Digital panoramic radiography is in a tremendous growth period. Most of you don't have it, but again, get ready! There are a few highly effective devices on the market, but they are expensive and will continue to be so. If you are interested in tomographic radiography as an addition to your panoramic unit, which you should be if you are doing implant surgery or implant prosthodontics, some of the brands can produce tomography and some can't. Be sure to check. Two popular brands that can do tomography are Planmeca and Sirona. Digital radiography is here and growing.

ORAL AND MAXILLOFACIAL SURGERY

 

Although the extraction of teeth has declined, oral surgeons keep busy with third molar extractions and implants. At this time, general dentists still complete most of the regular day-to-day extractions. Oral surgeons are continuing to become more active in medical areas sometimes considered to be peripheral to dentistry, and that trend will continue.

ORTHODONTICS

This is another area of high activity and change. General dentists and pediatric dentists are much more active in orthodontics, obviously stimulated by the increased popularity of the Invisalign (Align Technology) concept. This relatively simple method to move teeth with minimal to moderate malpositioning is popular among nonorthodontists and some orthodontists. This is the first major breakthrough that general dentists have made into the previously impenetrable orthodontic specialty stronghold. It will continue with the introduction of other relatively simple concepts.

PEDIATRIC DENTISTRY

 

This is another area that was supposed to die. It has not done so. Pediatric dentistry is still very alive and active. Children love candy, and they continue to have developmental challenges as well as frequent accidents. Pediatric dentists are doing far more orthodontics than in the past. The highly perfected resin-based composites of today are being used in children for both posterior restorations as well as crown/veneer restorations on anterior teeth. Compomer, the most popular brand being Dyract eXtra (DENTSPLY), and  resin-modified glass ionomers such as Fuji II LC (GC America) are being used in posterior deciduous teeth, and some dentists are using the old standby, silver amalgam, in children. General dentists still do most of the pediatric dentistry, as is the case in most of the dental specialties.

PERIODONTICS

I have been told by periodontists that less periodontal therapy is being done by periodontists because of the significant increase in implant placement by periodontists. I suggest that periodontal therapy is one of the most significant needs in dentistry. Patients are suffering with periodontal conditions, and few are being treated. I suggest that dental hygienists should be assigned to identify patients needing periodontal therapy in your practice, and that they should take over conservative periodontal therapy for those patients who will not see a periodontist. The well-researched, conservative therapies are as follows:

  • frequent scaling and polishing (every 2 or 3 months  instead of every 6 months),
  • tongue cleaning with a tongue scraper (twice daily),
  • oral antimicrobiologic rinses (once or twice daily),
  • systemic antibiotics-doxycycline hyclate (Periostat), and
  • local antibiotics (Arestin [OraPharma], Perio Chip [Dexcel Pharma], Atridox [Collagenex Pharmaceuticals]).

 

Educated hygienists can accomplish these conservative procedures easily for patients in a typical general practice who have ongoing periodontal disease  but will not see a periodontist. Periodontal disease is not going away, and in spite of about 5 alleged cures for it promoted during my career to date, none have been successful. Go for it!

PREVENTIVE DENTISTRY

 

A strong movement is observable in what is being called minimally invasive dentistry. I had the opportunity to speak to the World Congress of Minimally Invasive Dentistry recently, and I was impressed with the organization's orientation toward preventing dental therapy instead of always picking up a handpiece. New remineralizing chemicals, such as MI Paste from GC, and other concepts in all areas of dentistry are actually making an impact in the profession. I predict that this movement will grow and have a significant influence.

The major impediment to minimally invasive dentistry is convincing dentists that they can still make a living preventing disease instead of treating it. I believe that it is possible.

PROSTHODONTICS, FIXED AND REMOVABLE

 

I was told by some dental administrators and prognosticators quite a few years ago that by the year 2000, there would be no more need for prosthodontics because of the coming impact of preventive dentistry and the demise of dental caries. They were wrong.

Currently, fixed prosthodontics is the single-most income-producing area of dentistry, with the amount estimated to be about one-third of the income of a general dentist. Additionally, there are still at least 40 million edentulous patients in America alone.

Implant prosthodontics will assist in solving some of the tooth loss problem, but many patients cannot afford a mouth full of implants. For those patients, I suggest at least 2 or more implants combined with an overdenture that the implants retain and support.

The new zirconium oxide-based crowns and fixed prostheses will, in my opinion, eventually replace the venerable PFM. DENTSPLY Cercon and 3M ESPE Lava are leading the entry of the profession into these strong, all-ceramic, fixed prostheses. The respective companies as well as independent researchers have research support for use of these prostheses up to 6 units long. Currently, CRA has a major study underway, planned and administered by Dr. Rella Christensen, that will shed light on the long-term serviceability of zirconia-based fixed prostheses. I feel highly optimistic about zirconium oxide-supported, all-ceramic crowns and fixed prostheses, and I am using them in practice where indicated with success.

Prosthodontics (fixed,  re-movable, and implant), as well as maxillofacial prosthetics, is one of the most active areas in dentistry at this time, and the affluent, aging population, with a mouth full of remaining teeth, a few missing teeth, edentulous jaws, or missing facial parts, ensures the continuation of need and increased expertise in this area.

TECHNOLOGY

 

You can go bankrupt buying the new gadgets that are coming onto the market on a frequent basis. Some of the technology is becoming nearly mandatory, such as business computerization, digital radiography, caries detection devices (KaVo's DIAGOdent), intraoral cameras, electric handpieces, and digital photography. Other technologies are more elective, such as operating microscopes, bleaching lights, imaging, computerized shade selection, some lasers, air abrasion, and others.

I use the following reasoning to determine if I need a new technolog: do I currently have some device that does a given task as well as the proposed new technology, and is this new technology going to make my practice faster, easier, better, or less expensive to operate? If I do have something functioning well at this time, and the new technology will not make the practice faster, easier, better, or less expensive to operate, then I wait.

SUMMARY

 

What an exciting time to be in dentistry! The ongoing changes are enormous in quantity. The variety of procedures is overwhelming! The continuing entry of new technology into the profession is stimulating, if not daunting. The public need and demand for dental services is at an all-time high!

HoweverÛkeep in mind that as a profession, we have a service responsibility, and that means we should strive for an altruistic, honest orientation to serve the public and yet make a reasonable and respectable income for ourselves and our families.


Dr. Christensen is a prosthodontist in Provo, Utah, and is director of Practical Clinical Courses and co-founder and senior consultant of Clinical Research Associates. He is adjunct professor at Brigham Young University and the University of Utah. He can be reached at (801) 226-6569, This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or by visiting pccdental.com.



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