Digital tools have taken over the dental office, promising simpler and faster procedures. But how much have they improved efficiency? A recent study compared the time taken to fit and adjust implant-supported crowns using digital and conventional workflows.
The researchers treated 20 patients in a crossover design for single-tooth replacement in posterior sites, each with a customized titanium abutment plus CAD/CAM-zirconia superstructure (test: digital workflow; n = 20) and a standardized titanium abutment plus porcelain-fused-to-metal (PFM) crown (control: conventional pathway; n = 20).
Evaluation of the 40 reconstructions included feasibility of laboratory cross-mounting of each abutment crown connection and assessment of adaptation time for clinical adjustments of interproximal and occlusal surfaces. Statistical analyses were performed using the exact Wilcoxon rank sum tests.
Laboratory cross-mounting was feasible for 3 reconstruction pairings, revealing a 15% vice versa transfer success rate. All implant crowns could be provided successfully within 2 clinical appointments, independently of the workflow used.
The mean clinical adjustment time was significantly lower (P < 0.001) for test reconstructions for the digital workflow with 2.2 min (standard deviation [SD] +/- 2.1) compared with ones from the conventional pathway with 6.0 min (SD +/- 3.9).
The researchers concluded that the digital workflow was 3 times more efficient than the established conventional pathway for fixed implant-supported crowns. Clinical fitting could be predictably achieved with no or minor adjustments within the digital process of intraoral scanning plus CAD/CAM technology.
The study, “Clinical Fitting and Adjustment Time for Implant-Supported Crowns Comparing Digital and Conventional Workflows,” appeared in the September issue of Clinical Implant Dentistry and Related Research. It was written by Tim Joda, Dr MSc; Joannis Kastoulis, Dr MAS; and Urs Brägger, Prof Dr, and supported by Institut Straumann AG, Basel, Switzerland.
Residents of Kingsley Manor in Hollywood, Calif, no longer have to find a way to get to the dentist’s office. The office has come to them.
The Arthur A. Dugoni School of Dentistry at the University of the Pacific will use a $275,000 grant from the California Wellness Foundation to operate a virtual dental home at the retirement community. Dental hygienists will use telehealth technology to link up with dentists elsewhere to provide care on site.
“Hygienists collect a full set of diagnostic records,” said Dr. Paul Glassman, professor at the university. “They’re taking x-rays. They’re taking photographs. They’re doing dental charting. It’s really populating a full electronic dental health record, the same dental records that you would see in a dental office that, as people say, has gone paperless.”
The equipment is portable and can be set up in about 20 minutes. For example, it includes a digital x-ray machine that is about the size of a large hair dryer. Glassman notes that it takes a lot less radiation to expose a digital sensor than traditional film. All of the patient’s information then goes into a laptop and uploaded to a cloud-based server, which associated dentists can access from their offices.
“Between patients or during lunch or at the end of the day, the dentist will get on the computer and review the records and make a diagnosis and a treatment plan,” said Glassman, adding that consultations with dentists in real time is logistically difficult and unnecessary. “If the hygienist captures images one day and the dentist views them the next day, it’s no big deal.”
In fact, Glassman says that only about a third of the patients seen at these remote locations ever require referral to a dentist for more invasive care like extractions and implants. Meanwhile, virtual dental homes like the clinic at Kinglsey Manor provide a full range of other preventative treatments.
On location, dental hygienists perform fluoride varnishes, cleanings, scalings, replanings, prophys, and sealants. Additionally, California is one of a handful of states that allow dental hygienists and extended function dental assistants who have completed appropriate training to perform interim therapeutic restorations.
“There is no anesthesia or drilling involved,” said Glassman. “They use hand instruments to clean out the soft material, whether that’s a little bit of yesterday’s lunch or some soft decayed tooth material. They don’t even have to remove all of the decay in the tooth. And then they’re able to bond in a tooth-colored filling material.”
These materials adhere to the tooth and seal in decayed structures to stop decay from progressing. Unlike temporary fillings, which can fall apart within a few weeks, these restorations are designed to last for many years. Dentists then only need to monitor them, later deciding if replacement is necessary or not.
This kind of accessible care is necessary, Glassman says, because more than half the population of the United States is not getting dental care on a regular basis. Only about 46% of children see a dentist annually, he says, with worse numbers for low-income populations: of this group, only about 25% of children and 20% of working age adults have an annual visit.
“The people visiting dental offices these days in general are the wealthiest and healthiest in the country. More dentists are doing mostly diagnostic and preventative work because they’re working on mostly healthy people,” Glassman said. “So why don’t people access dental offices? If you do surveys, people say that dental care is too expensive.”
Other factors play into the lack of care as well. For example, low-income populations may face transportation barriers in getting to dental offices. They may have difficulties taking time off work for appointments. Cultural barriers are present, too, as the makeup of the dental profession doesn’t always match the makeup of the patient population.
“Some people see dental care as being something that’s delivered by rich white people for rich white people,” Glassman said. “Then there’s the whole culture of poverty where people sort of begin to accept their lot in life as having bad teeth and toothaches and losing their teeth.”
The Pacific Center for Special Care, which Glassman directs, has created best-practice models for developing virtual dental homes to fulfill this need. Its network treats otherwise underserved populations in schools, community centers, residential facilities, and other group settings for underserved populations all over the Golden State.
“We have been working in 13 different communities, all the way from Eureka down to San Diego,” said Glassman. “It’s been about 50 different sites where this idea has been tested over the last 6 years.”
Dental caries represent the biggest problem for children, and virtual dental homes can play an instrumental role in treating and preventing them. But Glassman also notes an interesting and emerging change in dental care for aging patients such as those at Kingsley Manor—senior citizens with actual teeth.
“Baby boomers were raised in a time when there was more fluoride in the water so people had better dental health growing up,” said Glassman. “And pretty much the baby boom generation has grown up with the idea that they’re going to keep their teeth their whole life. That’s very different from previous generations.”
Complicating matters, many elderly patients take at least one of the 400 medications that cause dry mouth, which in turn causes tooth decay. Yet these patients often have impaired mobility and are unable to get to dental offices, in addition to living on a fixed income, making virtual dental homes at locations where they live essential to oral health.
“It’s sort of the perfect storm of people who need a lot of care and have a lot more difficulty getting it,” Glassman said.
So far, Glassman reports success in treating these patients with preventive care and early intervention, eliminating the need for more extensive care later. Overall, the virtual dental homes have retained about two thirds of the patients they have been seeing.
“And these have been purposefully picked populations of people with the least access to dental care, most likely to actually have advanced dental disease, most likely to have problems and end up in the emergency room,” Glassman said. “We’re able to keep about two thirds of the populations of those sites healthy with the hygienist being the only one physically touching them.”
Insurance companies are on board with using this preventive care to save costs in the long run. The goal of the 3-year grant is to demonstrate the program’s efficacy and ability to be self-sustaining. For instance, recent legislation in California now requires the Denti-Cal insurance program to pay for services provided through virtual dental homes and other telehealth centers.
“We’ve been testing this delivery system model for 6 years and very clearly demonstrated we can make it work,” Glassman said. “We can get care delivered in community sites. We can emphasize prevention. We can have dentists involved through the teledentistry system. We can make referrals. We’ve demonstrated all that.”
Now, Glassman explains, there is a billing stream for these programs to pay for themselves through revenue. The Pacific Center for Special Care is working with the Queens Care federally qualified healthcare center to provide staffing such as hygienists and dentists and help it understand the new billing regulations so these programs can shift from grant-funded to billing-funded projects.
“Once commercial dental benefit companies begin to realize that they can reduce costs and do a better job of actually making people healthy at a lower cost, then it’s going to become pretty widespread across the dental benefit industry,” Glassman said.
As virtual dental homes see greater use, these locations will need personnel who are familiar with the model. That’s why the university will use a federal grant to begin training students in teledentistry practices. Faculty and students in its hygienist program will perform the work in locations around San Francisco, and dental students back at school will review records and make treatment recommendations.
“By the time they graduate, we will be the first school in the country to graduate students who have had experiences working in these telehealth connected teams,” Glassman said.
These facilities aren’t being set up to compete with established dental practices, though. On the contrary, they are opportunities for dentists to expand their practices and reach out to patients they otherwise would not have the opportunity to see, Glassman says.
Glassman encourages dentists to learn more about the model at his course, Expanding Dental Practices Using Telehealth Connected Teams, at next spring’s meeting of the California Dental Association. More information also is available at virtuadentalhome.org.
“The idea was the dental office ended at the 4 walls of your office. That’s where the practice was. But now we have the option to be able to extend into the community where some members of the team are at a site like Kingsley Manor, doing the diagnostic records and preventive procedures, and even these interim restorations,” Glassman said.
“But it’s all one practice,” he said. “It’s a very different way of thinking about what a dental practice is and how you keep people healthy in the long run.”
With access to care at dangerously low levels for low-income and other disadvantaged populations, dentists are encouraged to participate in free screenings and clinics whenever and wherever they can. But this participation can lead to some tricky ethical questions.
That’s why the ADA Council on Ethics, Bylaws and Judicial Affairs (CEBJA) has published “The Ethics of Temporary Charitable Events.” This free, online white paper provides guidance on ethical issues based on the ADA’s Principles of Ethics and Code of Professional Conduct.
“We’re hoping it eliminates problems before they occur,” said Dr. Elizabeth Reynolds, one of the authors of the paper. Its topics include:
- Access to, maintenance of, and confidentiality of patient records;
- The elements necessary for informed consent;
- Patient abandonment;
- Honestly educating patients about treatment options and the limitations of a temporary charitable event;
- The temporary nature of these events precluding development of an ongoing relationship with patients.
For example, event sponsors typically keep patient records, not the dentists. Problems with treatment could arise later, so patients should be clearly informed about how to obtain those records and how to schedule follow-up care. The paper suggests simply ensuring patients get the phone numbers of the organization or person in charge of the records along with the emergency contact responsible for postoperative care.
Also, providers must ensure patients understand available treatment options along with their risks and benefits. For instance, patients may opt for a root canal to save an abscessed tooth without realizing they will need a crown to protect it. Perhaps the crown seemed too expensive or unnecessary. The unprotected tooth could break later, though, requiring emergency surgery. These patients would benefit from a better awareness of options and consequences before selecting treatment.
The paper addresses personnel as well. It says that volunteers must be properly trained, credentialed, supervised, and legally authorized to perform their assigned duties for their subsequent treatment and advice to be considered appropriate. Dental and auxiliary students who provide direct care must be versed in the treatment they are administering. And, coordinators must continually monitor and supervise the event to ensure these principles are upheld while also meeting any local requirements.
The authors note that charity events often produce unintended consequences and conclude the paper with a list of questions that volunteers should ask before participating. For example, if these events are too successful, could patients use them as dental homes? Are dollars and cents the best way to define the success of these projects? Is anyone watching to be sure that these projects don’t become a platform for heroics by providers who may not be proficient in a specific area?
Finally, the paper includes a pair of checklists to ask during the event—one for patients and one for dentists. Questions for patients include if they understand that the treatment is being rendered in a less than ideal environment, if they are aware of alternative sites for care, and if they are forthcoming about all medical conditions. Among other queries, dentists should ask if the treatment they are providing is necessary and appropriate, what their supervisory responsibilities may be, and if their specialty precludes them from performing the procedure.
Invivo 5.4 from KaVo Kerr Group Imaging enhances the company’s CBCT 3-D imaging treatment planning software. It is fully integrated and exclusively used with Instrumentarium Dental, Gendex, and SOREDEX 3-D imaging systems. Also, its upgraded feature-rich software provides more control in designing crowns, abutments, and implants right from the Cone Beam 3-D scan, according to KaVo Kerr Group Imaging.
The update is designed to simplify the entire implant selection process. With the ability to adjust and size the implant directly within the 3-D rendering, dentists now can set implants individually or in parallel groups. It also offers quick and easy bone grafting simulation, according to the company.
“If the implant is already placed, it takes one click to activate the tool and one click to create the graft,” said Yena Chokshi, associate 3-D software product manager. “You can get your results in seconds.”
Invivo 5.4’s tools help dentists design crowns fitting prepped teeth, abutments, or pontics. With its mesh manipulation tools, dentists can make fine mesh adjustments to the restoration shape. The restoration fitting tools allow for proper crown to abutment/prepped tooth interlacing. Collision indicators and stone model registration display how crowns are spaced with regards to existing structures for better positioning and shaping. And, Invivo 5.4 can be used to create pontic crowns or bridge structures.
Additionally, the updated interface and enhanced abutment view during custom abutment creation now can interface with restoration correctly and with group abutments for parallel insertion. The update’s richer and more detailed airway analysis includes anterior/posterior right/left distance and cross-sectional area data along any point in the airway. Furthermore, Invivo 5.4 provides accurate jaw articulation simulation.
“In the absence of an articulator, this tool can be used as a reference for occlusion and potential interference,” Chokshi said. “Accuracy depends on the scans. Intraoral scans will provide greater accuracy. The user can always adjust the condyles and stone models manually.”
Invivo 5.4 treatment software is included with new OP300 Maxio Cone Beam 3-D scanners, Gendex GXDP-700S and SOREDEX CRANEX 3Dx and SCANORA, giving general dentists and specialists the tools to place and restore implants; perform oral surgery; perform periodontics, prosthodontics, and orthodontics; utilize CAD/CAM applications; and analyze the temporomandibular joint and airway with greater confidence and lower radiation options, according to KaVo Kerr Group Imaging.
Invivo5 for Mac includes all of the implant planning and orthodontic designing capabilities of Invivo 5.4 on the PC in addition to the latest software features. As a work in progress, it will continuously receive updates to implement all of the features available in the PC version, including the add-on modules.
For more information, call (704) 587-7271 or visit gendex.com/invivo.
Rheumatoid arthritis (RA) affects the joints, causing pain, swelling, and stiffness. Anyone can get it, though it affects women more than men, and it’s most common among older people. The immune system attacks the body’s tissues, but its exact causes aren’t known. Yet research has found a connection between RA and periodontal disease.
One recent study included 44 patients diagnosed with RA according to American Rheumatism Association criteria attending the Morales Meseguer Hospital Rheumatology Service in Murcia, Spain, and 41 control subjects. Patients younger than 18 or suffering systemic diseases that could affect the immune system were excluded.
Each patient received a full periodontal examination. Bleeding on probing was significantly greater in the RA group (0.9 +/- 0.36) than the control (P < 0.001). The plaque index also was significantly higher in the RA group (0.76 +/- 0.34) than the control group (0.55 +/- 0.2, P < 0.001).
Overall, the researchers concluded that the RA patients showed a 0.13 increased risk of periodontal disease (95% confidence interval, 0.05 to 0.37). They also determined that these patients must be instructed to intensify their oral hygiene regimes.
The research, “Clinical Evaluation of Periodontal Disease in Patients With Rheumatoid Arthritis: A Cross-Sectional Study,” was published in the October issue of Quintessence International. It was written by Alvaro Pons-Fuster, DDS, PhD; Consuelo Rodríguez Agudo, DDS, PhD; Pepe Galvez Muñoz, MD, PhD; Encarna Saiz Cuenca, MD; and Francisca M. Pina Perez, MD; Pia Lopez-Jornet, MD, DDS, PhD.
Bone loss is one of the most significant consequences of periodontitis. Yet researchers at the University of Pennsylvania (UPenn) School of Dental Medicine have demonstrated that the Del-1 protein can inhibit the bone loss that’s associated with the disease. They also found that Del-1 curbs the activity of osteoclasts, cells that absorb bone tissue, explaining how the protein can prevent potential bone loss.
“This is not just important for periodontitis,” said George Hajishengallis, senior author of the study and the Thomas W. Evans Centennial professor in the department of microbiology at UPenn School of Dental Medicine. “It could also have implications for other inflammatory diseases where bone loss is involved, like osteoporosis and rheumatoid arthritis.”
Previous studies by Hajishengallis et al have demonstrated the important role that Del-1 plays in inhibiting the movement and accumulation of neutrophils in gum tissue in mice, and they have found a similar mechanism occurs to reduce inflammation in the central nervous system. In both scenarios, Del-1 can restrain the recruitment of neutrophils, which prevents damaging inflammation.
The UPenn scientists demonstrated that applying Del-1 to the gums can inhibit inflammation and bone loss in a mouse model of periodontitis. But evidence from those studies also suggested that Del-1’s effect on bone loss wasn’t only due to its inhibition of neutrophil recruitment.
“When we compared Del-1 with a small-molecule inhibitor of neutrophil recruitment side by side, we found that Del-1 was much more effective at inhibiting bone loss,” Hajishengallis said. “That suggested to us that Del-1 may have an additional mechanism to inhibit bone loss, perhaps by acting directly on the osteoclasts.”
Del-1 is known to be expressed on various soft tissues such as the gums, brain, and lungs. To confirm their suspicions that it also might be involved in bone preservation, though, the researchers stained bone tissue for the molecule. They found evidence of Del-1 in the same areas as osteoclast activity and followed up by generating human and mouse osteoclasts in vitro, finding Del-1 mRNA and protein expressed at high levels. Osteoclasts from mice lacking Del-1 or from cell lines lacking the protein could be differentiated faster and stronger.
“In fact, Del-1 doesn’t block the formation of osteoclasts, but it does put the brakes on the process,” Hajishengallis said.
Further experimentation in vitro with human osteoclasts and in vivo in mice identified a portion of the Del-1 protein that was particularly important for containing osteoclast activity, though additional parts of the molecule were needed to have the most potent inhibition of inflammation and bone loss. In further mechanistic experiments using different parts of the protein, the researchers were able to dissociate the anti-inflammatory action of Del-1 from its anti-osteoclastogenic action.
“Even when we administered Del-1 after the peak recruitment of neutrophils, we were still able to significantly inhibit bone loss,” Hajishengallis said.
With this new understanding of how Del-1 can inhibit periodontal bone loss, both by reducing inflammation and by restraining the activity of osteoclasts that resorb bone tissue, the researchers tested it in a preclinical model periodontitis. Del-1 significantly reduced inflammation and tissue damage, and there was significantly less bone loss.
Hajishengallis et al have implicated Del-1 in other inflammatory diseases, including multiple sclerosis, and are beginning to examine its possible involvement in rheumatoid arthritis and osteoporosis. Unlike some drugs used to treat these diseases, Del-1 is a protein that the human body produces. Administration of a Del-1 based drug like would be safer than some of the alternatives, then, especially for local inflammatory diseases.
“I’m convinced that this is a drug that could work in humans,” Hajishengallis said.
The research appears in Science Translational Medicine. In addition to Hajishengallis, the co-lead authors included Jieun Shin and Tomoki Maekawa, in addition to co-authors Toshiharu Abe, Evlambia Hajishengallis, Kavita Hosur, and Kalyani Pyaram. The UPenn team collaborated with Triantafyllos Chavakis and Ioannis Mitroulis of the Technical University of Dresden in Germany.
The research was supported by the National Institutes of Health’s National Institute for Dental and Craniofacial Research and National Institute for Allergy and Infectious Disease, the Deutsche Forschungsgemeinschaft, the Excellence Initiative by the German Federal and State Governments, and the European Research Council.
Rotary files are essential to endodontic work. But everyday wear and tear can affect their performance, and failures during procedures can be dangerous. Accurate estimates of their endurance and lifespans are vital to their safe operation.
The finite element method (FEM) has been proposed for analyzing stress distribution in NiTi rotary instruments, but it has not been assessed for predicting the number of cycles to failure (NCF). Recently, researchers at Politecnico di Torino and the University of Turin Dental School in Turin, Italy, attempted to predict NCF and the failure location of NiTi rotary instruments by FEM virtual simulation of an experimental nostalgic fatigue test.
The researchers tested ProTaper Next (PTN) X1, X2, and X3 files from DENTSPLY Maillefer (n = 20) to failure using a customized fatigue testing device. Computer-aided design software replicated the device and file geometries. Computer-aided design geometries (geometric model) were imported and discretized (numeric model). The typical material model of an M-Wire alloy was applied. The numeric model of the device and file geometries were exported for finite element analysis (FEA).
Multiaxial random fatigue methodology was used to analyze stress history and predict instrument life. Experimental data from PTN X2 and X3 were used for virtual model tuning through a reverse engineering approach to optimize material mechanical properties. Tuned material parameters were used to predict the average NCF and failure locations of PTN X1 by FEA; t tests were used to compare FEA and experimental findings (P < 0.05).
Experimental NCF and failure locations did not differ from those predicted with FEA (P = 0.098). The researchers concluded that FEA may predict file NCF and failure location. Virtual design, testing, and analysis of file geometries could save considerable time and resources during instrument development, they noted.
The research, “Prediction of Cyclic Fatigue Life of Nickel-Titanium Rotary Files by Virtual Modeling and Finite Elements Analysis,” was published by the Journal of Endodontics. It was written by Alessandro Scattina, MS, PhD; Mario Alovisi, DDS; Davide Salvatore Paolino, MS, PhD; Damiano Pasqualini, DDS; Nicola Scotti, DDS; Giorgio Chiandussi, MS, PhD; and Elio Berutti, MD, DDS.
Designed to be used with all restorative dental procedures, the Tornado turbine from Bien-Air Dental delivers 30W of output power, which the company calls the best performance in the profession.
“Its new rotor design provides optimal air pressure distribution and exhaust flow, yielding 30 W of power and a compact head size,” said Ashley Whobrey, assistant general manager at Bien-Air USA Inc.
With this kind of power, dentists can complete their procedures in less time, according to the company. The Tornado also operates at 55 dB, which is 4 dB quieter than previous models.
“Its SteadyTorque technology and specially designed ceramic ball bearings make it the most silent, vibration-free turbine on the market,” said Ms. Whobrey.
The Tornado handpiece also sprays water from four ports for optimal cooling and offers LED illumination. For superior durability, the custom-designed ball bearings can handle the highest speed and heaviest loads, Bien-Air says. And, the Tornado’s bur-locking mechanism has been improved.
“Accu-Chuck PreciPlus, an extremely efficient bur-fastening system, authorizes vibration-less movement and comfort,” said Ms. Whobrey. “The Soft Push bur-release system is quick and safe. Less force is needed to insert and remove the bur.”
For details, call (800) 433-2436 or go to bienair.com.