Two Essential Procedures to Strengthen Your Practice

Bruce L. Cassis, DDS


Dentistry is in an exciting transition! Patient behaviors are constantly evolving, new technologies are flooding our practices, and the winds of economic change are creating opportunities for dentists to approach the profession in new ways.

As you review your day-to-day practice, you may be facing questions as the winds of change blow through your waiting rooms. What technologies should you add to your practice? What and when should you consider upgrading? What new technologies will create the most value for your practice? What kinds of new procedures can you implement to generate additional revenues and spark patient interest?

To answer these questions, it is always important to understand the business of dentistry, such as cash flow, return on investment, production, and efficiency. There are many resources available for today’s dentists to learn that side (eg, Dental Business Institute [Henry Schein]). However, when it comes to incorporating new technologies, I present 2 “bread and butter” clinical cases that many general practices will encounter daily. Due to their common occurrence, if your general practice can become equipped to handle these clinical cases seamlessly—and with efficiency, revenue, and enjoyment—many tangible and intangible benefits will be realized, as I’ve learned from 36 years of personal experience.

Practicing in Rural West Virginia
I, along with 2 other independent full-time general practitioners (GPs) in our community, currently practice in a town of 2,500 residents. The most reasonable geographical pull is an estimated 30,000 patients from the surrounding area, with 150 fellow dentists practicing in the same region. I differentiate my practice in a rural location by driving patient demand through offering state-of-the-art technology, with a heavy emphasis on same-day dentistry. Like most dentists, I have a strong desire to take care of people and to be active in the local community. The challenge of delivering a great patient experience, by getting the dentistry completed as quickly and with as few complications as possible, is what excites my team every day.

My team and I operate with 7 treatment rooms: 4 for restorative and 3 for hygiene. All rooms are interchangeable depending on the types of services in demand, as all of our lasers, 3-D scanners, and other chairside technologies are mobile. Typically, we treat 10 to 15 restorative patients per day and 10 to 15 hygiene patients per day. We are staffed with 3 chairside assistants, 2 full-time hygienists, and a part-time hygienist/assistant, with 2 front office assistants.


In 2000, I made the decision to add all-tissue and diode lasers to my practice. While there was a learning curve as I adapted to new techniques offered with both types of lasers, efficiencies were gained in simple things and immediately felt within the practice—such as managing soft-tissue more effectively1 with less swelling, while achieving a success rate of approximately 60% injection-free cavity preparations2 (a rate which has only improved to a self-reported 98% as my experience has grown). Our office can best be described as a laser-assisted practice in which nearly every dental procedure has a laser component to it. This includes treatment involving restorations, implants, and periodontal disease to treating denture sore spots for immediate pain relief and faster healing through biostimulation. Whether it was the variety of clinical situations that gave me the incentive to put the lasers to use or the need to provide care to remote patients making a rare trip to the dentist, both the Er,Cr:YSGG all-tissue laser (Waterlase iPlus [BIOLASE]) and soft-tissue diode laser (ezLase and Epic X [BIOLASE]) generated immediate dividends.

CAD/CAM and 3-D Imaging
Our success in clinical lasers led to a growing confidence among the team to incorporate other technologies, so we soon added caries diagnosis lasers (Diagnodent [KaVo] and SoproCare [ACTEON North America]) to detect and treat minimally invasive to small cavities with more efficiency. Laser detection of cavities is far superior to using a probe or explorer,3 and, in the mid-2000s, we turned our laser profits into the practice’s first 3-D cone beam device. We believed that this would aid in diagnosis of disease conditions while also delivering a unique depth of knowledge for the patients being presented with choices for their oral care. It turned out to deliver at a level above and beyond our expectations.

To introduce a digital workflow in our restorative practice, we recently invested in CAD/CAM (E4D [Planmeca; Henry Schein]) and intraoral scanners (TRIOS [3Shape]). Both technologies speed our minimally invasive, laser-created restorations to completion. As with many dental practices diving into the digital restorative workflow, the synchrony of devices with systems and third partners is still somewhat undefined. In addition, there are occasional challenges with the flow of digital information; however, the promise is certainly there.

The following case reports will showcase these procedures with 2 different patients. They represent how dentistry is currently done in my rural practice by utilizing the latest in technologies, products, and techniques to deliver a unique, same-day experience for patients that drive many hours for dental care.

The Bread and Butter Procedure: Managing Moderate Periodontal Disease

Statistics report that approximately half of patients 30 years of age or older have early to moderate periodontal disease.4 With the right tools and training, treating periodontal disease can be a huge value-added procedure to offer in a general practice. Note that any advanced or severe periodontal procedures should be referred to a specialist as needed. Yet, there are systems available for GPs to unlock the potential of more thorough and comprehensive periodontal care.

A 31-year-old female patient presented with a chief complaint of “sore gums.” The patient’s health history was unremarkable and within normal limits (WNL). She stated that she had not been to the dentist for “at least 7 years” and had previously undergone orthodontic treatment. Her oral cancer screening was negative, and her blood pressure and heart rate were also WNL.

When the patient was initially scanned for oral cancer, the fluorescent imaging was captured to accentuate the marginal inflammation (SoproCare [ACTEON])—a helpful tool to show this discovery to the patient (Figure 1). Then, we captured a 3-D CBCT image, as seen in Figure 2, using the Planmeca ProMax 3D (Planmeca; Henry Schein).


Figure 1. Preoperative view showing gingival inflammation in the posterior; additional inflammation was present throughout (not pictured).
Figure 2. Pre-op view using 3-D CBCT imagery; note the generalized horizontal bone loss.
Figure 3. Initial probing showed bleeding and 4.0 to 6.0 mm of generalized horizontal bone loss on the upper posteriors. Figure 4. REPaiR Perio protocol (BIOLASE) using an Er,Cr:YSGG laser was performed for laser intervention and therapy.
Figure 5. Immediate postoperative view.

Next, probing was done and revealed depths of 4.0 to 6.0 mm (generalized) with horizontal bone loss on the upper posteriors and bleeding upon probing (also generalized) (Figure 3). Clinically, there was heavy calculus with moderate plaque, and she admitted that her breath had a distinct odor, which her husband and children had also pointed out to her. A diagnosis of moderate periodontitis was confirmed.

The treatment plan presented to the patient included utilization of the Waterlase iPlus laser and the REPaiR Perio protocol (BIOLASE). The initial step involved completing full-mouth therapeutic scaling and root planing using scalers (Hu-Friedy) and the Cavitron (Dentsply Sirona). The patient was then scheduled for a follow-up appointment at 6 weeks and re-evaluation for REPaiR Perio therapy. At the follow-up appointment, the patient still exhibited signs of moderate periodontitis. The Waterlase iPlus was used to conduct the REPaiR Perio protocol (Figure 4), including de-epithelialization of the gingiva, sulcular debridement and degranulation, and decortication of the osseous tissue to promote healing followed by the final removal of residual debris. Pain control was accomplished with the use of local anesthetic and nitrous oxide-oxygen analgesia.

Clotting was accomplished immediately following the procedure (a common benefit of using laser therapy). The patient also reported no complications or discomfort from the procedure (Figure 5).

The Bread and Butter Case: Bicuspid Root Canal Therapy and Crown Lengthening

One of the advantages of modern dental technology (eg, lasers, CAD/CAM, and endodontics) is that unique challenges can be addressed, often in a single patient visit.

In this case, a 78-year-old female patient, healthy and with no significant medical history, presented with a fractured lower bicuspid with signs and symptoms of irreversible pulpitis (Figures 6 and 7).

First, it was determined that removing the existing amalgam and marginal tooth structure would necessitate adjusting biologic width. The lower bicuspid was prepped, establishing a new restorative margin, and, after sounding for bone, the Waterlase iPlus laser was used at minimal power settings to reestablish biologic width and to adjust the height the osseous tissue to allow for a successful restoration (Figure 8). After biomechanical preparation was completed, the Waterlase iPlus was used to cleanse and disinfect the canal spaces. The flexibility and design of the laser’s radial firing tips have been shown to provide a higher level of cleansing/disinfection than any chemical product and are a must for long-term success of root canal therapy5 (Figure 9).


Figure 6. Pre-op view showing the anticipated restorative margin and imaged tissue, resulting in degradation of the osseous tissue and the clinical indication for crown lengthening. Figure 7. Pre-op lingual view showing impinged tissue on the distal of No. 20.
Figure 8. After the existing restoration was removed, a root canal was performed using WaveOne (Dentsply Sirona). Figure 9. Er,Cr:YSGG laser used to
disinfect and clean the canal space prior to obturation.
Figure 10. A gingival trough is created with minimal bleeding using the Er,Cr:YSGG laser and a radial firing periodontal tip (RFPT8 [BIOLASE]). Figure 11. Final restoration placed.

After canal fillings were placed (Thermafil [Dentsply Sirona Endodontics]) and a post was placed (FlexiPost [Essential Dental Systems]), the tooth was prepared and readied to take the final impression for the final restoration. Gingival retraction was accomplished with the laser specifically using a radial firing periodontal tip (RFPT8 [BIOLASE]) on the laser handpiece) (Figure 10).

We used a digital intraoral scanner (TRIOS) to capture the impression in about 30 seconds. After scanning, the lithium disilicate crown (IPS e.max [Ivoclar Vivadent]) was designed, milled, and tried in (E4D Planfit [Planmeca; Henry Schein]). The crown was then fired in the porcelain oven (Programat CS2 [Ivoclar Vivadent]) before adhesively cemented into place using RelyX Ultimate (3M).

The patient reported no immediate adverse events, and healing and recovery was without incident (Figure 11). Our patient was grateful for the same-day dentistry that we could deliver, having completed multiple procedures with the technology available in our practice.

Even with a host of transformative dynamics affecting our profession, GPs have real opportunities every day (if properly equipped) to overcome the challenges often associated with treating patients who present with a variety of problems in need of solutions. Lasers, 3-D CAD/CAM, and digital intraoral scanning, when properly integrated into every day procedures (such as crown lengthening, gum disease, and endodontics), are just a few of the technologies that can help general dentists grow and flourish.


  1. Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium: yttrium, scandium, gallium, garnet laser on mucocutanous soft tissues. Oral Surg Oral Med Oral Pathol, Oral Radiol Endod. 1996;82(4):386-395.
  2. Poli R, Parker S. Achieving dental analgesia with the erbium chromium yttrium scandium gallium garnet laser (2780 nm): A protocol for painless conservative treatment. Photomed Laser Surg. 2015;33(7):364-371.
  3. El-Housseiny A, Jamjoum H. Evaluation of visual, explorer, and a laser device for detection of early occlusal caries. J Clin Pediatr Dent. 2002;26(1):41-48.
  4. Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
  5. Cheng X, Guan S, Lu H, et al. Evaluation of the bactericidal effect of Nd:YAG, Er:YAG, Er,Cr:YSGG laser radiation, and antimicrobial photodynamic therapy (aPDT) in experimentally infected root canals. Lasers Surg Med. 2012;44(10):824-31.

Dr. Cassis, a 1980 graduate of West Virginia University School of Dentistry, practices general dentistry in Fayetteville, W Va. He has served as chairperson for both the AGD’s Program Approval for Continuing Education Council and the AGD Communications Council and is currently the chairperson for the AGD Membership Council. He also helped in the development and clinical testing of many dental products. He is a member of the AGD, ADA, American Academy of Cosmetic Dentistry, the Dental Organization for Conscious Sedation, the West Virginia Dental Association, and the West Virginia AGD. He can be reached at

Disclosure: Dr. Cassis received an honorarium from BIOLASE, Inc, for writing this article. He occasionally receives paid compensation for teaching continuing education courses sponsored by manufacturers mentioned herein.

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