When I bought my dental practice in Glendale, Arizona, eight years ago, they were offering patients a choice of flavors for topical anesthetic. I truthfully thought it was silly and that we would stop doing it. With experience, however, I came to realize that giving a choice was valuable for both patients and team members. Today we are still offering a choice of flavors.

When a patient is seated, the dental assistant will say, “As you know, as part of the process for getting you numb, we will be using a topical anesthetic. We have five flavors and you get to tell me which flavor you would like to use today.”

It is really interesting to listen to the dialog, but also to realize what is happening for the patient. The choice gives the patient an opportunity to settle into a conversation and something to focus on other than that they will be getting an injection and the logistics of that.

The process almost creates a fun, quirky conversation, as the patient thinks about the choices. Sometimes patients say, “You choose, and I’ll guess which one it is. Let’s see if it really tastes like that.” When patients pose themselves this challenge, the whole time I am giving the injection, they are trying to figure out which flavor of topical we have used.

Sometimes patients ask, “Which flavor is your favorite?” or “What do other patients like most?” In this case, we talk about it.

We have the mint flavors everyone else has but we also rotate in cherry, strawberry, bubble gum and pina colada. In summer, we offer watermelon. At any one time, we typically have five flavors and they vary throughout the year. A patient who has come in a few times, may even start the conversation with, “Do you have any new flavors for me to try today?”

One of my favorite conversations is whether the pina colada actually has rum in it and how funny it would be if we could just use the rum. An ice-breaker conversation such as this is a great way for us to ease the tension at the front end of an appointment that will require anesthetic. It truly adds an element of fun that has become for us a practice distinguisher.

It can be very frustrating to take a series of dental photos only to realize there were scratches or watermarks on the mirrors when you review the images later on a computer. Cleaning mirrors without damaging them can be a challenge.

I happen to like the [chromium or titanium] coated buccal, lingual, occlusal and anterior contact Intraoral Handle Mirrors from PhotoMed®. These feature a stainless steel handle that keeps fingertips out of the photograph. And, if your patient is cooperative, they can hold the mirror to free up your assistant. All of the handle mirrors from PhotoMed are single-sided, autoclavable, and can be cold sterilized.

In my practice, we try to protect our mirrors as much as possible from scratches, because once they happen, there is nothing you can do about it. Watermarks, on the other hand, can be eliminated and also cleaned away.

To avoid watermarks, we always wrap our mirrors in a paper towel before putting them in the autoclave bag. To clean away fingerprints and water spots, we use premoistened lens cleaning wipes that are designed for cleaning eyeglasses. They can be purchased in bulk, and we find them economical, efficient, and effective in cleaning our intraoral mirrors for crisp intraoral photo images. We keep a box in every operatory, where they do double duty in cleaning our eyeglasses and loupes.

Most dentists have some stories about buying and trying different types of face shields as we have started to practice again. The challenges of fit, being comfortable and working with loupes are common conversations. I have tried six types to date with more on the way.

I started with “What can we get?” Then I moved on to “What will be the most comfortable and best on our loupes?”

I and my two hygienists wear loupes. I wear a 4.0x power, flip-up loupe. The hygienists wear 1.5x power loupes. In addition to the loupes, we wear a light.

We’ve tried face shields that hang from a visor. This is the kind my assistants love and wear all the time. However, this type of shield does not fit over my loupe. It fits over my hygienists’ loupes but by the end of the day, they have a headache from the pressure of the temple pieces on the visor.

We tried the disposable face shields that hang from a headband with foam padding. They did not fit over loupes.

A third type from Bio-Mask® turned out to be my hygienists’ favorite and the one I wear when I am doing a consult and not wearing my loupe. This type of visor frame has replaceable face shields. It is lightweight and comfortable (due to its weight, adjustable head strap, and foam padding), and it is designed to be worn with loupes. The replaceable shields can be washed with hot soapy water. The shields are designed to protect from splatter and spray that might come over the top of the visor, so you have full-face protection. I can wear it over my loupe by enlarging the headband and resting the front of the visor frame on my light.

Just recently I came across a different face shield designed to wear over dental loupes that I really like. It’s the PRO-TEX® extra-wide 13″x 7″ shield (model FSX). It clips directly onto the frame of my loupe. I wear eyeglasses, a face mask, my loupe with a light, and then clip the face shield to my loupe frame. This is the least pressure on my ears and temples that I have discovered. The shield can be washed between patients with warm soapy water.

I know a lot of people are praising loupe face shields from Ultra Light Optics®. I am looking forward to trying these when they come in because they are designed so you can mount your light outside the shield and not have to reach under the mask to flip down your light.

In light of today’s heightened need to reduce aerosol viruses, weighing the benefit of using a rubber dam may outweigh the challenges of using one. But I have found a barrier solution that is easy to use, highly efficient for isolation and reduction of aerosols, and more patient-friendly. It is actually a rubber dam replacement called OptraDam® Plus from Ivoclar Vivadent.

For some time now it has been part of my restorative toolkit, because the isolation improves restorative outcomes and, once again…it is efficient, easy to use, and patient-friendly. I call it “the friendlier version of a rubber dam.”

OptraDam® Plus comes prepacked in two sizes, regular and small. It has a figure 8 OptraGate for holding the lips out of the way and has a solid rubber dam back that is pre-marked for where to punch the holes. It is easy to insert and more comfortable in place. Because it does not require a lot of retention, I can use it without a clamp. This means I do not have to deliver palatal anesthesia on the maxillary or long buccal anesthesia on the mandibular. This is much kinder and gentler for the patient. It does not come in a Latex-free version, but it is a barrier solution you may want to consider.

SpeedCEM Plus is a dual-cure self-adhesive resin cement from Ivoclar that has been designed to be used with restorations that have inherent mechanical retention. It can be used for most materials – all-metal restorations, zirconia oxide ceramics, or something in the lithium disilicate category. The material will fully pull MRIs on its own, but it can also be light-cured. It has great esthetics, low technique sensitivity from the standpoint of using the material, and great bond strength. It is easily cleaned up. 

Prepping the Internal Surface of the Restoration 

Oxide-based ceramic restorations are etched with air abrasion. Your laboratory can do this, or you can use between 30 and 50-micron aluminum oxide to air abrade the intaglio of the restoration. Confirm with your lab if they are going to be doing this. 

The internal surface of lithium disilicate based restorations is etched using chemistry. You can use hydrochloric acid at 5% for no more than 20 seconds, or you can use an Ivoclar Vivadent product called Monobond Etch & Prime for 60 seconds.  

If you try in the restoration after it has been etched, as I like to do, then the restoration will need to be cleaned again before it is bonded. For this cleaning purpose, I use Ivoclar Vivadent’s Ivoclean. It’s a phosphate-free restorative cleaning material that can be used on metal, oxide-based ceramic materials, and on lithium disilicate materials. I simply vigorously shake the bottle and apply Ivoclean for 20 to 30 seconds, rinse the restoration and dry it. I recommend using a clean air source for drying such as an Adec airline on your unit. 

If you are going to use metal ceramics or lithium disilicate, you now need to condition the inside of the restorative material. I use the product Monobond Plus, which is appropriate for all kinds of materials.  

If you are working with zirconia or an oxide-based ceramic, one of the advantages of SpeedCEM Plus is you do not have to do anything to the inside of the restoration other than the air abrasion and cleaning because the chemistry in the SpeedCEM Plus will prime or condition the inside of the zirconia restoration.  

Prepping the Prepared Tooth 

With SpeedCEM Plus, we do not need to do anything to the tooth prior to cementation other than cleaning the tooth. I like to clean the prepared tooth with light air abrasion and apply a 2% chlorhexidine solution to the prep and clean the tooth with a bristle brush in a slow-speed handpiece. 

SpeedCEM Plus Application & Cure 

After cleaning the prep, you can load the restoration with SpeedCEM Plus and seat the restoration. SpeedCEM Plus comes with a mixing tip through which you express the adhesive.  

You now have two choices. You can hold the restoration in place with firm pressure and allow it to go to its self-cure mode which intraorally takes approximately 3 minutes. Alternatively, you can use your curing light to speed up the process.  

After I seat the restoration, I like to check the margins with an explore to make sure I have not had a mis-seat and then I pick up my curing light and, at a distance of 1 to 10 mm, I cure for one second at each line angle. We call this the quarter technique… mesial buccal one second, distal buccal one second, mesial lingual one second and distal lingual one second. I can now quickly go in and clean up all excess cement, making sure I get excess cement out of the interproximals. It’s important to cure on the line angles, not just buccal and lingual, or you will leave a lot of material that doesn’t reach the gel phase interproximally.     

Once all the excess material is cleaned off, I cover all of the margins with an oxygen barrier, and I do a 20-second cure on each of the four line angles using the quarter technique. The patient is good to go once you check the occlusion. 

Notes 

• SpeedCEM Plus comes in three shades 
• It is designed to be capped in the refrigerator. Never remove the used mixing tip and put a new empty tip on as this would leave the base and catalyst at the ends of the barrel exposed to air. You can either replace the used mixing tip with the original manufacturer’s cap or leave the used mixing tip on and disinfect it just like you wipe your light-curing unit. I recommend you do the latter, as it decreases the risk of contaminating the resin and initiating the self-cure process in the barrel. 
• Because the material is so versatile, you also can use it for placing your posts. 

It used to be a challenge for me to help patients who came in with recurrent aphthous ulcers, lichen planus or erosive lichen planus, burning mouth, burning tongue, or geographic tongue that was uncomfortable. I’d worry about the pharmaceutical reactions of prescription options such as prednisone, steroid mouth rinses, and lidocaine rinses. Now, that challenge is greatly reduced due to the success we have had treating these problems with nonprescription topical antioxidants. 

There is a group of nonprescription topical antioxidant products that I rely on weekly from PerioSciences. These products not only promote healing but also provide significant relief from soft tissue pain, xerostomia, and burning sensations in the mouth. This is PerioSciences’ AO ProVantage line of mouthwashes, gel, and toothpaste. They are without a doubt the best products I have come across in my career for oral medicine applications. They were developed by dental scientists and other researchers and contain two antioxidants from the skin of apples. The products are marketed to help with a number of things in addition to oral wound healing, for example, to treat superficial gingivitis and to maintain patients who are at advanced risk of perio inflammation.  

In my practice, I have two patients who have chronic erosive lichen planus. We discovered that the application of the AO ProVantage gel to a lesion, four or more times a day, allows the body to heal the lesion. Within three to four weeks, the lesion is gone completely. After lesions are gone, my patients stop using the gel and start using AO ProRinse three to four times a day to prevent the outbreak of another erosive lesion. If they get another lesion, they go back to using the gel. The mouth rinse has reduced the number of outbreaks for these patients, and having these products on hand, has allowed my patients to successfully manage outbreaks on their own. 

I have lots of older patients who suffer with burning mouth or burning tongue. AO ProRinse mouth rinses have worked well for them. Some of my patients have severe dry mouth in association with the burning—some with Sjogren’s syndrome, some with Lupus disease. We start them on the hydrating formula of AO ProRinse, and they rinse their mouths four to six times a day with remarkable results. It’s also been of great value to my patients going through chemotherapy to keep their mouths hydrated and comfortable.  

The PerioSciences products are nonprescription and now readily available via Amazon. Once introduced to the products and given guidance, my patients have found it easy to determine when to start using the products and how often to use them. Topical antioxidants are just one more example of industry breakthroughs I am grateful to have in my clinical toolkit and widely available to patients.  

LuxaCrown is a new material that was released by DMG America last year. LuxaCrown is a dual cure composite material that comes in a convenient chair-side cartridge. Because it has the physical properties of composite, it is much stronger and longer lasting than bisacryl provisional material. The manufacturer says it can last in the oral environment up to five years, maybe longer. It is stain–resistant and color stable, so you can leave it in the mouth for long periods without concern that the color will change. I though it would be helpful to share the situations in which I now use LuxaCrown instead of a bisacryl material for provisionals. 

Multi-Unit Restorations 

In my own practice, I don’t use LuxaCrown for single crown preps where the provisional will be in the mouth for a couple of weeks, perhaps a month, or a little more. But, the strength of LuxaCrown and the color stability of this new composite material make it what I consider to be an incredible new clinical tool in my practice to provisionalize multiple units where there is pontic space. With LuxaCrown, I no longer need to reinforce the pontic with Ribbond or orthodontic wire. I don’t have to do anything to make sure we don’t get fracture at the connectors, because the material is strong enough and durable enough it to hold up, even long term.  

Anterior Veneers 

The other situation in which I use LuxaCrown routinely is with my shrink wrapped provisionals for anterior veneers. The strength of the material makes it more durable in a partial coverage anterior setting. And the color stability is appealing because the veneer may be in provisional for two months or three months, depending on how long it takes us to get patient approved provisionals for shape and contour that the patient really loves. Not having to worry about the color changing over time has been a huge bonus.  

Anterior Onlays 

Another situation in which I am using LuxaCrown is for partial coverage onlays in the posterior. So often we experience bisacryl onlay provisionals popping off the teeth, but LuxaCrown provisionals stay where you put them.    

Phased Dentistry 

And, I use LuxaCrown whenever I am phasing dentistry…when I am doing what I call “interim restorations” and the provisional restorations will be in the mouth multiple months before the patient receives ceramic restorations. Perhaps, the patient will be in provisionals six to 24 months while they go through orthodontics and we do final restorations in quadrants or even sextants of the mouth. Patients don’t mind having LuxaCrown in their mouths for long periods, because in addition to its stability, it polishes pristinely smooth and is glossy.   

All restorative materials have wear properties. We need to understand both how they wear and survive in the oral environment and how they impact opposing natural teeth.  

The wear of enamel is the basis for comparison.

Despite what we sometimes see clinically, enamel is highly resistant to wear (attrition and abrasion), with average annual wear rates of 30-40 microns. The range is from as low as 15 microns to as high as 100+ microns, and there is variability depending on the tooth position in the arch.  

Unlike enamel, which basically all has the same structure and properties, composites come in many different formulas. The chemical and physical properties of the material have a direct impact on its wear resistance and impact on other teeth. Some examples of this include: 

• Size, shape, and hardness of filler particles 
• Quality of the bond between filler particles and polymer matrix 
• Polymerization dynamics of the polymer 

These same properties affect the other physical and handling properties of the material and have to be balanced to create a composite that works clinically.  

Creating improvements in the physical properties of composites has eliminated the high degree of wear in non-contact areas we witnessed years ago. The loss of restorative material gave the appearance of fillings losing their shape and contour. Today our primary concern is in areas of direct occlusal contact.  

One approach might be to avoid using composite that has direct occlusal contact.

I would say this is not only not practical but not necessary. We have a variety of materials available today, with a range of handling and physical properties, and wear rates that are between 30-200 microns a year.  

We need to choose a composite based on things like wear versus polish–ability, anterior versus posterior, and the properties of the particular material we are using. In addition, we can manage the occlusion to maximize the success of the natural teeth as well as the composite. 

Both dentin and enamel can be worn down at a more than normal pace when exposed to very abrasive toothpastes.

We have learned that this damage is not being caused by the toothbrush, but the material being put on the toothbrush. As the desire to have whiter and whiter teeth has become popular, manufacturers have increased the abrasiveness of toothpaste to more effectively remove the external stains. In addition, tarter control and other newer versions of toothpaste designed to grab market share of consumers can also tend to be more abrasive. 

Ideally, we would like to be brushing with a material that has an RDA (relative dentin abrasiveness) of less than 80, but the FDA allows toothpaste to be sold with an RDA up to 200. The original Colgate toothpaste has an RDA in the 70’s. Most Sensodyne have RDA’s below 85, but several of the 2 & 1 tarter control and whitening have an RDA close to the maximum of 200. The abrasiveness can damage restorations, increase wear of exposed dentin and exacerbate sensitivity. At my Scottsdale, AZ practice, we keep a list of the most common toothpastes with their RDA, so we can discuss this with our patients. 

Prophy paste, even the fine, is generally more abrasive then over the counter toothpastes.

In addition, it is applied using a prophy cup going at 20,000 rpm’s with much more pressure. Even though the incidence is much less frequent, being 2 to 4 times per year instead of every day, this can still be a significant issue. 

A cool little experiment is to take some microscope slides and using your fingers rub prophy paste around on them and then rinse. Look at the slides with light behind them. You’ll be surprised to see a slide is scratched after just one application. This is the same thing that will happen to ceramic restorations. The glaze will be easily scratched. The surface of the crown or veneer will begin to deteriorate. 

Similarly, abrasive prophy paste will increase a patient’s sensitivity if used on exposed roots, accelerate the wear on exposed dentin or cementum, and can damage other restorative materials. The RDA of prophy paste can range from 150 for fine to up over 300 for coarse. Alternatives are to use products like Clinpro 5000 or MI Paste as a prophy product, both of which are low in abrasiveness. In my office, we use a product called Proxyt, from Ivoclar. It is a non-abrasive prophy product and is available in 3 grits and with and without fluoride. All three of the varieties have RDA’s between 7-83 and are safe to use on dentin, cementum, and ceramic. 

Sleep issues and sleep apnea is a very serious concern today for our patients’ health. I have been giving patients an Epworth sleepiness self-assessment for several years. It is a great way to find out if patients should pursue their sleep with a physician and inquire about having a sleep study.

Another incredible indicator of apnea is if someone else hears you stop breathing. Of course, there are challenges with this approach. First, there has to be someone near you when you sleep to hear what is happening. Second, someone has to be awake in order to listen and watch while you are sleeping. Third, someone has to interpret what is happening. I recommend the SnoreLab app that records and evaluates the sounds made while sleeping. It can even show you graphs of what was happening. Not only is this a great self-learning tool, but the recordings can be taken to the doctor as part of the information to determine if a sleep study is indicated. The product is available on the web and through the App Store.

Several of my patients have used the SnoreLab app and had follow-up studies in a sleep lab. Within my Glendale, AZ practice, I have a Dental Sleep Medicine practice and treat patients with sleep apnea appliances.

To serve patients to the best of their ability, I recommend general dentists learn how to competently develop a Sleep Dental Medicine niche within their practice. I can honestly and wholeheartedly say that The Pankey Institute’s 5-day immersion Dental Sleep Medicine course is one of the best programs in the nation. It is uniquely designed to give dentists the experience of being a sleep apnea patient themselves.