Lee Ann Brady, DMD 

I’m a big fan of retraction pastes, which are aluminum-based hemostatic agents. Their attributes make them highly effective when I need them, but they are also technique sensitive. 

• They are great for hemostasis within sixty seconds
• For a stringent retraction, you can leave them in place for two to five minutes
• They are so thick and viscous you can see them and easily rinse them off
• They do not cause prep discoloration like liquid hemostatic agents do
• They can interfere with the set of VPS or polyether impression materials but are less likely to do that than the liquids because they are so easily rinsed off

We must still be careful, though, to remove retraction paste from the sulcus. If residue is left behind, the impression material will not fully polymerize around the margin. So, while I love retraction pastes for hemostasis, I don’t use them unless I need them. I still prefer a two-cord technique using plain cord and epinephrine. When I do use a retraction paste, I am extremely methodical about rinsing the paste out of the sulcus. 

By Michael (Mike) Rogers, DDS

Close to my office there is a small strip center that includes a realty group and a small church. At one end, there is no sign to show what it is, but it has a drive-through window. Every day there is a significant line of cars going up to that window. Cars line up waiting their turn, and the line is so long the cars snake through the parking lot, out into the street, with hazard lights flashing. 

I have a friend who loves to create stories about what is going on in strangers’ lives. Why is someone driving so fast? What meal are they going to create with food in a shopping cart? Why are two people arguing?  

Fantasized from some level of observation, my friend has captured what this drive-through is all about. He believes that because the drive-through is adjacent to a church, you can pull up to the window and are given a donut along with a prayer. It’s a small ministry for people to have a better day. That’s not a bad narrative but no real basis for the story. I say that as the line of cars grows longer, the prayers gain power. I get a warm feeling of their impact on others. 

I find we make up stories in my office as well. We make them up about why someone didn’t show up for an appointment, why someone didn’t move forward in care that has been advised, or why someone won’t pay a balance. Our tales are based on some level of observation, but they are tales none the less. 

I try to remember to look at these moments in three ways. 

• What do I know? 
• What do I think I know? 
• What do I want to know? 

We practice this in our office. I encourage my team to not live in “what I think I know.” This state of mind too often leads to creating stories that reflect a judgement. If I hear a team member begin to create a narrative based on a circumstance with the phrase “I think…,” I try to politely make them aware of what they are doing. They most certainly recognize when I do it and politely let me know. I just grin to hide my disappointment in myself. Maybe someday, I’ll say, “thank you.” 

In relationship-based practices, we have such marvelous opportunities to help people be healthier. Asking questions about what we’d like to know and sometimes creating self-discovery for the patient as well. We often get repeated moments to connect and learn with each other. The need to make up stories is dissolved when we get to hear their story. Sometimes that story is fun, other times hard. We get to walk along that story with them. What a gift to live a life in that connection! 

Recently, a member of the realty group on one end of the strip center came in to see me. I couldn’t resist asking what the line of cars is about. It turns out it is an Ignition Interlock site for people that have had a recent DUI. You go up to the window for your installation time of the small handheld breathalyzer to prevent your car from starting after drinking alcohol. 

I haven’t shared that with my friend. I like his story better. 

By Lee Ann Brady, DMD 

When a crown comes off and we are going to put it back in the mouth, we need to remove the old resin cement that is inside the crown. What is the best way to go about this? 

First, we need to know if the crown is made of zirconia or lithium disilicate. If you have a radiograph of that restoration, you can tell immediately which one of those two things it is. If you don’t, you can always attempt to X-ray it. (That’s what I do.) Alternatively, you can assume the crown is made of lithium disilicate, which is the more technique-sensitive material when it comes to removing cement. 

For crowns confirmed to be zirconia, employing 30-micron aluminum oxide air abrasion effectively clears out the old resin cement. Subsequently, re-etching the inside of the zirconia prepares it for reseating. For crowns presumed to be lithium disilicate, this approach should be avoided to prevent crack propagation. 

In the case of lithium disilicate crowns, two alternative methods can be employed: 

1. The crown can be placed in a porcelain oven to liquefy and evaporate the old resin. However, caution must be exercised to avoid rapid heating of the hydrated ceramic that has been in the oral environment. Rapid dehydration will introduce cracks and lead to crown fracturing. 

1. An alternative method involves using a brown silicone point in a high-speed handpiece, adjusted to lowest speed. A brown silicone point at slow speed effectively removes resin without damaging ceramic. 

How will you know when all the resin has been removed? When etching lithium disilicate, whether using red 5% hydrofluoric acid or Monobond Etch & Prime from Ivoclar Vivadent, any remaining resin will be evident because the dye sticks to it after the etching solution is rinsed off.  

By Lee Ann Brady, DMD 

For addressing the access hole of a screw-retained implant crown, my preferred method involves applying Teflon tape over the hole followed by temporary filling material, such as Telio Inlay from Ivoclar Vivadent. 

I emphasize to patients the importance of maintaining accessibility to the screw for potential adjustments without jeopardizing the integrity of the ceramic crown. Hence, immediately after seating the crown, I ensure no adjustments are needed before doing the filling. 

Patients are scheduled for a final post-op appointment with the surgeon after the restoration is in place. If there are no issues requiring crown removal, the Teflon tape and Telio Inlay may remain indefinitely, monitored during hygiene recall appointments. As long as the temporary filling remains intact, replacement is unnecessary. 

In cases where the Telio Inlay dislodges but the Teflon tape remains intact, I inform the patient of our plan to reapply the temporary filling. However, if repeated dislodgment occurs, leading to inconvenience, we consider transitioning to a permanent filling. In such instances, fresh Teflon tape is applied, and the access hole is filled with composite that precisely matches the crown’s color. 

Even if years pass and the Telio Inlay needs replacement, I opt for a temporary filling for ease of identification if removal is necessary. Only if frequent filling replacements prove bothersome do I consider switching to a permanent filling because I prioritize easy retrievability of the screw. 

Caring for a Dental Leaf Gauge 

Lee Ann Brady, DMD 

In the Pankey Essentials courses, we use dental leaf gauges to train dentists in how to feel for the first point of occlusal contact, as a method for occlusal deprogramming, and as a tool for articulating models on an articulator in centric relation. Dental leaf gauges not only assist us in diagnosis and treatment planning but also in enabling our patients to discover the nature of their occlusion as we help them understand how malocclusion can manifest in TMD symptoms, parafunction, tooth damage, and more. 

In our Essentials 1 course, I am sometimes asked how to take care of leaf gauges, so I thought I would share my answer.  

Although they don’t last forever, dental leaf gauges do last a long time and you can autoclave them between uses. When you sterilize them, the leaves become sticky, so I separate them like a hand of cards before putting the gauge in the autoclave bag and separate them again when I take them out of the bag just before going to the mouth. 

Over time, with use, a leaf gauge will start to look a little beat up. I’m looking at one now. The Teflon screw that holds it together has turned color from going through the autoclave. I can see some ink stains from Madame Butterfly silk. It’s at the point where I think it looks too grungy to keep using. Although it might continue functioning for quite some time, I’m going to toss it and use a new one. After all, they are relatively low cost with a high return on investment.  

I’ve never seen a dental leaf gauge break after many trips through the autoclave. I tested cold sterilizing one and discovered the chemistry in the ultrasonic cleaner started to make the leaves brittle and they came out stickier than when autoclaved. So, my preference (and the protocol in my practice) is to bag them and put them through the autoclave. 

In recent years, dentists, physicians, and the public have become highly aware of the interrelationships among occlusion, oral inflammation, airway problems, and systemic health. As dentists, we’ve stretched our care domain to coordinate patient care across all settings of care. Often, we are dismayed at the growing prevalence of chronic diseases among our aging patients. We want to help improve their lives. We know of ways to do this.

To do our best for our patients, it does matter if the patient has diabetes, cardiovascular disease, sleep apnea, gastric reflux, or poor nutrition. It does matter if we want to be master problem solvers in collaboration with our medical colleagues. Looking for oral and systemic health interrelationships every day with every patient is a basic element of many dental practices. Collaboration with physicians is a basic element of my practice.

Has your approach to patient care extended into at least the first phase of integrative dental medicine? This is the phase of sincerely asking the Why questions and searching for solutions. While I was in practice with Dr. Pete Dawson, for 40 years, I heard him say, “We’re going to ask why about problems until we don’t have to ask why anymore.” He called this “finding a better way.”

The 3 Pillars of Integrative Dental Medicine

In 2019, Dr. Shanley Lestini and I published a book titled The Shift: The Dramatic Movement Toward Health Centered Dentistry. In this endeavor, we were fortunate to have the support and input of two of the world’s most preeminent clinicians and educators, Dr. Peter E. Dawson and Dr. Bradly Bale. It was our goal to influence dentists and medical physicians toward fostering solutions together for their mutual patients in three pillar areas of integrative dental medicine:

1. TMD and Occlusion
2. Inflammation & Infection
3. Breathing and Sleep Disorders

Finding a Better Way Is Up to All of Us

My goal in this essay is to fuel your passion for operationalizing what we all know will make us better doctors – that which will enable us to be truly health-centered dentists. It comes down to relentless curiosity about the causes of diseases, the modalities for eliminating those causes, and how our best “individualized” efforts with a patient will have the greatest positive impact on the prevention, elimination, and management of health conditions that adversely affect their quality of life.

“We’re going to ask why about problems until we don’t have to ask why anymore.” – Peter E. Dawson, DDS

In this era of heightened awareness surrounding the intricate connections between oral health, overall wellness, and the growing prevalence of chronic diseases, we, as healthcare providers, find ourselves at a crossroads. It is our commitment to improve the lives of our patients that propels us forward. Embracing the principles of Integrative Dental Medicine (IDM) beckons us to explore the “Why” questions and seek innovative solutions. Don’t miss your chance to embark on a journey that redefines the boundaries of healthcare with the upcoming course “Integrative Dental Medicine: Creating Healthier Patients & Practices” – for more information visit the course page.

Give patients opportunities to discover what lies beneath their smile

Ewelina is part of my office team. She’s from Poland. She’s beautiful but early in our doctor-patient relationship, I realized she had a closed-smile grin. One day, I asked her if she was aware that she was guarding her smile. She wasn’t but the question made her curious. Later, she came by and said, “I realize it now.”

So, I raised another question, “Now that you notice this, what do you think about your teeth? Were you guarding them subconsciously?”

She thought momentarily and said, “I wasn’t happy with their appearance. I think I unconsciously I do guard my smile.”

So, I raised one more question, “At what point in your life did you say to yourself, I wish my teeth were more attractive?”

Her answer surprised me: “I thought about it when I got married and bleached them, and after I had kids, I thought my teeth looked more unattractive than they did years ago.”

I spoke to Laura Harkin, a dentist I admire, about this. She said that it’s common for women to become more critical of their appearance after having children. Their bodies have gone through so many changes. Ewelina seemed to guard her smile long before she had children so I wondered if there may be cultural differences between her old and new adopted home. I asked her if she became more self-conscious about her teeth after coming to the United States. She answered in the affirmative, “People’s teeth generally look better here than in Poland.”

I loved that there was a long thoughtful pause before her answer. I intentionally gave her time to think between questions. I offered to give her a smile makeover, which she readily agreed to. In doing my case workup, we found she had a two-step occlusion that needed to be corrected. When I got to my wax-up, the anterior changes were minimal and I did an equilibration on the wax-up to try out the results. This set the stage for the changes we would try out in provisional.

Provisional restorations are something I always do to test if the speech will be affected, whether the new occlusion is comfortable, and if the patient feels “good” psychologically about all the changes — not just the aesthetics.

While wearing the provisionals, she began to smile with a Duchenne smile. In photos, I could see a postural difference, too.

My ceramist did an amazing job duplicating in ceramic the provisionals that I created. When the case was completed, I asked Ewelina how she felt. She said, “Great, happy, healthier, cleaner, brighter, very happy.” Cleaner, brighter, healthier, happy – that was a huge learning moment for me! Not once did she mention her teeth, just the feelings around her treatment outcome. It began to dawn on me how much we not only change teeth, but we can change lives!

“I’m happy,” she said. “I think I smile more and I feel like they’re my natural teeth. It’s hard to explain, but I feel like these are the teeth I’ve had all along.”

“How does your bite feel?” I asked. “Were you surprised how the small adjustments made big differences?”

“Before, I felt a little muscle soreness and dull pain back here, but after a day or two of the adjustment, I felt nothing. I feel great,” she said with a big, broad smile.

I think if we spend a lot of time with our patients and develop relationships, it’s ideally like psychological therapy. We give patients opportunities to discover what lies beneath their smile, show them a vision of what could be, and lastly, help them to reach their full potential, as described in Part 1, with a beautiful, confident Duchenne smile.

We have a unique opportunity to not only restore teeth but also change lives through our efforts.

Wax-ups are essential for my aesthetic case designs

Part 2 was originally presented to the Restorative Nation in February of 2023: It’s All In The Smile: Psychologic & Technical Considerations – Restorative Nation

My esthetic evaluation is similar to the curriculum taught in the Pankey Institute Essentials and Aesthetic Focus courses. I generally like to look at every aspect of a patient’s smile through photography, with emphasis on the following:

1. Facial Height – To evaluate possible skeletal defects that can lead to a smile not appearing attractive, I measure the middle 1/3 of the face and the lower 1/3 portion of the face. If there is a one-to-one (1:1) ratio, then I can essentially rule out either vertical maxillary excess or loss of vertical dimension. If there is a one to greater than one (1:>1) ratio, I can look at vertical maxillary excess. If there is a one to less than one (1:<1) ratio, I can look for extreme wear and loss of vertical dimension.
2. Lip Length — The average woman’s lip is 20 to 22 millimeters in height, and the male’s is 22 to 24 millimeters. Our lips, like everything else sag over time. We lose a mm of tooth display after age 41 at a rate of about one more millimeter per decade.
3. Lip Mobility — How high does the lip rise when the patient smiles? The average amount of lip mobility is between six and eight millimeters. A hypermobile lip can give the “gummy smile” and fool us into thinking that there is a vertical maxillary excess
4. Upper Lip Drape — Generally, we like the lip to fall at the free gingival margins of the canines and the central incisors.
5. Lower Incisal Edges –We like the lower lip to cradle the lower teeth with the line formed by incisal edges following the shape of the lower lip.
6. Gingival Heights — We like our gingival heights to be symmetrical. I like canines even, the centrals even with the canines, and the laterals a little lower.
7. Central Incisor Length and Width — The average central incisor is about 10 to 11 millimeters in length, and the average width of a central incisor is about 75% of the length.
8. Other Anterior Teeth Length and Width — The rule of Golden Proportions says that a central incisor should be proportional to a lateral incisor by a factor of 0.6, and the canine should be proportional to the lateral by a factor of 0.6.
9. I photograph the patient in repose, their “regular” smile, and then their “biggest E” smile in order to get a sense of how they look when they present with the Duchenne smile. Patients often will give you some form of a guarded or half smile on photographs and that presentation can be misleading. We need to see their full tooth and tissue display to properly evaluate esthetics.

Once I have had a chance to evaluate the virtual patient via photos, printed study models mounted on articulators, and radiographs, I can then propose esthetic changes. I am a huge proponent of fabricating my own “working wax-up” as I like to call it. It is not presentation quality and can be made from wax or old composite. The importance is that it previews the changes that I am proposing, and I use those workups to either make a silicone index for provisionals or I send them to the lab for cleanup and completion. I always keep an original mounted study cast and then have a second model that I play with.

I always start my working wax-ups by placing upper incisors exactly where I want them in the most esthetic position, then I make the rest of the anterior teeth proportional to those incisors. Once the upper anterior teeth are in optimal position, I’ll place or wax the lower teeth to be parallel to the upper and in contact with the upper lingual surfaces of the anterior teeth. In E4 we teach all of the above concepts and discuss how vertical dimension can be evaluated and altered appropriately with the anterior esthetic evaluation. We then look at developing the axial inclination of teeth and posterior occlusal planes to be in harmony with the anteriors.

I encourage all dentists to practice with “working wax-ups.” It truly shows the patient our expertise and artistry in action not just what the laboratory fabricates for us.

Want to see some of the more complex cases I have done? I invite you to view the Restorative Nation video linked above.

Smile behavior is influenced by the individual’s feelings about their smile.

Smiles are an integral part of human communication. They make us appear more attractive, approachable, happy, agreeable, and attentive. Studies have shown that people who are happy with their smiles are more confident, have a greater sense of well-being, and this is also reflected in their behavior. In one study, subjects were shown photos of people with nice smiles. The subjects deemed these people as being more socially competent, with greater intellectual achievement and better psychological adjustment. These smiles are contagious and It’s easy to reciprocate when someone gives you that “genuine smile.” We’ve all seen this smile, but what makes it genuine?

There are a variety of smiles that reflect a wide array of emotions. From flirtatious to embarrassed, our smiles reflect our mood and communicate our thoughts. Or do they? When people are unhappy with the appearance of their smile they present a variety of guarding. There’s upper lip guarding, lower lip guarding, both lips guarding, covering one’s mouth with a hand, and of course close lip grins.

As dentists, we must be able to spend time with our patients, to see those smiles, and to delve into why a patient may be guarding. In a sense, we must become esthetic psychologists. It is not an overstatement to say that as dentists, we don’t just change teeth; we can change lives. We can shape how others see our patients. If a patient cannot give a genuine unencumbered smile, perhaps, they’ll miss an employment opportunity or meeting that special someone. Perhaps they’ll be seen by others as unfriendly or unapproachable.

So, is there a “genuine smile” that can be quantified? In the 1800s, a French anatomist by the name of Guillaume Duchenne sought to answer that question. Duchenne, through stimulating facial muscles, found that the most genuine, sincere smile occurred when 3 muscle groups fired: the orbicularis oris and zygomaticus major in the mouth and the orbicularis oculi of the eye forming crows’ feet.

Most consider the resulting Duchenne smile to be the genuine smile that is spontaneous and sincere. Studies have shown that this type of smile can elevate mood, change body stress response, and is responsible for the release of endorphins, dopamine, and serotonin. In all, the Duchenne smile is the Holy Grail. It is certainly about the smile but a major component is the formation of crows’ feet around the eyes. Just think of the song When Irish Eyes Are Smiling. The Duchenne smile in all its splendor is sure to steal your heart away. My point is that we need to remember that the Duchenne smile is about the mouth AND the eyes; these elements are interconnected.

What we’ll need to evaluate as Dentists is whether Botox injections and plastic surgery affect the Duchenne smile. Certainly, in the case of the Botox smile, the answer is yes since the elevator muscles of the mouth are injected thus altering the Duchenne muscle contractions. Obviously, it is vital then to take a good health history and determine whether a patient is smile guarding or simply cannot fire the muscles that make up the Duchenne smile.

In making dental changes, we change lives. We shape how others see our patients and how they see themselves. This is priceless work. It is worthy work. But until a patient desires the best results that today’s dentistry can achieve and trusts us to execute the technical aspects of their new smile, we are in listening, understanding, and guidance mode. We are leading them forward with primary, essential care and taking them on a long journey to achieve what is possible. With each new dental restoration, they may smile more broadly and lift their head higher. They will feel the release of endorphins and serotonins. They will experience the positivity of greater self-confidence.

Artful comprehensive dentists are like behavioral psychologists who have the sincere intention of doing their utmost for the benefit of their patients.

You know what greater smile benefits are possible if the patient understands and wants to continue with aesthetic treatment. Patience is a virtue. So, spark the curiosity of your patients and lead gently but with confidence. Never forget that a patient who is concerned about the cost of elective treatment today will be thanking you profusely two to three years from now and saying the decision to move forward with a comprehensive smile makeover was one of the best decisions of their life.

When I first came out of dental school, palate expansion with an orthodontic device was limited to children and young adolescents. We thought the palatal suture was closed and fused, and we could no longer use a fixed orthodontic device to change the shape of the maxillary arch and expand the palate. Today we know that we can do palate expansion for patients who are older, and we have the additional ability to do surgically facilitated orthodontic treatment.

Why is this important?

Because today we understand how the shape of the maxillary palate, the shape of the arch form, and the ability to put the tongue solidly against the roof of the mouth have a positive impact on eliminating apnea, hypopnea, and breathing issues.

At what age is palatal expansion with an orthodontic device no longer effective?

I asked this question to two board-certified orthodontists whom I respect. And interestingly, I got the exact same answer. They both said that until age 35 we can get palatable expansion with a fixed orthodontic device. And after age 35, it may work but it becomes unpredictable. The older a patient is beyond their mid-thirties, the less predictable the results are. The patient must understand this when they accept treatment.

When I inquired if they had attempted palatal expansion on a patient over 35, both orthodontists said they had done so with good results, but treatment is slower and thus takes longer. They explain to patients that they can try surgically facilitated ortho with a palate expander, and if it doesn’t work, there is a pure surgical solution. The patient can choose to skip over the orthodontic device and go straight to the surgical solution. They fully inform the patient about the options, and the risks and benefits of treatment. They’ve had adults over 35 choose to proceed with treatment.

Up until age 35, palate expansion with an orthodontic device is predictable and a treatment we can confidently recommend. There are alternative treatments for adults over age 35.

Can Invisalign or other aligners expand the palate?

Aligners do not expand the palate. They can, however, widen the arch and alveolar bone by 1 to 2 mm. Putting this in perspective, this is a widening of less than a tenth of an inch (about 0.08 in). Aligner treatment can be used to reposition the teeth to make more space for the tongue to press solidly or more solidly against the roof of the mouth. For many adult patients, this is a treatment modality that improves their airway.

The goals of palate expansion with an orthodontic palate expander or pure surgery are to achieve greater than 1 to 2 mm of expansion.

At the Pankey Institute

Comprehensive dentistry that addresses the airway and breathing is a common topic of conversation among dentists who participate in Pankey courses. We welcome these conversations. Because every patient presents with a complex of factors, I advocate for a holistic approach to looking at underlying causes of apnea, hypopnea, and breathing issues.

At Pankey, we have a very in-depth Essentials Series that cover an array of important dentistry topics. During our Essentials 1 course, we include a special Airway Management section for dentists to practice on a regular basis. Check out our upcoming course dates here.

Here are four Pankey Webinars you may want to view to develop your understanding of the importance of the airway in the patient’s total health and what dentists are doing to integrate airway support in their practice. It’s exciting to see the expertise that has developed among our faculty and participants. Some have developed into niche providers to better serve the needs of their communities.

1. The Goals of New Orthodontics: How Airway Thinking is Impacting Dentistry
2. Breathing and Airway Support
3. Open the Airway Tonight and Other Tips from the Dental Sleep World
4. Airway Centric Dentistry