By Lee Ann Brady 

Many dentists warm composite by placing it on top of the operatory light, but I wonder what the patient is thinking when you reach for it on top of the light.  

Some dentists have water heated in one of the green bowls from the lab. I wouldn’t do that either because I wouldn’t know the precise temperature and water intrusion could occur into the composite syringe or compule. 

Composite warmers are not a big expense in a dental practice. I have one in every one of our operatories. The warmers come with two interchangeable top pieces. One is designed for syringes, and one is designed for compules. They warm composite to a specific temperature. 

When you heat composite, there’s no permanent change to the chemistry. As composite is warmed, its viscosity is reduced but as soon as the composite cools, it goes right back to its original viscosity. Studies show that the reduction in viscosity results in better marginal adaptation because it is more flowable, softer for sculpting, and much easier for us to push it against the margins. We also get a greater depth of cure because composite polymerizes more effectively at reduced viscosity. This reduces the shrinkage of the material and increases the longevity of our restorations.  

Note: If you leave a composite warmer on with composite in it for days on end, the warming will evaporate some of monomer and the composite will become brittle and crumbly. So, have your assistant load the composite you plan to use for the day at the beginning of the day or at the beginning of the appointment. You can turn the warmer on when you are delivering anesthetic, and it will be warm when you are ready to use it. We’ve developed the habit of turning off the warmer at the end of each appointment. 

By Stephen K. Malone, DMD and Michael Costa, DDS, MHS 

We all know that the instrumentation options for dental hygiene services have come a long way since the first dental hygienist scaled teeth in 1906.   Early in the 20th century, the only technology a hygienist had was a set of sharp metal instruments and a spinning brush of gritty pumice. In the 1950s, ultrasonic technology was invented which helped disrupt calculus, but hygienists still had to follow up with scalers and polishers. Similarly, since the days of first scientific articles regarding oral micro-organisms in the 1870’s, our knowledge has increased exponentially regarding the role of oral biofilm not only in oral diseases, but whole-body health.   

In 2021 our office staff attended continuing education courses with legendary periodontist, Dr. Sam Low. Dr. Low introduced our practice to new technology that would help elevate our hygiene practice by improving biofilm removal, increasing patient ownership of personal oral hygiene practices, decreasing damage to root surfaces and restorations, and providing a gentler patient experience.   

The instrumentation is provided though a unit called a Prophylaxis Master – which is a combination of two different treatment modalities.  The hygienist first uses the Airflow unit to remove soft biofilm and young calculus.  The airflow handpiece delivers a combination of water, air and fine erythritol powder to lift and suction away the biofilm as well as stains.  Once the biofilm, young calculus and surface stains are removed, the hygienist moves to the integrated Piezo scaler to gently emulsify the remaining calculus. There are several different tips for both units to access deep pockets and implant surfaces safely. 

Scientific research has demonstrated this system is the gentlest and most efficient way to eliminate bacteria around cosmetic work and titanium implants, on enamel and root surfaces, and even on soft tissues. 

The GBT Protocol 

To get the most out of our investment, we implemented the “GBT” protocol, which is recommended by EMS, the company that manufactures the Prophylaxis Master. The 8-step GBT protocol is as follows:  

1. Assess the teeth, gingiva, periodontal tissues, and any implants and peri-implant tissues. 
2. Use disclosing solution to identify areas of biofilm accumulation. The color will also guide the hygienist to remove the biofilm with Airflow handpiece, after which calculus is easier to detect. 
3. Show the patient the colored biofilm to raise awareness. Spend time educating the patient and emphasizing the importance of prevention. 
4. Removal of biofilm, early calculus and stains with the Airflow. Airflow Plus powder is safe to use on teeth, root surfaces, gums, tongue, and palate. It can also be used to clean dental implants, restorations, orthodontic appliances, and clear aligners. 
5. Use Airflow Plus powder with the Perioflow® nozzle to remove biofilm in >4 to 9mm pockets, root furcations, and on implants. 
6. Remove the remaining calculus, using the minimally invasive EMS PIEZON® PS instrument supra and subgingivally in up to 10mm pockets and clean >10mm pockets with a mini curette. Use the EMS PIEZON® PI MAX instrument around implants up to 3mm subgingivally and on restorations. 
7. After checking to make sure all biofilm and calculus has been removed, diagnosing for caries, and applying fluoride for a fresh and smooth feeling. 
8. Schedule the patient’s recall visit based on risk assessment. 

What Our Patients Love About It  

• Patients trust the thoroughness of the therapy because they can see the disclosed biofilm before it is removed and its absence after it is removed.  

• The therapy is more comfortable than traditional methods. The water is warmed, and there is minimal root surface sensitivity compared to traditional hand and ultrasonic instrumentation.  

• This technology gently reaches into places where traditional instruments couldn’t remove stains and tartar.  

• The education patients receive from our hygienists highlights the value of the therapy.  

• We have found that this is a superior stain and calculus removing technology.  

• The erythritol powder that is mixed with warm water is pleasant tasting.  

 What Our Hygienists Love About It  

• Less hand instrumentation means less body fatigue.  

• There is superior stain removal and visual evidence that the biofilm is completely removed.  

• Patients don’t complain about sensitivity or “poking.”  

 What Doctors Love About It 

• Patients are happier.  

• Hygienists are happier.  

• It eliminates patient complaints about hygienists who are either “too aggressive” or “not aggressive enough” with instrumentation.  

• It prevents damage to cosmetic and implant restorations, as well as root and enamel surfaces.  

Note: We are not paid to promote EMS or Guided Biofilm Therapy. We honestly think this is the best way we can efficiently, comfortably, and thoroughly provide the comprehensive care our patients deserve—and we thought we should share our great experience 

By Lee Ann Brady, DMD 

Cleaning the larger gingival embrasures around a posterior dental implant can be a challenge for patients. In my practice, posterior implant patients are some of the individuals we give X-Floss samples to try at home.  

X-Floss is a dental floss made by iDontix® that is designed to make flossing easier for individuals with bridges, braces, implants, or larger-than-normal gingival embrasures. It resembles yarn, has a thick texture, and has a hard end, making it easy to push under orthodontic wires, bridges, or in embrasure spaces. It effectively cleans larger spaces while remaining gentle on the gums. The soft material minimizes the risk of injury during flossing, even in subgingival areas, and it is conveniently available on Amazon and in drugstores.  

There are two varieties. Green X-Floss from is too thick for some spaces. Blue X-Floss Lite is less thick and just right for some spaces. You and your hygienist may want to give samples of both to your patients to try. Some of your patients are likely to more effectively and consistently floss once they are using this type of floss.  

Laura S. Harkin, DMD 

I’m the owner of a third-generation dental practice. My father was a special person who cared for his patients as much as he did his dentistry. One important piece of advice that he gave was to make sure that my patient records were always complete and pristine. He said, “Anything that you are sending to the laboratory or to a specialist, even down to how you write your lab script or note, must be precise. And the reason is not only to minimize adjustment at the end but to also set an expectation for the same level of care returned by the lab or specialist.” 

As a team, we have spent time evaluating our models and photos to discuss how they can be improved and to recognize our highest standard. Recently, I became a little concerned about some of the radiographs we’d taken in the office. I encountered a few bitewings in which I was able to see the bone levels or the image wasn’t anterior enough to check the distal of the canine. So, as a team, we set aside time to review current x-rays and discuss the diagnostic qualities that we seek to achieve in each type.  

A team huddle provides built-in time and a safe place to do something like this. While reviewing the images, it became very clear that the team knew how to take vertical and horizontal bitewings. They also had a clear visual for how the images should look. Sometimes, however, a team member was shy about retaking an x-ray for they worried that a patient would be uncomfortable with the process. Other times, I imagine, they felt pressed for time and hurried to move down their checklist. 

Our review of images reinforced the level of care we collectively aim to achieve in all facets of our clinical day. Just as we strive for beautiful, mounted study casts, we take our x-rays with intention for our ourselves, our referral sources, and, above all, our patients. Consider taking a team meeting to share each other’s tips and tricks for taking x-rays in patients with difficult anatomy, a gag reflex, or missing teeth. Our own team members have a wealth of knowledge that sometimes doesn’t move from one treatment room to the next! 

Stephen Malone, DMD 

Our Knoxville, Tennessee, dental practice has grown to where we now have four dentists, as well as four hygienists, six dental assistants, two patient coordinators, a practice manager with two front-office patient care specialists, and one more primary partner in our dental practice—Bob Cutshaw. Bob is a master lab technician with over 40 years of experience and owner of Cutshaw Labs. He has been a partner in care with me for nearly 25 years and collaborates with our doctors on all dental restorations requiring lab work. 

Recently, I was thinking again about how grateful I am for my association with Bob and for the many benefits of having his lab located downstairs within our practice facility. Perhaps, having a lab in-house is something other dentists might aspire to eventually have in their own private practice. 

Bob is involved in care planning just as much as I and the other dentists. We can sit side by side to collaborate on treatment using a combination of digital 3D modeling and analog articulated models and wax-ups. 

For patients with complex needs, he routinely comes into the operatory or the consultation room to meet with patients. As he explains his involvement in their care and how the highest quality materials and latest techniques will be used, they become fascinated in the laboratory methods and technologies. Some request a tour of the lab and want to watch some of the process. 

We use digital designs for all prosthetics. Bob’s professional-grade 3D printers work all day long for predictable, efficient fabrication of custom restorations. Then he hand-paints and glazes the crowns and prosthetics for optimal natural aesthetics. Because he is involved in planning our most complex cases that involve implant supported hybrid denture, he is deeply invested in the details that allow the finished product to be delivered with ease. 

Having his lab in-house allows us to rapidly fix issues that arise, for example, alterations to a restoration when it doesn’t quite fit right or has a slightly incorrect shade. Instead of waiting for days or weeks to deliver back and forth a restoration to an outside lab, we make the changes here on the same day. 

For Patients undergoing clear aligner treatment, we manufacture our clear aligners in-house. If a patient loses or damages a tray, it is immediately replaced so the patient doesn’t lose precious time in treatment. The same goes for our occlusal splints, night guards, sports mouth guards, and Essix retainers. 

One of the branding traits of our practice that has earned us our high reputation is the in-house laboratory. Without a doubt, having this lab just downstairs is a major way in which we enhance the quality of care we provide to our patients. 

Charlie Ward, DDS

In this article, I’ll share how I save my Dental DSLR photos and choose between the file formats of RAW versus JPEG. There are specific reasons why we might need one format or the other, or perhaps both. I’ll also share how I store and protect my ever-growing collection of images. 

The Difference Between RAW and JPEG Format 

We have a choice when we’re shooting with our DSLR about how we want to save our files. On the menu of our camera, we see that we can choose between RAW and JPEG, and the quality of JPEG. When RAW is selected, all data that hits the camera sensor is saved. A JPEG is a processed image resulting in a compressed (smaller) file size.  

The data stored in RAW images can be 3 to 4 times more than in JPEG images, depending on the quality of JPEG you select on the camera menu. The processor in your DSLR camera will remove data from a JPEG image that it perceives to be imperceptible to the human eye. The greatly smaller size of JPEGS makes them universally preferred, not only for storage but for quick upload, download, and opening for viewing online. I routinely shoot high-quality JPEGs for diagnostics and routine lab communication.  

(If you are wondering what JPEG stands for, it’s for Joint Photographic Experts Group. Once JPEG images are in your computer, they can be saved as different file formats ending in different extensions such as .eps, .pdf, .jpg, .jpeg, .bmp, .tif, and .tiff.) 

If I take an image in both RAW and JPEG format, at first glance, the JPEG and RAW images may look the same, but on closer inspection, I may see that the stain on a tooth’s enamel or surrounding skin tones appear lighter in the RAW image. The camera itself has processed the image and determined that some of that data is unnecessary.  

When to Shoot RAW Images 

For most of what dentists do with our DSLR cameras, JPEGS are fine. There are three situations when we should choose to shoot RAW images. 

1. When we want to edit images like a professional photographer. 

1. When we shoot images for accreditation for the American Academy of Cosmetic Dentistry. The Academy requires images in raw format so they can tell that the images have not been edited.  

1. When we are using a digital shade matching system like eLab or Matisse that requires RAW input. 

Why Shoot Both Versions When You Want RAW 

If you are storing CBCT and RAW images on your server, a lot of data can accumulate quickly. I shoot JPEG versions of the images I shoot in RAW format so I can delete the RAW files from my server when they are no longer needed and still have a case record with the JPEG files. 

Storage Tip: In my practice, we download the patient’s or the day’s images from the SD card on to our server in a patient folder. We have one main folder and within it a subfolder for each letter of the alphabet. Inside each alphabet letter’s folder is another subfolder labeled with the patient’s name for each patient whose last name begins with that alphabet letter. Inside each patient’s folder are appropriate subfolders, labeled for example, “Name-Prep-Date.” 

Charlie Ward, DDS  

Whether you want to use a digital SLR camera for documentation, patient education, lab communication, making presentations at dental events, dental publications, or accreditation in the American Academy of Cosmetic Dentistry, you have choices to consider in multiple price ranges.  

Dentists can spend $1,800 and get a good system for documenting cases, patient education and lab communication. Dentists can easily spend $3,800 or more on a setup to equip themselves to take higher quality images. 

Camera Body: Most dentists shoot with a Nikon or Cannon DSLR camera. These are comparable brands. My experience is with Canon but my lab technician uses Nikon and gets wonderful results. I am shooting with the Canon EOS 90D. The comparable Nikon is the D7500. More entry-level models are the Nikon 3500 and the Canon Rebel T8i. 

Lenses: We can get a third-party Sigma 105mm or a Tokina 105mm lens that gives us decent quality, or we can purchase the Canon 100mm or Nikon 105mm version at twice the price. When I upgraded to the finer Canon lens, I noticed a huge difference in image quality. I recommend an upgraded lens for the highest-quality images you need for accreditation. 

Flashes: The ring flash is a great entry-level option and significantly less expensive but there are limitations to what you can do to control your light. I’ve been using a dual point flash for some time. I can pull a flash off and shoot from a different angle. By changing where the light is coming from, I can accentuate the angle lines for more depth and visual clarity.  

Sometimes, I’ll take one of my flashes off, hold it on the opposite side of what I am shooting, and shoot the flash back into the lens of the camera. When I do this, I get an ethereal-appearing image or an image with a white background. I appreciate the versatility of using the dual point system.  

For my best-looking images and portraits, I’ll use softboxes. This gives smoother, more diffuse light and a beautiful appearance. These are necessary for everyday dentistry but make a huge difference in showcasing aesthetic cases.  

Consider the Long Term: When dentists invest in cameras and lenses, they typically use them for a long time. If you are on the fence about how much you want to invest, my own experience might be helpful. I honestly wish that I had upgraded sooner than I did with the Canon EOS 90D and the Canon 100mm lens. After taking photos for 12 years, the upgraded equipment has only increased the joy I have for photography and pushed me to take more pictures! 

Why Use an Essix Retainer Versus a Flipper During Dental Implant Therapy 

Lee Ann Brady, DMD 

When it comes to choosing a provisional during implant therapy in the anterior aesthetic zone, we have two removable options. One is called a “flipper.” It’s an interim partial denture composed of an acrylic base and a denture tooth. The other is an Essix retainer.  

There is no question that both options are taxing for the patient for the three to five months that the patient is edentulous and must deal with having this removable device to replace the tooth. So, I always tell my patients that they are going to have to manage the provisional for that time, but it’s worth it because, in the end, they have replaced the tooth with an implant with all the benefits of an implant versus an alternative prosthetic solution. 

In my practice, I use Essix retainers in nearly 100% of the cases. Why? Because an Essix retainer is tooth-borne. The pressure is placed on the teeth and not on the surgical site. In the case of a flipper, the prosthesis is primarily tissue-borne with a little pressure placed on the adjacent teeth. We really don’t want any pressure on the surgical site while it is healing. Pressure can induce biological problems in bone grafts and connective tissue, which affect the long-term outcome. From an aesthetic perspective, the most challenging thing about anterior implant aesthetics is replicating the size, shape, and position of the tissues of the alveolar ridge and papilla. I want to do everything I can to eliminate pressure on the healing tissue. 

In my practice, we do Essix retainers that don’t have a full solid tooth in them. Instead, we simply paint flowable on the facial so that there’s zero pressure anywhere around that surgical site after extraction, after grafting, and after implant placement.  

In addition to explaining the improved outcomes associated with using an Essix retainer, I assure my patients that the retainer will be more comfortable to wear than a denture and be easily removed by them for eating, for drinking liquids other than water that are likely to stain the retainer, for teeth cleaning, and for cleaning the prosthesis. When out in public, such as in a restaurant, patients may carefully eat while wearing the Essix retainer.  

Dental Sleep Medicine in Restorative Practice Part 6: The Question of Software 

By Todd Sander DMD 

Numerous companies offer software solutions for dental sleep medicine that integrate with billing services. These companies can take over the paperwork and billing for medical insurance. Some of them have letter templates built into them.  

I look at software all the time, and when I do, I evaluate the efficiency we would gain versus the number of appliances I would need to deliver to make using the software worthwhile. Their billing service fees are high. Currently, I average 10-15 dental sleep medicine patients per quarter and not all of these are candidates for oral appliance therapy. Remember, I have a busy restorative practice. Colleagues who practice full-time dental sleep medicine may see this number in a week! 

I’ve been fortunate to have team members who don’t mind researching how to file medical insurance claims for appliances. Most of my colleagues use a software platform designed for dental sleep medicine. So far, I have chosen not to use one. Instead, I have assigned the duties to team members and they have taken dental sleep medicine, Eaglesoft, and medical billing courses. Currently, we have customized template forms and letters in our Eaglesoft system but it is not set up for filing medical claims.  I must admit, it is getting harder to do this. and I may be forced to decide about dedicated software soon. However, the decision will be made considering financial feasibility as a primary concern. 

It did take time to develop our template forms and letters in Eaglesoft but now we are highly efficient. I dictate the notes for our records, the SOAP note for medical insurance, and the information we want to share in letters with physicians. In addition to the cost savings, I like that I am recording the data I want in my documentation in a structure I want for how I practice—not just for the SOAP note and representing my findings to referring physicians. 

One of my mentors has me considering the possibility that I might want to separate my dental sleep medicine patients’ charting from my dental patients’ charting. Using software designed for the practice of dental sleep medicine would give me a clean way to segregate the patients on my computers. So far, I’ve decided that the expense of the software will not give me a return on my investment. 

When my daughter Kaitlyn (currently in through E2 at Pankey) finished dental school in 2020, I strongly recommended that she learn analog first, then once mastered, make the transition to digital. This lasted about four months. I learned rapidly that this generation sees things in the digital realm far better than we do. She reminded me that “she grew up with a screen in her hand.” 

We began to focus on her learning the concepts of occlusion, esthetics, biology, tooth-by-tooth structural integrity, and visualizing and planning in the virtual (digital world). We quickly learned that, although she could easily visualize things on the computer, the patient is ultimately analog. We began to utilize an analog articulator for her to learn the hand skills of what we would do on the patient. 

A great example of this is equilibration. A “trial equilibration” on a virtual articulator is a 5-minute process that lets us determine if equilibration is an appropriate treatment option. The problem is that, unlike analog, you do not learn the brush strokes that will be required to perform this skill in the mouth. I have performed hundreds if not thousands of equilibrations. I know the brush strokes. For me, once I see on the virtual articulator that I can do the equilibration without too much tooth structure removal, I am ready to go to the mouth. For Kaitlyn, who has very limited equilibration experience, once visualized on the virtual articulator, then it’s time to go back to analog. She mounts the printed models on an analog articulator to perform a traditional trial equilibration. In this way, she learns the brushstrokes of this incredibly important procedure. 

I think it is extremely important that dentists, who are learning to equilibrate intraorally, work on mounted analog models to develop their equilibration skills. 

Returning to the consideration of the financial cost of bringing new technology into your practice—input devices (scanners and CBCTs), output devices (printers and mills), and software to manipulate the data all cost money. Doctors that are going down this road usually like technology and consider the dramatic increases in efficiency to ultimately increase the productivity and profitability of the practice. This is certainly something I have seen. The bottom line is dental stone will go away. We all must make the decision when it is appropriate to make the jump. 

Dr. Lee Ann Brady has invited me to audit all the Pankey Essentials courses over the next year. I am super excited about this. She has asked me to recommend ways to appropriately implement examples of digital technologies and workflows into these core classes. While younger dentists are drawn to digital information, it is important for us to remind them that our patients are ANALOG. We are training dentists to perform complex procedures on patients, not on computers. This requires great study and a commitment to understand timeless concepts, while simultaneously developing the hand skills to accomplish these procedures accurately and use digital workflows to make things more efficient. 

In 2024, The Pankey Institute is also implementing a digital hands-on course for those doctors who would like to make the transition over to virtual articulation and digital workflows—something that I am excited to be part of. Dentistry is in a great transition. I look forward to making sure the concepts that we have all built our practices around do not get lost in the digital world.