DT U.S. 1909

Informatics and IT in dentistry: a look forward / An interview with Dr. Sam Kherani - president of the International Association of Comprehensive Aesthetics / Enhancing teamwork through ‘team play’ / Five more of the top 10 reasons why associateships fail / IACA Conference / Introducing Icon / Save lives - save your business / Cosmetic Tribune 5/2009 / Hygiene Tribune 5/2009

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DENTAL TRIBUNE
The World’s Dental Newspaper · U.S. Edition

July 2009

www.dental-tribune.com

CosmetiC tRiBUNe
the World’s Cosmetic Dentistry Newspaper · U.s. edition

Enhancing teamwork

Find out how “team play” results in better teamwork

u Section 5A

Mutilated dentition

Full-mouth fixed rehabilitation of a mutilated dentition.

u Section 1B

Informatics and IT in
dentistry: a look forward
By John O’Keefe, B. Dent. Sc., M. Dent.
Sc., MBA

In this edition, we conclude the
interview Dr. John O’Keefe, editor of the Journal of the Canadian Dental Association, conducted
with Dr. Titus Schleyer, associate
professor and director of the Center for Dental Informatics, University of Pittsburgh.
This part takes a look at the
impact of information technology
(IT) on dental education, including continuing education, the
future of the practice of dentistry
and opportunities for organized
dentistry.

Is training in IT by dental
schools increasing?
Well, I hear about courses in computing for dental students once
in a while from places where I
haven’t heard it before, so the
answer is “anecdotally, yes.” I
think people probably are paying
more attention to that now.
Even at the University of Pittsburgh we do have a course on
computing in dentistry, but I cannot say that I am 100 percent comfortable asserting that our graduates are completely capable of
managing an IT infrastructure,
either by themselves or with the
g DT page 2A

Vol. 4, Nos. 19 & 20

HYGIENE TRIBUNE
The World’s Dental Hygiene Newspaper · U.S. Edition

Gums gardening

Antimicrobials and periodontal therapy.

u Section 1C

The IACA Conference heads to San Francisco

The city of San Francisco hosts the IACA Conference from July 30 to Aug. 1.
You can register for all lectures and workshops online at www.TheIACA.com.
gIACA Conference, pages 10A & 11A

Dentist says xylitol prevents caries
By Fred Michmershuizen, Online Editor

Aside from regular brushing,
flossing and dental check-ups, a
good way to prevent caries is to
chew gum sweetened with xylitol, a
Florida dentist says.
“It may seem counterintuitive
to parents, but using chewing gum
with xylitol can actually help to promote healthier teeth,” says Delray
Beach, Fla.-based dentist Dr. Craig
Spodak.
Xylitol is a naturally occurring

organic compound. It is roughly as
sweet as sucrose with only twothirds the calories.
“Of course, consumers need to
remember that the best way to prevent cavities and gum disease is
to visit the dentist every six to 12
months and to undergo a yearly
periodontal screening after the age
of 40.”
In studies, xylitol appears to inhibit bacterial growth, including Streptococcus mutans — the main bacteria
implicated in dental decay. DT
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[2] =>

News

Dental Tribune | July 2009

f DT page 1A
help of consultants.
The problem is that there is not
enough time in the curriculum
and we don’t go into enough depth
tk
to graduate dentists who
are very
Source:
ADA
comfortable at managing IT. And,
of course, there is the problem of
attitudes.
The other day my IT manager
told me about a dental student
who wasn’t able to copy a file onto
a USB drive. When she suggested
that he should be able to do this,
he said: “I’m here to become a
dentist, not an IT person.” Well,
this guy is in for a surprise later
on.
I think one of the big barriers
to productive IT use in dentistry is
the fact that a lot of people struggle and learn only by trial and
error. That pain could be reduced
and we could be a lot more efficient and waste less money, time
and effort with better educational
approaches to this and with a better consulting infrastructure.
Let’s face it, some dentists hire
consultants with relatively little
understanding of what they can
do, and then it turns out that
the consultant really doesn’t know
very much. It is a little bit like having your kitchen renovated: Once
you get to the end of the job, then
you know how good your contractor really was, but you typically do
not know that up front.

have that much access to local
courses versus the dentist in a big
city who does. So the rural dentist
just doesn’t have the options that
other people have and, in that
case, it might be very helpful to
take a course over the Internet.
Clearly, one challenge is when
courses are offered by corporate
interests. For instance, let’s take
implant companies. We really
have to look very closely at the
validity and correctness of the
material that’s presented.
What I mean is that there is an
inherent bias there that sometimes shines through very clearly, and sometimes information
doesn’t get presented that would
put the product in a little bit more
balanced light.
On the other hand, with universities and other providers who follow ethical guidelines closely or
who take the mandate of providing balanced information seriously, that fear is not there as much.
But clearly I think that’s an issue.
Another issue is the quality of
the instructional material and the
presentation. As you know, we’ve
done some research in that area in
the past, and many years ago the
quality just wasn’t very good.
Partially as a reaction to that,
the ADA’s Standards Committee
for Dental Informatics has come
out with guidelines for the design
of educational software that we
helped develop. So hopefully the
quality of what’s out there has
improved, but I don’t really have
any data to support that hope.

Do you see information technology and communication technologies playing a bigger role in
the next five to 10 years in the Beyond the IT sector, what are
the most important developarea of continuing education?
The industry, and also academia to ments that may have an impact
some degree, have invested signif- on the future of the practice of
icant resources in online learning dentistry in North America?
and distance education. It’s not as The main one I would point to is
better accountability
howIswe
if this
is ahave
particularly
new subDo you
general comments
or criticism
you would like tofor
share?
a particular
topiceducation
you would like
to see
more
articles
about?
Let in
spend
our
health
care
dollars
ject.there
We’ve
had distance
know the
by e-mailing
us at feedback@dtamerica.com.
If you would
like to in
care dollars
wayusbefore
Internet started.
So general, and dental
make
any change
your asubscription
(name, address or to opt out)
we’re
simply
talking to
about
new particular.
please send
an e-mail
at database@dtamerica.com
and be sure
We have this movement
intothe
technology,
notus
a new
concept.
include
which
publication
you
are
referring
to.
Also,
please
note
more
I think partially remote learning United States toward a muchthat
subscription changes can take up to 6 weeks to process.
and distance education can help accountable way of providing
dentists stay more in touch. Think
g DT page 3A
about the rural dentist who doesn’t

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By Fred Michmershuizen, Online Editor

DENTAL
ENTAL TRIBUNE
RIBUNE
TheWorld’s
World’sDental
DentalNewspaper
Newspaper· ·US
USEdition
Edition
The

Publisher
Torsten Oemus
t.oemus@dtamerica.com
President & CEO
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Chief Operating Officer
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Group Editor & Designer
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Editor in Chief Dental Tribune
Dr. David L. Hoexter
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Managing Editor/Designer
Implant Tribune & Endo Tribune
Sierra Rendon
s.rendon@dtamerica.com

National Museum of Dentistry Executive
Director Rosemary Fetter, left, Dr. Irwin
Smigel and Immediate Past Board Chair
Dr. Roger Levin cut the ribbon on the new
Smile Experience exhibit.
The National Museum of Dentistry, located in Baltimore, celebrated
its 13th anniversary on June 5 with
an exhibition opening and a preview
of new projects. The celebration
honored supporters and friends who
help the museum in its mission to
celebrate the history of dentistry and
to raise awareness of the importance
of good oral health.
Dr. Irwin and Lucia Smigel joined
Museum Board of Visitors Chair
Michael Sudzina, Executive Director
Rosemary Fetter and Immediate Past
Board Chair Dr. Roger Levin to cut
the ribbon on the new Smile Experience exhibit. It reveals how the art
and science of cosmetic dentistry
creates beautiful and healthy smiles.
As a feature of the evening’s
program, Dr. Irwin Smigel, known
as the father of esthetic dentistry,
was honored. A plaque bearing his
likeness was unveiled and will be
affixed to one of the soaring pillars
in the museum’s atrium. DT

Children on Medicaid
receive less care for
cleft lip and palate
Children with cleft lip and/or palate experience significant differences in obtaining dental care depending on the type of insurance coverage
they have. Those with Medicaid are
more often refused care, have fewer
checkups and report less satisfaction
with their dental care, according to
a report in the May 2009 issue of
the Cleft Palate–Craniofacial Journal, the official publication of the
American Cleft Palate–Craniofacial
Association.
Parents and caregivers of 171
children ages 7 to 12 with cleft
lip and/or palate were interviewed
for a study. Although 85 percent of
the children received regular dental
care, those who did not were predominantly covered by public insurance rather than private insurance. DT

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the ultimate esthetic
provisional material

Museum celebrates
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(Source: American Cleft Palate–
Craniofacial Association)

5/22/09 10:01:31 AM

Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
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Online Editor
Fred Michmershuizen
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Published by Dental Tribune America
© 2009 Dental Tribune America, LLC
All rights reserved.
Dental Tribune strives to maintain the
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or content that requires clarification,
please contact Group Editor Robin
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Dental Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility for product names or statements made by advertisers. Opinions
expressed by authors are their own and
may not reflect those of Dental Tribune
America.

Editorial Board
Editorial Board
Dr. Joel Berg
Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
Dr. Arnaldo Castellucci
Dr. Gorden Christensen
Dr. Gorden Christensen
Dr. Rella Christensen
Dr. Rella Christensen
Dr. William Dickerson
Dr. William Dickerson
Hugh Doherty
Hugh Doherty
Dr. James Doundoulakis
Dr. James Doundoulakis
Dr. David Garber
Dr. David Garber
Dr. Fay Goldstep
Dr. Fay Goldstep
Dr. Howard Glazer
Dr. Howard Glazer
Dr. Harold Heymann
Dr. Harold Heymann
Dr. Karl Leinfelder
Dr. Karl Leinfelder
Dr. Roger Levin
Dr. Roger Levin
Dr. Carl E. Misch
Dr. Carl E. Misch
Dr. Dan Nathanson
Dr. Dan Nathanson
Dr. Chester Redhead
Dr. Chester Redhead
Dr. Irwin Smigel
Dr. Irwin Smigel
Dr. Jon Suzuki
Dr. Jon Suzuki
Dr. Dennis Tartakow
Dr. Dennis Tartakow
Dr. Dan Ward
Dr. Dan Ward

[3] =>

Dental Informatics

Dental Tribune | July 2009
f DT page 2A
health care and measuring outcomes, probably leading in many
aspects when you compare it to
the rest of the world. In dentistry
we haven’t had much of this, but I
think it’ll come.
In America, dentistry is about 5
percent of total health care costs.
DT
So tknot
many people have paid
attention to how this money is
being spent when there are a lot
of bigger pieces to look at. But I
think measuring what goes in and
what comes out is definitely in the
future of dentistry, too.
The ADA is working, once
again, on developing diagnostic
codes. What we need to do as a
profession is to relate diagnoses
to treatment and treatment outcomes, and we have not really
done that in an explicit way.
Yes, I am sure it happens in
some dental offices. Dentists who
are into detailed record keeping
write lists of problems, then they
write what they did, and obviously from the record you can tell
whether the patient improved or
not.
On the other hand, I have also
seen dentists simply dictate treatment plans. In that case, there’s
no evidence from the record whatsoever what was wrong with the
patient in the first place.
So that approach doesn’t lend
itself very well to the “pay for
performance” approaches that
are emerging in American health
care, and eventually, dentists have
to face up to that reality.
Do you see diagnostic codes
being a reality within the next
10 years in the United States?
I would hope so. The American
Dental Association clearly has gotten the message that diagnostic
codes should be developed, and
I think the Department of Health
and Human Services probably
didn’t hide the fact that if dentistry doesn’t come up with them,
then they’ll come from somewhere
else.
I think that’s something that the
ADA and other stakeholders in the
dental profession would not like
to see.
On the other hand, the ADA is
now in its second attempt to develop SNODENT (a set of diagnostic
codes for dentistry), and it appears
to be a large, cumbersome and dif-

‘Hiring a consultant is a bit
like having your kitchen
renovated. When the job is
completed, you know how
good your contractor really
was, but you typically do not
know that up front.’
ficult process.
I probably would have picked
a different strategy. A limited set
of codes, on the order of a few
hundred, can probably describe
70 to 80 percent of the conditions
that general dentists encounter on
a day-to-day basis. I would have
started with that and built out
from there.
Are there any opportunities that
you see for the leadership of
organized dentistry to advance
our profession?
I think we can become better dentists collectively in many ways,
but I think one of the things we
haven’t really exploited that much
in this context are electronic data.
Right now we spend a lot of our
time duplicating on the computer
what we had on paper.
For instance, the electronic
patient records as we know them
right now, most of them actually
do look like somewhat poor imitations of the paper records we
have. And, that’s not really what
computerized records or what
informatics should be about.
We have great opportunities
to use digital data in much better ways, which is why it’s so
much fun to do dental informatics
research all day long. What we
need to do is we need to invent
those ways.
We need to imagine what we
can do, not just be constricted by
the knowledge of what we have
done.
For instance, one project we’re
working on is a three-dimensional
model of the patient as the centerpiece of a general dental record.

In my mind, it is perfectly possible
to create the virtual patient on
the computer, and we’re working
on it.
This is not such a huge technical challenge. The challenge is
to imagine what you can do with
this model, how the information
should be presented in the context of this model, how the dentist
should interact with it, and what
value-added functions this system
provides to the dentist.
I’m a firm believer in creating
things that help improve patient
care and that help dentists do
their work more effectively and
efficiently.
Thus, I think leveraging information technology is probably
one of the biggest opportunities in
dentistry.
I know that sounds like a hammer looking for a nail because I
am in dental informatics, so it’s
logical that I would pick this, but
I think it has some credibility. DT

About the interviewee

AD

Titus Schleyer, DMD, PhD
Associate Professor & Director
Center for Dental Informatics
School of Dental Medicine
University of Pittsburgh
3501 Terrace Street
Pittsburgh, PA 15261
Tel.: (412) 648-8886
Fax: (412) 648-9960
E-mail: titus@pitt.edu
Web: www.di.dental.pitt.edu

3A

[4] =>

IACA Conference: Interview

Dental Tribune | July 2009

‘To elevate dentistry
around the world …’
An interview with Dr. Sam Kherani, president of the International Association of Comprehensive Aesthetics
By Robin Goodman, Group Editor

For those readers not familiar
with the IACA, can you please tell
us about the organization?
The IACA is a leading organization in dentistry that brings together like-minded professionals who
would like to promote a comprehensive understanding of esthetics that
is grounded in science and predictable longevity.
The IACA prides itself in being
the most inclusive and innovative
organization of its kind in the world.
The mission statement of the
IACA says it all,
“To elevate dentistry around the
world through an exchange of doctors’ experiences and knowledge
for the betterment of humanity. To
remain a dynamic dental organization that serves as a catalyst for the
fusion of contributions from all disciplines that serve mankind in attaining health and beauty.”
The IACA is a place where you’ll
find a group of uplifting and passionate dentists who love what they
are doing. We realize that we can all
learn from each other, and this is the
basic foundation of the IACA.
What is the main focus of the
IACA?
The main focus of the IACA is to create an association of professionals
that see value in such an association,
and whose primary objective is to
move the profession forward and be
relevant to the public that it serves.
The IACA does this primarily by
sourcing out speakers espousing
various philosophies, ideas, techniques and research that can be
shared with all, which would then
lead to the constant positive evolution of the profession for the benefit
of the final recipients, the patients.
The IACA works hard to be a truly
inclusive organization for posterity.
The IACA was established to not just
provide a venue for a dentist to
attend and receive advanced dental
AD

education. We wanted to provide an
enjoyable experience for the dentist,
family and his/her team.
I understand that the IACA has an
annual conference. Can you tell
readers about that?
The annual IACA conference allows
members to get together and share
information with each other, assimilate information from the highly valued speakers who present each year,
and attend workshops that endeavor
to teach new techniques and technologies.
It also fosters social interaction
which, as we know, is the purveyor
of knowledge. As the saying goes,
“you learn more outside of the classroom.” This year’s IACA conference
is being held at the Westin St. Francis in San Francisco from July 30
through Aug. 1. Complete information, including speakers and lecture
titles, can be found on the IACA Web
site at www.TheIACA.com.

sented by leaders
in the industry,
camaraderie with
like-minded individuals, information that is free of
any bias from the
organizers,
significant value for
the investment in
time and resources, leading edge
discussions
and
forums and much
more.
The IACA was
established
and
developed to be
dynamic, and an
entity that easily changes and
evolves as it grows.
The IACA was created to be a forum
for all dental philosophies to be
heard and discussed, and our members appreciate that.
Who can join the IACA?
Any individual who makes a contribution to the comprehensive esthetics of the human population can join
the IACA. This includes dentists,
physicians, dental hygienists, dental
assistants, dental technicians, chiropractors, physiotherapists, etc. DT

About the interviewee

www.dental-tribune.com
Missed the last edition of
Dental Tribune? You can
now read some of its content
online!
Implants displaced into
the maxillary sinus
By Dov M. Almog, DMD,
Kenneth Cheng, DDS
& Mohammad Rabah, DMD
www.dental-tribune.com/articles/content/scope/specialities/
section/implantology/id/542
Washington cracks down
on big tobacco
By Fred Michmershuizen,
Online Editor
www.dental-tribune.com/articles/content/id/480
Five of the top 10 reasons
why associateships fail
By Eugene W. Heller, DDS
www.dental-tribune.com/
articles/content/id/507/scope/
specialities/region/usa/section/
practice_management
‘Aren’t you that guy on
“Extreme Makeover”?’
An interview with the face of
modern cosmetic dentistry, Dr.
William M. Dorfman
By Robin Goodman, Group
Editor
www.dental-tribune.com/
articles/content/scope/specialities/section/cosmetic_dentistry/
id/543
New smile, new life: Innovative
technologies and techniques
can transform a smile
By Lorin Berland, DDS, FAACD
& Sarah Kong, DDS
www.dental-tribune.com/
articles/content/scope/specialities/section/cosmetic_dentistry/
id/544

Here’s some other online
content that might be of
interest to you …
Protective extraoral and
reinforced instrumentation
strategies
By Diane Millar, RDH, MA
www.dental-tribune.com/articles/content/scope/specialities/
section/dental_hygiene/id/545

In addition to the conference, what
other perks do members receive?
IACA members enjoy Webinars preShamshudin (Sam) Kherani, DDS,
FAGD, LVIM, is a graduate of University of Western Ontario and has been
in general practice since 1981 with a
special interest in adhesive dentistry.
Prior to joining LVI full-time as a
clinical director, he served as a clinical instructor at the institute as well
as a regional director. He currently
serves as the president of the International Association of Comprehensive Aesthetics (IACA). Kherani can be
reached at (888) 584-3237 or by e-mail
at s.kherani@theiaca.com.

Special Operations Forces
dental clinic brings smiles to
Iraqi children
By Jeffrey Ledesma, USA
www.dental-tribune.com/
articles/content/id/535/scope/
politics/region/usa
Ancient teeth question
origin of men
By Daniel Zimmermann, DTI
www.dental-tribune.com/articles/content/scope/news/region/
asia_pacific/id/505

[5] =>

Dental Tribune | July 2009

IACA Conference: Practice Matters

Enhancing teamwork through ‘team play’
Headline
By Sherry Blair, CDA

Deck

New team techniques are
required to involve these team members. Could one of those techniques
include team games and activities?

Teams are becoming increasingly important in today’s organizations. Whether they are striving to
improve quality, increase efficiency tkor focus on customer satisfaction, people support what they are
involved in.
The focus on employee participation requires a more facilitative,
empowering and less directive controlling leadership style. Facilitative
leaders learn to use the abilities of
their groups to solve problems and
make decisions.

By line

‘Team play’

What is a team?
I recently read a great definition
of a team: A group of people with
a high degree of interdependence
geared toward the achievement of a
goal or the completion of a task.
In other words, members of a
team agree on a goal and agree that
the only way to achieve the goal is
to work together. Some groups have
a common goal but do not work
together to achieve it.
For example, many teams are
really groups because they can work
independently to achieve the goal.
Some groups work together but do

not have a common goal.

What do team members want?
Team members are seeking empowerment. They want to get involved
in the way decisions are being made

in the workplace.
People have rediscovered the
advantages of learning through the
sharing of experiences and insights.
This trend has created a demand for
new forms of leadership.

Let’s look at the definition of an
instructional game or activity: A
structured process that involves participants interacting with one another to share their experiences and
insights.
There are two key elements:
experience and interaction. Participants take an active role in jointly
experiencing an event, reflecting on
it and sharing what they learned
from it.
Because teamwork involves participants interacting with one another, it makes sense that they should
also learn in situations presented by
games and activities.
Science research indicates that
people learn more effectively and
apply their newly learned knowledge
and skills more effectively through
games and activities. Research on
such diverse areas as stress, anxiety
and creativity reinforce the generalization that we need to play more in
g DT page 6A

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[6] =>

6A IACA Conference: Practice Matters
f DT page 5A
order to improve our learning.
Recent studies on the nature of
intelligence have eliminated traditional IQ measures as the sole
indicator of effective performance.
Newer frameworks of intelligence
emphasize that there are several
avenues to learning other than the
conventional use of language and
logic.
Games and activities tap into
alternative intelligences.
Events that are accompanied
by emotions result in long-lasting
learning. Games and activities that
include appropriate levels of cooperation within teams and competition across teams add emotional
elements to learning.

Sample activities
Feedback from these activities
can also provide opportunities for
practicing interpersonal skills.
Two Truths & A Lie
One of the activities I like when
conducting in-office consulting is
called Two Truths & A Lie. I use this
when working with a team that has
been together for a number of years.
Each team member will tell two
truths and a lie about themselves.
The other team members will guess
which one is the lie. Because they
are trying to stump their teammates,
a team member will typically reveal
something about themselves that
the other team members did not
know.
During the activity, keep focused
on the goal to prevent the activity
from becoming an end in itself. After
AD

the activity, there must always be
a debriefing discussion. Ask participants to share their insights with
one another. Ask them to report on
what they learned from the activity,
and to develop action plans based
on the newly learned principles.
One of the most insightful statements I heard during a debriefing
after this activity was the fact that
“we may not know our long-term
patients as well as we think we do.”
Could there be an emotional “hot
button” that we are not finding out
about those patients?

Dental Tribune | July 2009

ties to get you started. There are,
after all, “Endless possibilities!”
The important thing is to remain
flexible. Although games and
activities have rules, don’t become
obsessed with them.
An important requirement for
effective teamwork is to maintain
your sense of humor and to take
serious things playfully. So lighten
up and have some fun! DT

About the author

Slogans
Another favorite is an activity called Slogans. This activity will
give team members an opportunity
to reflect on the image of the team.
All you do is provide a list of the
following slogans to your team and
have them identify the companies to
which they belong:
1) The Real Thing
2) Drivers Wanted
3) Think Different
4) Find your own road
5) In touch with tomorrow
6) It’s all within your reach
7) Where do you want to go
today?
Have them choose the slogan
that best represents your team and
discuss why.
[And here are the company
names: 1) Coca Cola, 2) Volkswagen, 3) Apple, 4) Saab, 5) Toshiba,
6) AT&T, 7) Microsoft.]

Endless possibilities
These are just a couple of activi-

As director of the Dynamic Team
Program at the Las Vegas Institute
(LVI), Blair shares her more than 33
years of experience managing each
and every system within the dental
practice. Her extensive exposure
to most forms of practice management and dental systems, as well as
her strong focus on patient satisfaction, make her uniquely qualified to
enhance the effects of any dental practice. Blair can be contacted by phone
at (888) 584-3237 and by e-mail at

sblair@lviglobal.com.

Sherry Blair at the
IACA Conference
Thursday, July 30
1:30–3:30 p.m.
Do You Need A Title to Lead?
How many different definitions of
leadership have been interpreted by
how many different people?
Bass’ (1989, 1990) theory of leadership states that there are three
basic ways to explain how people
become leaders. The first two
explain the leadership development
for a small number of people. These
theories are:
1) Some personality traits may
lead people naturally into leadership
roles. This is the Trait Theory.
2) A crisis or important event may
cause a person to rise to the occasion, which brings out extraordinary
leadership qualities in an ordinary
person. This is the Great Events
Theory.
3) People can choose to become
leaders. People can learn leadership
skills. This is the Transformational
Leadership Theory. It is the most
widely accepted theory today and the
premise on which this presentation
is based.
• To empower people to take control of their lives in order to make a
positive difference.
• Identify leadership traits and
how to apply them.
• Develop principles and skills to
influence others.
For more information about the
IACA Conference, see pages 10A & 11A.

[7] =>

[8] =>

Financial

Dental Tribune | July 2009

Five more of the top 10 reasons why associateships fail
By Eugene W. Heller, DDS

The “American Dream” is still
to own a home. The “Dentist’s
Dream” continues to be the ownership of a practice. Thirty years
ago, the “Dream” was to graduate from dental school, buy equipment, hang out a shingle and start
practicing. Today the road to ownership is a little different.
Due to extensive debt, most new
graduates enter practice as associates to improve their clinical skills,
increase their speed and proficiency, and learn more about the
business aspects of dentistry. Most
hope the newfound associateship
will lead to an eventual ownership
position.
Instead, many find themselves
building up the value of their host
dentist’s practice, only to be forced
to leave. This forced departure is
the result of a non-compete agreement when the promised buy-in/
buy-out didn’t occur.
The following reveal the next
five most common reasons many
associateships fail to result in ownership or partnership.

Reason No. 6: access to
patient base

Insufficient access to the patient
base by the associate can take different forms. Perhaps the senior
dentist never intended to turn over
existing patients, but rather to
give the associate new patients or
patients obtained only by the assoADS

ciate’s own efforts. Under such circumstances, the productive capability of the associate would be
greatly compromised.
If the intended result is a partnership between the dentists, one
of the most important things that
the associate is buying is “equal
access” to the existing and new
patient base.
The patient base comprises the
goodwill value of the practice and
typically constitutes 70 to 80 percent of the value of a practice.
If the senior dentist fails to
recognize the need to turn over
existing patients to the associate,
then the associate will be frustrated by his/her efforts to produce
dentistry, earn his/her salary and
improve skills.
It is usual for the senior dentist to be concerned about turning
over existing patients; however,
this must occur if the relationship
is to blossom into ownership.

Reason No. 7: letting go

This problem is related to the senior
dentist’s unwillingness or inability to “let go” and turn treatment
responsibility over to the new dentist. In the case of a senior dentist
who is close to retirement, this may
be a very emotional decision. When
the senior dentist has identified
retirement pursuits, there will be a
greater ability to turn over practice
responsibilities to another dentist.
The new dentist who is consider-

ing an associateship should investigate the senior dentist’s outside
interests and activities in support
of an easier transition. Good signs
indicate that the senior dentist will
have no problem “letting go.”
Conversely, the senior dentist
who is proud of the number of
hours “lived” at the office or who
has no other interests in life, should
raise serious concern on the part of
the new dentist as to whether or not
this dentist is willing to let go.

Reason No. 8: philosophically speaking

Different business and/or practice
philosophies may reveal incompatibilities that may retard successful completion of the practice sale. This particular problem
deals with integrity issues as well.
It is important for the new dentist to ascertain the attitudes and
philosophies demonstrated by the
senior dentist.
A senior dentist who is willing
to share his/her practice numbers, profit and loss statements
and tax returns with the new dentist generally indicates a dentist
who is open and honest. A dentist
who is unwilling to share numbers and personal financial information will probably not change.
One important question to ask
a dentist who has been in practice for more than 20 years is
the status of that dentist’s retirement plans. If the senior dentist is
having financial stresses after 20
years of practice, the partnership
will probably not occur.
A dentist who has a well-funded pension/profit-sharing plan
and is proud of personal financial accomplishments, provides a
strong indicator that the practice
will be strong enough to launch
the new dentist into a similar
state.

Reason No. 9: a good match

Unfortunately, personality conflicts are a frequent reason for
associateships failing to lead to
buy-ins/buy-outs. If two dentists have conflicting personalities, there may be stress and friction within the practice, which
will spill over onto the staff and
patients.
A few common-sense rules can
easily determine whether a potential for conflict exists. The assessment for personality conflicts
will be ongoing during the initial
interview process.
If there are significant concerns about compatibility for dentists who will be in a partnership
arrangement spanning from three
to five years, the warning signs
should be carefully evaluated at
the onset.
If a long-term relationship is
intended, it may be prudent to
seek professional personality
assessments.

Reason No. 10: good advice

The final reason has, in fact, nothing to do with the dentists or
the practice. Instead, individual
attorneys have proceeded to cause
problems in the relationship.
It is extremely important that
both dentists realize the boundaries that must be set relative
to their attorneys’ involvement
in finalizing the buy-in/ buy-out
arrangements. Attorneys should
be your advisors, not your decision-makers.
The negotiations relative to the
proposed buy-in/buy-out were
conducted at the onset of your
relationship as detailed in the Letter of Intent.
Attorneys are not hired to
“renegotiate” the transaction.
Attorneys’ personalities and styles
should not spill over into the dentists’ relationship.
Problems occurring while producing the Employment Agreement and the Letter of Intent may
be an indication of significant
problems that can be anticipated
at the conclusion of the employment period and during the preparation of Partnership Agreements.

Summary

This article has been aimed primarily at a one-dentist practice
evolving to a two-dentist practice;
however, the issues apply equally
to larger group practices.
One-to-two-year associateships
with the senior dentist retiring
at the end of the associateship
and a three-to-five-year partnership ending with the new dentist
purchasing the remaining equity
position of the senior dentist at
the end of five years can also benefit from the insights provided in
this article.
Unfortunately, nothing can
guarantee a successful outcome.
However, by identifying the potential pitfalls at the beginning of the
relationship, chances of success
can be greatly improved. DT

About the author
Dr. Eugene W. Heller is a 1976
graduate of the Marquette
University School of Dentistry.
He has been involved in
transition consulting since 1985
and left private practice in 1990
to pursue practice management
and
practice
transition
consulting on a full-time basis.
He has lectured extensively to
both state dental associations
and numerous dental schools.
Heller is the national director
of Transition Services for
Henry Schein Professional
Practice Transitions. For further
information, please call (800)
730-8883 or send an e-mail to
hsfs@henryschein.com

[9] =>

[10] =>

10A IACA Conference

Dental Tribune | July 2009

IACA schedule at a glance
Grab a highlighter and mark the lectures you want to attend
ADS

P&F Ad-DTA

1/14/09

2:45 PM

Join like-minded professionals at
the Westin St. Francis in San Francisco from July 30 to Aug. 1 for the
5th annual IACA Conference.
The conference’s daily program
is designed to present a comprehensive understanding of esthetics that
is grounded in science and predictable longevity.
And with a host city like San Francisco, you’ll not want for any food or
fun activities once the learning is
done at 6 p.m. every day.
Check out the schedule on these
two pages! DT

Page 1

Thursday,
July 30
Sponsor: MicroDental/DTI
8:15 a.m. Opening
8:30–10 a.m.
• Higher, Swifter, Stronger,
Neal Jeffrey
• Dental Service Excellence
John & Jimmy Garcia
10–10:30 a.m. Break

™

10:30 a.m.–noon
• Bynum “Unplugged,” It’s
Your Life: The World Is Watching YOU!, Dr. Matt Bynum
• Controlling New Patient
Exam Dynamics, Dr. Steve
and Joey Burch
• Common TMJ and Jaw
Problems That Can Affect
Outcomes in Comprehensive
Aesthetic Dentistry, Dr. Larry
Wolford
• The Scientific and Clinical
Basis of Neuromuscular Dentistry, Dr. Bob Jankelson
• Workshops: Las Vegas
Esthetics; HOYA ConBio
Noon–1:30 p.m. Lunch
1:30–3 p.m.
• Do You Need a Title to Lead?,
Sherry Blair
• We Are All Connected, Dr.
Doug Chase Dr. Ronald Jackson, Ms. Sally McKenzie
• Risk Management Plus
Expert Witness Basics, Dr.
David Miller
• Workshops: Aurum Ceramic
Dental Lab; Ivoclar

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3–3:30 p.m. Break

For technical information
contact Pulpdent at

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3:30–5 p.m.
• The Power of “UN,” Dr. Fred
Calavassy
• Implants for Dummies:
Everything You Need To Know
But Were Afraid To Ask!, Dr.
Leo Malin
• What About the Maxilla? The
Cranial, Skeletal and Dental
Position of the Maxilla and
Its Relationship to Occlusion,
Function and Smile Design,
Drs. Bob Walker/Kaye McArthur
• Science-Based Adhesive
Excellence for Indirect Restorations, Dr. Byoung Suh
• Workshop: MicroDental/DTI
5–6 p.m. Reception

[11] =>

Dental Tribune | July 2009
Friday, July 31

Saturday, cont’d

Sponsor: Williams Dental Laboratory

• Team Panel: Image — Is It Everything?, Sherry
Blair, Ginny Hegarty, Judy Kay Mausolf, Sally
Mc-Kenzie, and Heidi Dickerson moderating

8:15 a.m. Opening

10–10:30 a.m. Break

8:30–10 a.m.
• Economic Stimulus Panel,
Drs. Bob Beebe, Brad Durham,
Prabu Raman, Ron Willis and
Bill Dickerson moderating
• If Your Practice Isn’t What
You Want It to Be, It’s Your Own
Darn Fault!, Ashley Johnson

10:30 a.m.–noon
• Increase Your Production in A Down Economy,
Dr. Dick Barnes
• Materials Update, Dr. Mark Duncan
• The Power of Team, Dr. Lori Kemmet
• Connecting You to Your Potential: Image Is
Everything, Judy Kay Mausolf

10–10:30 a.m. Break
10:30 a.m.–noon
• Unconventional wisdom or
conventionals stupidity?, Drs.
Michael Sernik/Brett Taylor
• Integrating Sleep-disordered
Breathing, Dr. Kent Smith
• Transitioning Your Practice,
Dr. Tom Snyder
• Workshops: Williams Dental
Lab; Myotronics
Noon–1:30 p.m. Lunch
1:30–3 p.m.
• Effects — Diagnosis and Treatment for Upper Airway Obstruction in Pediatric Orthodontic
Patients, Dr. Jay Gerber
• Giving Your Patients Something to Smile About: Direct
Resin Artistry, Dr. Ronald Jackson
• If You Are Going To Do It, Do
It Different: Results and Case
Presentation, Dr. Art Mowery
• Supporting Your Partner or
Doctor Through His or Her LVI
Journey, Susan Duncan/Farzana Kherani
• Workshop: BISCO
3–3:30 p.m. Break
3:30–5 p.m.
• Minimal Preparation for Porcelain Veneers, Dr. Ross Nash
• Physical Referrals and the
Medical-Dental Connection, Dr.
Lee Ostler
• Working Smarter: Managing Your Practice & Future
for Financial Gains, Dr. David
Keator
• LVI Global’s 2009 National
Marketing Effectiveness Survey,
Mr. Bob Weiss
• Workshop: Imaging Systems
5–6 p.m. Reception

Saturday, Aug. 1
Sponsor: Arum Ceramic Dental
Laboratories
8:15 a.m. Opening
8:30–10 a.m.
• The Intersection Between
Neuromuscular Dentistry
and Physiology, Dr. Norman
Thomas

Noon–1:30 p.m. Lunch
1:30–3 p.m.
• The Transformation of Endodontics in the 21st

IACA Conference 11A

Century, Dr. Stephen Cohen
• 5 M’s of A Successful Practice, Sally McKenzie
• Introduction to Scan Interpretation, Bill Wade
• The Smartest Investment You’ll Ever Make,
Dan Solin
•Workshop: Cadent iTero
3–3:30 p.m. Break
3:30–5 p.m.
• Periodontal Disease and the Systemic Link, Dr.
Dee Nishimine
• What Does Your EQ Say About You?, Ginny
Hegarty
• Epigentic Orthodontics: Restoration of Craniofacial Health and Esthetics, Dr. Dave Singh
5–6 p.m. Reception

[12] =>

12A Industry

Dental Tribune | July 2009

Introducing Icon
The revolutionary treatment for incipient caries and white spot lesions … without drilling!
ENGLEWOOD, N.J.—DMG America introduces an entirely new, revolutionary
tk DT approach to treating incipient caries: Icon, a caries infiltrant.
Until now, dental professionals
had only two options for treating
caries: fluoride and other remineralization therapies if caries was not
too advanced, or the “wait and see”
until it was time to use the “drill and
fill” approach.
Caries infiltration is a major
breakthrough in micro-invasive
technology that fills, reinforces and
ADS

stabilizes demineralized enamel without drilling or sacrificing
healthy tooth structure.
“Icon represents a new category
of dental products,” says Tim Haberstumpf, DMG America director of
marketing. “It is the first product to
bridge the gap between prevention,
fluoride therapy and caries restoration.”
“Icon’s micro-invasive infiltration technology can be used to treat
smooth surface and proximal carious lesions up to the first third of

dentin (D-1). In just one
patient visit, Icon can
arrest the progression
of early enamel lesions
and remove white spot
lesions.”
When a dentist discovers incipient caries
that is beyond preventive therapies though
too early for restorative
treatment, Icon offers
a simple alternative
to the “wait and see”
approach.
With Icon, the dentist can offer immediate treatment without
unnecessary loss of healthy tooth
structure. Icon prevents lesion progression and increases life expectancy for the tooth.
Icon also provides a highly esthetic alternative to micro-abrasion and
other restorative treatments for cariogenic white spot lesions. White
spot lesions infiltrated by Icon take
on the appearance of the surrounding healthy enamel.
“The Icon infiltration system is
simple and user friendly,” Haberstumpf says. “Total treatment time
is about 15 minutes, so it saves
patients time and frees up additional
chairtime.”
After isolating the tooth with a
rubber dam and placing wedges to
separate the teeth, the tooth surface
is prepared with a 15 percent HCl
gel to open the pore system of the
lesion body. Next, the surface is
rinsed, dried with ethanol and also
dried with air.
The Icon Infiltrant resin, which
has a high penetration coefficient,
is applied onto the lesion, excess
material is removed and the material is light cured.
The manufacturer recommends
applying a second layer of the infiltrant, followed by additional light
curing.
For
complete
information,
detailed product descriptions, treatment steps, a training video and
an overview of the 12 international

studies currently being conducted with Icon, visit the Drilling No
Thanks! Web site at www.drillingno-thanks.com.
Icon will be available in the United States in September in Proximal
and Smooth Surface kits.
The Icon kits provide everything
necessary for treatment except the
rubber dam, including: specially
designed dental wedges; patented
perforated applicator tips for the
materials; individual syringes filled
with Icon-Etch, Icon-Dry (ethanol),
Icon-Infiltrant; and both written and
diagrammatic instructions.
All syringes come in a special
screw-type applicator to ensure
the materials are gently and slowly
extruded onto the tooth.
Icon Proximal is available in a
mini-kit with two treatment units, or
a package of seven units. Each proximal treatment unit contains enough
material for two proximal lesions.
The Icon Smooth Surface mini-kit
includes two treatment units and is
also available in packages of seven
units, enough material for two or
three smooth surface lesions per
unit. DT
DMG America manufacturers and
distributes quality restorative materials and prevention products. For
more information, call (800) 6626383 or visit www.dmg-america.
com.

Fight oral cancer!
Prove to your patients just how committed you are to fighting this disease by signing up to be listed at www.oralcancerselfexam.com. This new
Web site was developed for consumers in order to show them how to do
self-examinations for oral cancer.
Self-examination can help your patients to detect abnormalities or
incipient oral cancer lesions early. Early detection in the fight against
cancer is crucial. Secondly, as dental patients become more familiar with
their oral cavity, it will stimulate them to receive treatment much faster.
Conducting your own inspection of patients’ oral cavities provides the
perfect opportunity to mention that this is something they can easily do
themselves as well. You can explain the procedure in brief and then let
them know about the Web site, www.oralcancerselfexam.com, that can
provide them with all the details they need.

[13] =>

Dental Tribune | July 2009

Industry 13A
AD

Save lives,
save your
business
In good times and in bad, your
office needs an emergency
drug kit. Here are five reasons.
TK DT

By Jeff Sheets

“An unforeseen combination of circumstances or the resulting state that calls for
immediate action.” That’s how Merriam-Webster defines the word emergency — a word
Americans are all too familiar with these days,
thanks to the global economic downturn.
As damaging as it was “unforeseen,” that
downturn has hurt businesses and consumers
in virtually every sector of the United State
economy, and therefore demands “immediate
action,” just like the dictionary says it does.
Dentists and their patients are no exception
to the rule. Like their peers in manufacturing,
retail and travel, their businesses have been
bruised by the recession.
And although recovery is inevitable, in dentistry and elsewhere, things are certain to get
worse before they get better.
To cushion the blow when they do, dentists
must mitigate their risks and minimize their
risk exposure.
Among the largest risks facing dental practices are dental office emergencies, of which
surveys have shown that there are more than
30,000 every year in the United States. Risk
mitigation therefore starts with emergency
planning and response.
Because while the world’s economic emerg DT page 15A

[14] =>

[15] =>

Industry 15A

Dental Tribune | July 2009
f DT page 13A
gencies can’t be controlled, your
patient emergencies can — so
long as your office has the proper
equipment, including an emergency drug kit, such as Savalife’s
M100, for treating common emergencies related to angina, asthma,
insulin problems, allergic reactions, fainting and heart attacks.
Emergency drug kits are critical
when it comes to saving patients’
lives.
They’re equally important, however, when it comes to saving
your practice, particularly during
an economic downturn, when the
financial consequences of patient
emergencies can be especially
damaging.
Unfortunately, many dentists
wrongly assume, “My practice is
safe.”
If you’re among those who
assume this, consider the following five reasons for equipping your
office with an emergency drug kit
that will help your business weather the recession and thrive during
the recovery.

Drug kits can …
1) Protect your bottom line.
Although it can help you minimize the financial burden of
an emergency, insurance is no
match for prevention, planning
and response, which can help you
safeguard the investments you’ve
made in your business.

2) Provide legal protection.
In the event of an emergency, having the right emergency response
equipment may save your business
from costly litigation.

3) Give you a competitive advantage.
Having equipment that other offices lack gives you a leg up on your
competition, which can help you
attract new patients and retain
existing ones.

4) Promote professional development.
Emergency planning requires education, and professional development has been shown to increase
employee engagement, loyalty and
productivity.

5) Empower patients.
Because many patients are afraid
of going to the dentist, just having
an emergency drug kit can help
you calm their nerves; and because
happy patients talk, it can also
help you stimulate referrals. DT

Jeff Sheets is a spokesperson for
Savalife.com, a Fort Wayne, Ind.based company that manufactures
emergency drug kits and supplies
emergency planning training materials for dental offices nationwide.
He can be reached at jsheets@
savalife.com.

PhotoMed/Canon Rebel T1i digital dental camera
Canon has recently released
the latest in the popular Rebel
series of digital cameras: the
Rebel T1i. The T1i is a 15 megapixel camera and the first consumer level camera to offer HD
quality (1080p) video capture.
Canon states in their user
guide that you need a “class
6” SD memory card to capture
1080p HD video clips. You can
also capture video at two lower
resolutions: 1280 x 720 @ 30 fps,
640 x 480 @ 30 fps. (Call PhotoMed if you need help understanding the different modes.)
Like the Rebel XSi before
it, the T1i features Live View,
which allows you to use the

camera’s LCD screen as a
viewfinder (in manual focus
mode).
Canon has also increased
the resolution of the camera’s
LCD screen from 230,000 pixels (Rebel XSi) to 920,000.
This results in the ability to
see incredible detail and clarity on the camera’s built-in
screen. PhotoMed offers the
Canon Rebel XS as a complete
clinical camera system with a
choice of Canon or Sigma
macro lenses and macro flashes. Complete package contents and pricing can be found
at www.photomed.net or call
(800) 998-7765. DT
AD

[16] =>

[17] =>

Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition

July 2009

www.dental-tribune.com

Vol. 2, No. 5

Full-mouth prosthodontic rehabilitation
Combination of porcelain fused to metal and full ceramic restorations
By Ansgar C. Cheng & Elvin W.J. Leong,
Singapore

Full-mouth, fixed rehabilitation
of a mutilated dentition is always a
clinical challenge. Accurate diagnosis,
prudent choice of prosthodontic materials, and meticulous treatment execution are essential for a successful
treatment outcome over a long period
of time. The prosthodontic treatment
of a partially edentulous oral cavity with loss of vertical dimension
of occlusion is presented. Innovative
prosthodontic materials were used in
this report.
Prudent clinical judgement and a
careful balancing of the risks and
benefits of various treatment options
are essential for the long-term success of prosthodontic treatment. It is
known that the loss of vertical dimension of occlusion may pose significant
clinical difficulties in prosthodontic
treatment. The re-establishment and
maintenance of a new vertical dimension of occlusion is seldom taught
in the undergraduate dental curriculum. Various methods have been
proposed for the assessment and reestablishment of treatment of the vertical dimension. In general, alteration
of the vertical dimension of occlusion
should be approached with great care
and excessive changes of the vertical dimension of occlusion should be
avoided.
One of the challenges in full- mouth
fixed rehabilitation is obtaining an
accurate impression of multiple abutment teeth. Dental impressions sent
to commercial laboratories for conventional fixed prostheses have commonly been found to be deficient in
several respects. One of the major
deficiencies is that the prepared margins of tooth preparations are inadequately registered in the definitive impression. Because the master
blueprint for crown restorations is
the definitive impression, it is crucial that a good impression technique
be employed to obtain an accurate
impression that will allow fabrication
of precisely fitting indirect restorations, which may in turn determine
the restoration’s longevity. The optimal method of impression making
is to use as minimum an amount of
low-viscosity material as possible to
register fine detail. The bulk of the
impression is made with high viscosity material.
This article describes the prosthodontic management of a mutilated dentition using different types of
conventional and implant-supported

Fig. 1: Pre-treatment intra-oral
frontal view
presenting with
attrition, loss of
posterior support, reduced
occlusal vertical
dimension and
compromised
esthetics.

Fig. 2: Pre-treatment orthopantomogram X-ray showing inadequate
endodontic fillings, dental attrition
and inadequately restored teeth.

Fig. 3: Completed tooth preparations
for full coverage restorations
at the approximated treatment
occlusal vertical dimension. Note
the equi-gingival preparation
margins.

fixed restorations.

Wide-vue, Teledyne Waterpik, Fort
Collins, Colo.). Diagnostic wax-up
was carried out to restore the anterior teeth into proper form.
The resulting diagnostic waxup indicated an increase of vertical
dimension of 1.5 mm at the incisal
pin level. It was the authors’ experience that such level of change of
vertical dimension required no practical need for prolonged provisionalisation before definitive prosthodontic treatment.

Clinical report
A 45-year-old woman presented with
multiple missing and discoloured
teeth.
The patient desired to restore function and aesthetics. She presented
clinically with moderate dental attrition, defective restorations, loss of
posterior support, loss of occlusal
vertical dimension and compromised
aesthetics (Fig. 1).
The pre-treatment radiograph
showed inadequate endodontic obturation, missing mandibular posterior teeth, over-eruption of maxillary
posterior teeth and attrition of the
incisors. In spite of the overall condition, the natural teeth were free from
active dental caries and periodontal
probing was within normal limits.
The mandibular posterior bone sites
were diagnosed as type 2 (Fig. 2).
The overall treatment plan included placement of endosseous implants
in the mandibular posterior area, reestablishment of the vertical dimension of occlusion, re-treatment of the
endodontically involved teeth and
placement of fixed restorations in the
maxilla and mandible.
Maxillary and mandibular diagnostic casts were made of type IV dental
stone (Silky-Rock, WhipMix, Louisville, Ky.). The casts were mounted on
a semi-adjustable articulator (Hanau,

Because most of the teeth in the
maxillary arch required full coverage
restorations, fixed partial dentures
were prescribed for the replacement
of the missing maxillary right first
premolar and left first molar. Upon
completion of endodontic treatments,
posterior teeth were restored with
post-and-core foundations prior to full
coverage restoration preparation.
Seven
endosseous
implants
(Nobelreplace, Nobel Biocare, Yorba
Linda, Calif.) were placed in the posterior mandible with the presence of
a prosthodontist. All implants were
placed with 45 Ncm insertion torque.
In order to establish anterior guidance13, the treatment indicated that
the restoration of the anterior teeth
should be completed before the completion of the implant restorations.
The anterior teeth were prepared in
the usual manner for complete coverage crown restorations (Fig. 3).
The left maxillary and mandibular
second molars were also prepared to
receive provisional restorations for
additional vertical dimension support. Margins of the tooth preparations were kept supra-gingival and
no gingival displacement procedures
on the prepared teeth were necessary. High-viscosity vinyl polysiloxane
material (Aquasil Ultra Heavy; Dentsply DeTrey GmbH, Konstanz, Germany) was carefully injected onto all
tooth preparations, ensuring that all
tooth surfaces, including the margins,
were recorded.
A stock tray loaded with putty
g CT page 2B
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[18] =>

2B Clinical

Cosmetic Tribune | July 2009

COSMETIC TRIBUNE

f CT page 1B

The World’s Dental Newspaper · US Edition

material (Aquasil Putty; Dentsply
DeTrey GmbH, Konstanz, Germany)
was seated over the entire dental arch
to make the definitive impression. A
centric relation record was made with
a vinyl polysiloxane material (Regisil
PB; Dentsply).
The development of the planned
definitive complete coverage, indirect restorations, were carried out as
usual on the definitive casts. All maxillary and mandibular anterior teeth
were restored with Cercon (Degudent
GmbH, Hanau, Germany) full-ceramic crowns (Fig. 4).
The completed anterior restorations were cemented in resin-modified
glass ionomer luting agent (Rely-X
Unicem, ESPE, St. Paul, Minn.). Provisional crown restorations (Luxatemp
automix, Xenith/DMG, Englewood,
N.J.) were placed on the left maxillary and mandibular second molars
at the established vertical dimension
of occlusion.
Maxillary posterior teeth were prepared for restoration with complete
coverage porcelain fused to metal
crowns with metal occlusal surfaces.
(Fig. 5) Mandibular posterior teeth
were restored with complete coverage
porcelain fused to metal crowns with
porcelain occlusal surfaces (Fig. 6).
Definitive maxillary and mandibular impressions were made using
the technique described earlier. The
development of the definitive posterior restorations were carried out
in the usual manner on the definitive casts. Splinted, cemented-type
porcelain fused to metal restorations
with porcelain occlusal surfaces were
prescribed for the implant supported
mandibular posterior crowns.
After the mandibular implant, abutments were torqued to 32 Ncm. The
abutment screw holes were sealed
with gutta-percha (Mynol; Block Drug
Corp, Jersey City, N.J.). All maxillary and mandibular posterior crowns
were cemented in resin-modified
glass ionomer luting agent (Rely-X
Unicem, ESPE, St. Paul, Minn.).

Discussion
This clinical report required an
increase in the occlusal vertical
dimension. It was thus necessary to
make impressions that register all
tooth preparations in the anterior segment simultaneously.
The patient desired a high level
of esthetics; full ceramic restorations
were chosen for all anterior restorations. Because the minimum core
thickness for this full ceramic system
is 0.4 mm, this enabled conservation
of tooth structure while achieving reasonable aesthetics simultaneously.
Traditional porcelain fused to
metal anterior crown restorations
require the placement of labial crown
margins within the gingival sulcus in
order to mask the hue and value transition between the root surface and
porcelain fused to metal restoration.
By prescribing full ceramic restorations, intra-sulcular placement of
crown margins on the labial surface
becomes less crucial from an aesthetic point of view.

Publisher
Torsten Oemus
t.oemus@dtamerica.com

Fig. 4 Completed
anterior full ceramic
crown restorations.
Additional occlusal
support was gained
by provisional restorations to the left maxillary and mandibular
second molar.

President & CEO
Peter Witteczek
p.witteczek@dtamerica.com
Chief Operating Officer
Eric Seid
e.seid@dtamerica.com
Group Editor & Designer
Robin Goodman
r.goodman@dtamerica.com
Editor in Chief Cosmetic Tribune
Dr. Lorin Berland
d.berland@dtamerica.com
Managing Editor/Designer
Implant Tribune & Endo Tribune
Sierra Rendon
s.rendon@dtamerica.com

Fig. 5: Occlusal view
of completed definitive maxillary retorations. Note the metal
occlusal surfaces on
the posterior teeth.

Fig. 6: Occlusal view
of completed definitive
mandibular restorations with porcelain
occlusal surfaces.

C.E. Manager
Julia E. Wehkamp
E-mail: j.wehkamp@dtamerica.com

Dental Tribune America, LLC
213 West 35th Street, Suite 801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185

Fig. 7: Postoperative
radiograph showing
the combination of
prosthodontic treatment modalities. The
radio-opaque nature
of the full ceramic
restorations allow
radiographic assessment of restoration
fit.
In this report, the anterior teeth
were essentially caries free, teeth
preparation margins were made at
the gingival level and gingival retraction procedures were eliminated. As
gingival retraction cord packing was
not required, there was less physical
trauma to the gingival tissues and
less clinical time was needed. This is
particularly beneficial for thin gingival
biotypes.
Porcelain fused to metal restorations were used in the posterior teeth
because of their well documented
and long-term clinical track record.
In order to maximize the aesthetic
outcome, porcelain occlusal surfaces
were prescribed in the mandibular
teeth. In the maxillary posterior teeth,
metal occlusal surfaces were prescribed for its ease of fabrication and
superior structural strength.

Conclusion
The functional management of a complex prosthodontic rehabilitation is
always a clinical challenge. Various
restorative materials were used in this

report. A combination of full ceramic
restorations and porcelain fused to
metal restorations with metal and
porcelain occlusal surfaces enhances
the overall aesthetic outcome as well
as functional predictability. CT
(A complete list of references is available from the publisher.)

Cosmetic Tribune strives to maintain utmost
accuracy in its news and clinical reports.
If you find a factual error or content that
requires clarification, please contact Group
Editor Robin Goodman, at r.goodman@
dtamerica.com. Cosmetic Tribune cannot
assume responsibility for the validity of product claims or for typographical errors. The
publisher also does not assume responsibility
for product names or statements made by
advertisers. Opinions expressed by authors
are their own and may not reflect those of
Dental Tribune America.

About the authors
Dr. Ansgar C. Cheng obtained his dental training from the University of Hong Kong,
his prosthodontics specialty training from Northwestern University and his Certificate in
Maxillofacial Prosthodontics from UCLA. He is a prosthodontist with Specialist Dental
Group™, Mount Elizabeth Hospital, Singapore, and an adjunct associate professor at the
National University of Singapore.
Dr. Elvin W.J. Leong obtained both his dental training and prosthodontics specialty
training from the National University of Singapore. He is a member in Restorative Dentistry (prosthodontics) of the Royal College of Surgeons (Edinburgh) and a fellow of the
Academy of Medicine, Singapore. He is a prosthodontist with Specialist Dental Group,
Mount Elizabeth Hospital, Singapore.
For correspondence, please contact:
Dr. Ansgar C. Cheng
3 Mount Elizabeth #08-10

Web site: www.specialistdentalgroup.com

Singapore 228510

E-mail: drcheng@specialistdentalgroup.com

Republic of Singapore

[19] =>

[20] =>

[21] =>

HYGIENE TRIBUNE
The World’s Dental Hygiene Newspaper · U.S. Edition

July 2009

www.dental-tribune.com

Vol. 2, No. 5

Pest control in gums gardening
Locally applied antimicrobials as adjuncts to nonsurgical periodontal therapy
By Sandra Pierce, RDH, MPH

trol),” (Paquette 2004).

Success in gardening depends
partially on pest control. The use
of chemicals to inhibit pest growth
often yields a healthier crop. Periodontal therapy is to gums as pest
control is to soil.
The focused use of chemotherapeutics as antimicrobials can
enhance the outcomes of nonsurgical periodontal therapy, resulting in healthier mouths for our
patients.

Atridox
Two syringes are combined to
create a doxycycline gel that is
expressed through the canula.
When it comes in contact with sulcular fluids, the gel solidifies. The
doxycycline is released over time
as the product biodegrades in the
pocket.

Introduction

The benefits of chemotherapeutics
as adjuncts to nonsurgical periodontal therapy have been well
established. As a rule, locally
applied antimicrobials (LAAs) are
used in pockets with 5 mm or
greater depths. They can be placed
at the time of initial nonsurgical
therapy or as a secondary treatment for nonresponsive sites.
As adjunctive nonsurgical therapies have developed during the
last 30-plus years, several challenges presented themselves. The
antimicrobial products need to be
concentrated for an adequate time
in the treatment sites in therapeutic doses.
Although there are many antimicrobial mouth rinses, they do not
remain at adequate levels of concentration for a therapeutic length
of time. LAAs are another alternative.
LAAs are often a better choice
than systemic antibiotics in the
treatment of periodontal disease.
There are fewer risks and side
effects, such as upset to the gastrointestinal tract, systemic opportunistic infections, the development
of drug resistant bacteria, anaphylactic shock and patient compliance.
Systemic antibitotics are most
effective against individual bacteria. When they colonize into a
biofilm, the antibiotics must be
250 times more concentrated to be
effective.
According to Wilkins (2009),
general characteristics of an
effective chemotherapeutic agent
should include:
• Nontoxic: the agent does not
damage oral tissues or create systemic problems.
• No, or limited, absorption: the
action is confined to the oral cavity.
• Substantivity: the ability of an

Arestin placement.

Arestin syringe

Locally Applied Antimicrobials Available in the United States
Product
name

Type of antimicrobial

Delivery method

Estimated
cost

Arestin

minocycline

powdered microspheres are
expressed into the
pocket

$15–20 per site

Atridox

doxycycline hyclate

gel in prefilled
$11–69 per site
syringe with canula

PerioChip

chlorhexidine
gluconate

dissolving chip
inserted with
forceps

agent to be bound to the pellicle
and tooth surface and be released
over a period of time with retention
and potency.
• Bacterial specificity: may be
broad spectrum, but with an affinity for the pathogenic organisms of
the oral cavity.
• Low induced drug resistance:
low, or no, development of resistant organisms to the agent.

LAA summaries
Arestin
Microspheres of minocycline are
applied to the pocket in powdered
form. As fluid circulates, the minocycline is released over a period
of time.
Disadvantages
• Arestin can be costly to apply,
especially if it is needed multiple
times in multiple sites; there is
only one application per cartridge.
• In the initial study for FDA
approval, the product was applied
on three occasions. As sales representatives approached clinicians,
this fact was not disclosed and
clinicians failed to achieve similar
results, causing distrust with the

$15–20 per site

product.
• Patient acceptance went down
when second and third treatments
were recommended.
• The cartridges can occasionally be faulty, and may be damaged
by the operator.
• It is necessary to have specific
equipment to place (the syringe).
Advantages
• Substantivity is very good, and
the product can last up to 21 days.
• The application is convenient.
It is quick and easy to place.
• The product does not require
refrigeration, yet it has a good shelf
life.
• It “may block collagenases that
are implicated in host tissue breakdown” (Oringer 2002).
• The applicator is adaptable.
The cartridge can be bent to accommodate correct insertion angles.
Although the tip is somewhat bulky,
it can be modified with pressure
from the end of a mirror handle
and made flat enough to insert into
a pocket.
• “Patients with advanced periodontal disease, or smokers are
two to three times more likely to
respond (than to placebo or con-

Disadvantages
• The product has to be mixed
chairside 100 times, which can be
time consuming. (Some hygienists
have their patients mix it while
they complete instrumentation, to
save time.)
• The sticky and viscous nature
of the gel can cause it to stick to the
application canula, and be pulled
out as the canula is removed from
the pocket. This makes it somewhat
technique sensitive.
• There have been anecdotal
reports of the matrix left behind
after the doxycycline had dissolved.
Those remnants could potentially
harbor bacteria if left in the treated
site for a prolonged time.
• An allergic reaction is possible.
Advantages
• Good safety record.
• It is easily placed to the maximum pocket depth due to the small
size of the application canula, and
its flowability allows it to adapt to
root morphology.
• There have been no reports of
resistance to localized applications
of doxycycline to date.
• Lasts up to 21 days (Atridox
Web site).
• Works on smokers just as well
as nonsmokers (Ryder 1999).
• Its “efficacy can increase with
retreatment” (Lessem 2004).
• It has proven applications in
peri-implantitis (Renvert 2008).
• It is cost effective because one
syringe can be used in up to six
sites.
PerioChip
A flat rectangular chip, similar
in appearance to a popcorn hull,
the product is placed in a pocket,
where it dissolves slowly, releasing
chlorhexidine.
Disadvantages
• The product must be refrigerated before placement.
g HT page 3C

[22] =>

2C

Editor’s Letter

Dear Reader,
When you read an article in a
book, magazine or newspaper, do
you ever wonder how the author
managed to get her writing printed
or, maybe more importantly, how
did she know what to write about in
the first place? If you are an aspiring writer, these questions may
come to mind.
Dental hygienists have many
opportunities to write and there is
no shortage of topics! Talk to any
dental hygienist about the profession and she (or he!) will talk until
you figure out a way to gracefully
bow out of the conversation. If you
are a wannabe writer, listen to
people. Topics pop up left and right
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in everyday communications.
Better yet, listen to yourself
when you are having a discussion.
Subjects that make your voice raise
and make you speak faster are usually things that excite you. I would
recommend writing about those
issues. When deciding on a topic,
take into consideration your passions, areas of expertise and current hot topics.
The first step is to sit down and
write something: i.e., “seat of pants
to seat of chair,” is the expression
our group editor at Hygiene Tribune likes to use. Write about the
topic as you would speak about it
if you were talking to someone in
person.
Don’t worry about making everything perfect, just get your best

Hygiene Tribune | July 2009
thoughts out as they come to you.
My best ideas come to me as I lay
in bed at night trying to fall asleep.
I keep a note pad and pen on my
nightstand so I can write thoughts
down as soon as they pop up. Figure
out when you get your best ideas,
and make sure you have pen and
paper handy.
I challenge you to have something written by the next edition of
Hygiene Tribune. In that edition, I
will share with you what to do next!
Best Regards,

Angie Stone, RDH, BS
Editor in Chief

HYGIENE TRIBUNE
The World’s Dental Hygiene Newspaper · U. S. Edition

Publisher
Torsten Oemus
t.oemus@dtamerica.com

President & CEO
Peter Witteczek
p.witeczek@dtamerica.com

Chief Operating Officer
Eric Seid
e.seid@dtamerica.com
Group Editor & Designer
Robin Goodman
r.goodman@dtamerica.com

Editor in Chief Hygiene Tribune
Angie Stone RDH, BS
a.stone@dtamerica.com

Managing Editor/Designer
Implant Tribunes & Endo Tribune
Sierra Rendon
s.rendon@dtamerica.com

Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dtamerica.com

Online Editor
Fred Michmershuizen
f.michmershuizen@dtamerica.com

Product & Account Manager
Mark Eisen
m.eisen@dtamerica.com

Marketing Manager
Anna Wlodarczyk
a.wlodarczyk@dtamerica.com

Sales & Marketing Assistant
Lorrie Young
l.young@dtamerica.com

C.E. Manager
Julia E. Wehkamp
E-mail: j.wehkamp@dtamerica.com
Dental Tribune America, LLC
213 West 35th Street, Suite 801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185
Published by Dental Tribune America
© 2009 Dental Tribune America, LLC.
All rights reserved.
Hygiene Tribune strives to maintain utmost
accuracy in its news and clinical reports.
If you find a factual error or content that
requires clarification, please contact Group
Editor Robin Goodman, at r.goodman@
dtamerica.com. Hygiene Tribune cannot
assume responsibility for the validity of
product claims or for typographical errors.
The publisher also does not assume
responsibility for product names or
statements made by advertisers. Opinions
expressed by authors are their own and may
not reflect those of Dental Tribune America.

Tell us what you think!
Do you have general comments or criticism you would like to share? Is there
a particular topic you would like to see
articles about in Hygiene Tribune? Let us
know by e-mailing feedback@dtamerica.
com. We look forward to hearing from
you!

[23] =>

Clinical 3C

Hygiene Tribune | July 2009
f HT page 1C
• Handling the chip becomes
more difficult as it warms. The chip
loses its rigidity, and becomes difficult to place.
• The means of delivery prevents
taste alterations and tooth staining,
compared to chlorhexidine rinses.
• Because the chip keeps its
basic form, it tends to become displaced or lost before the antimicrobial action is complete.
• The product comes in a shape
that is not ideal for all pockets.
• The chip is too wide for many
pockets.
• The chip does not conform
to root morphology, especially in
furcations.
Advantages
• When the site is ideal, the
product is quick to place.
• No special tools are required to
place the chip.
• It lasts over seven days (per
package insert).

Considerations

With all of these antimicrobial
agents available to us, the question can be how to decide which
one to use. The answer depends on
practice philosophy, availability,
cost, efficacy, anatomical considerations, allergies and treatment

PerioChip placement.

planning. Some insurance companies won’t pay for periodontal
surgery for up to two years after a
site has been treated with an LAA.

Conclusions

In gardening, a seed must be planted in the proper soil. It must be
watered, nourished and protected
from pests. Dental hygienists are
caretakers of our patients’ health.
With LAA, clinicians can exponentially enhance the benefits of nonsurgical periodontal therapy.
Come garden in the gums with
me! HT
A complete list of references is
available from the publisher.

PerioChip packaging.

About the author
Sandra Pierce has been a dental
hygienist for 14 years, the last 12 of
which have been spent in a periodontal
practice. She has filled several service roles, most recently as vice president of the Utah Dental Hygienists’
Association. A clinical instructor and
associate professor at Utah College of
Dental Hygiene, Pierce is known as
“The Gums Gardener.” She lectures
nationally on nonsurgical periodontal
therapies and dental hygiene issues.
You may contact her at:
Tel.: (801) 372-0430
E-mail: sandypierce_rdh@yahoo.com
Web site: www.thegumsgardner.com
AD

[24] =>

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[cover] => DT U.S. 1909

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