MDDS Articulator Volume 17 Issue 3

ARTICULATOR MDDS

Connections for Metro Denver’s Dental Profession

Caries Risk Assessment for Clinical Practice 10 Planning the Shade Prescription 16

The CSI Effect: Redefining Dentistry’s Role in Forensic Sciences 18 Understanding the Biology & Biomechanics of Implant Dentistry - Respecting the Boundaries 32

RMDC Edition 2013 Volume 17, Issue 3

RMDC

EDITION The Colorado Convention Center

New to Management? Avoid These Three Common Mistakes 35

PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT 2882

The Articulator is a recipient of the 2012 International College of Dentists Silver Scroll Award

Photo: Denver Metro Convention & Visitors BureauB

Dental Laser Certification Full Spectrum Seminars Academy Academy of of Laser Laser Dentistry Dentistry Standard Proficiency Certification Certification Course

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as the excitement over laser dentistry been more smoke than substance? Since 1990, the U.S. Food and Drug Administration has cleared many different wavelengths for dental use. These different wavelengths create a world of difference in how the lasers operate, and their usefulness in the oral cavity. The use of lasers for specific procedures found in everyday general practice will be highlighted. The first day will detail laser use in the following subject matters: Non-Surgical, Surgical and Regenerative Periodontal Therapy Surgical and Restorative Implantology Fixed and Removable Prosthetics Oral Medicine/Oral Surgery/Oral Pathology Pediatric and Adolescent Operative Dentistry Endodontics Pediatric Dentistry Orthodontics Esthetic/Cosmetic Dentistry Practice Management/Marketing

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he second day workshop will give each participant hands-on experience with the various wavelengths, performing surgical procedures on in-vitro models. Real time videos of routine laser procedures will be part of the in-depth discussion of specific instrument settings and techniques for laser surgical procedures.

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r. Bob Convissar, founder of Full Spectrum Seminars, is a pioneer in Laser Dentistry. He was one of the first to incorporate Lasers into general practice, with over 22 years of experience with Diode, Erbium, CO2, and Nd.YAG wavelengths. He has authored/coauthored 4 textbooks and over a dozen peer reviewed papers. He has seen and heard it all—the truth and the hype--and works diligently to convey his knowledge and the benefits while dispelling the myths. Dr. Convissar recognizes that knowledge, proper training and certification will build the confidence required to allow you and your staff to incorporate Lasers effectively into your practice and use them to their fullest capacity. His latest textbook, Principles and Practice of Laser Dentistry is the # 1 selling laser dentistry textbook in the world.

W W W .FUL LSP ECT RUM SEM IN ARS .CO M

COURSE DATES March 22 - 23, 2012 LOCATION Denver, CO PRICE $895 Per Person

COURSE INSTRUCTOR Dr. Bob Convissar

For more information and to register for this course visit: Fullspectrumseminars.com

ARTICULATOR MDDS

Connections for Metro Denver’s Dental Profession

Volume 17, Issue 3

MDDS Articulator Editor Carrie Seabury, DDS

Director of Marketing and Communications Jason Mauterer Creative Manager & Managing Editor Chris Nelson Communications Committee Anil Idiculla, DMD, Chair Karen Franz, DDS Kelly Freeman, DDS Brandon Hall, DDS Jennifer Thompson, DDS Jeremy Kott, DDS Maria Juliana DiPasquale, DMD Nicholas Poulos, DDS Maureen Roach, DMD MDDS Executive Committee President D. Diane Fuller, DDS President-Elect Mitchell T. Friedman, DDS Treasurer Larry Weddle, DMD Secretary Ian Paisley, DDS Executive Director Elizabeth Price, MBA, CDE, CAE Printing Dilley Printing The Articulator is published bi-monthly by the Metropolitan Denver Dental Society and distributed to MDDS members as a direct benefit of membership. Editorial Policy All statements of opinion and of supposed fact are published under the authority of the authors, including editorials, letters and book reviews. They are not to be accepted as the views and/or opinions of the MDDS. The Articulator encourages letters to the editor, but reserves the right to edit and publish under the discretion of the editor. Advertising Policy MDDS reserves the right, in its sole discretion, to accept or reject advertising in its publications for any reasons including, but not limited to, materials which are offensive, defamatory or contrary to the best interests of MDDS. Advertiser represents and warrants the advertising is original; it does not infringe the copyright, trademark, service mark or proprietary rights of any other person; it does not invade the privacy rights of any person; and it is free from any libel, libelous or defamatory material. Advertiser agrees to indemnify and hold MDDS harmless from and against any breach of this warranty as well as any damages, expenses or costs (including attorney’s fees) arising from any claims of third parties. Inquiries may be addressed to: Metropolitan Denver Dental Society 3690 S. Yosemite St., Suite 200 Denver, CO 80237-1827 Phone: (303) 488-9700 Fax: (303) 488-0177 mddsdentist.com ©2011 Metropolitan Denver Dental Society

Member Publication

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RMDC 2013

Inside This Issue:

Some Words from our

Feed the Foundation - al LADO.............26

RMDC Chairman, Dr. Brett Levin ......4 Bonding Agents: Success Depends on Crispy Bacon ...................................6

Application.....................................28

Member Matters ..............................8

Event Calendar .............................30

Whooping cough: at the intersection of

Understanding the Biology &

dentistry and infectious disease .......9

Biomechanics of Implant Dentistry Respecting the Boundaries ..............32

Caries Risk Assessment for Clinical Practice........................10

New to Management? Avoid These Three Common Mistakes ...............35

A New GPS ...................................12 Planning the Shade Prescription.......16 The CSI Effect: Redefining Dentistry’s

Discovering Your Seven Me’s .........37 Classifieds.....................................38

Role in Forensic Sciences ...............18

BE SURE TO STOP BY OUR BOOTH AND SAY "HELLO!" RMDC HOST

OUR PARTNERS IN ORGANIZED DENTISTRY

Located in the Expo Hall Community Pavilion

2013 RMDC FREE

MOBILE APP! • Speaker and course info

• Course Evaluations • RMDC schedule and personal scheduler • CE code verification Sponsored by Patterson Dental

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RMDC Some Words From Our RMDC Chairman, Brett R. Levin, DMD

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f you are like me, January in Colorado means a few things. The certainty of snow falling and, for many of us, getting up to the mountains to enjoy some of the true beauty of this wonderful state. It also, and even more importantly, means it's time for the 2013 Rocky Mountain Dental Convention. The MDDS RMDC Programing Committee has once again been hard at work creating what should truly be one of the best educational experiences this region will see. If it has been a few years since you and your office have been there, then I really encourage you to attend in 2013. For those that have attended in the past, you already know what a great meeting this continues to be year after year. A meeting of this magnitude would not be possible without the help of all the volunteers and staff at the MDDS. Their help and support is truly second to none. As convention chair, I have been involved with every aspect of the planning of this meeting, much of it starting more than a year ago. I am thrilled to share with you some of the highlights of the upcoming meeting. Once again we are welcoming back both the Dawson Academy and the Pankey Institute for multiday courses. I know how hard it can be to travel out of town to attend a multiday course, and we are really proud to have them both in Colorado once again. If you think

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you have already “been there, done that,” I encourage you to take another look at each course, as they have been redesigned to meet the ever-changing and evolving needs of today’s dentist. The Dawson Academy is presenting “The Future of Dentistry in 2013 and

“Although the lectures take up the majority of the day, the exhibit hall will be bustling with activity with over 300 booths. It is as much about seeing old friends and reconnecting with colleagues as it is about learning.” Beyond: Physicians of the Masticatory System and Oral Health.” This course will cover it all, and dentists should be able to identify many of the prerestorative considerations to facilitate complete dentistry-health, stability and esthetics. The Pankey Institute's continuum will cover such topics as “Advanced Treatment Planning: Managing Esthetics, Occlusion, Joint, Airway and Worn Dentition.” It is continued by “Diagnosing Occlusal and Joint Health and Application in Everyday Dentistry,” followed by “Creating the Exemplary Comprehensive Practice.” As our convention continues to grow, we keep attracting world class speakers, and this year is no exception. Dr. Newton Fahl, Jr. from Brazil, one of the world authorities on composite will be lecturing on Mastering Anterior and

Posterior Composites Restorations. Dr. Gerard Chiche will be delivering his lecture on smile design and esthetic and occlusal techniques. Dr. Michael Norton from Great Britain will be discussing the biology and biomechanics of implants. Dr. Mike Miller will be covering dental materials (he is the force behind the “Reality” materials book), and Dr. John Kanca will be updating the changes in Adhesive Dentistry for 2013. Other topics include Practical Oral Surgery for the GP by Dr. John Alonge as well as a hands-on course for current concepts in Endodontic Therapy by Dr. David Landwehr. These are just a few of the topics geared for the dentists, with many others which I don’t even have the space to list. We are also excited about the plethora of choices for hygienists, assistants and front and back office personnel. Topics such as coding and practice profitability to infection control and handling conflict in the office are some of the choices for office staff. We have a tremendous hygiene fast track as well as a great pathology lecture. Maximizing social media and a technology update are also on the bill. We really have something for everyone. Although the lectures take up the majority of the day, the exhibit hall will be bustling with activity with over 300 booths. It is as much about seeing old friends and reconnecting with colleagues as it is about learning. Back by popular demand will be the

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RMDC Edition 2013

BOOTH #231

CONNECT party at the Hyatt Regency, followed again by an after party at Suite 200’s Marquis Room. Last year, both were very well attended with the after party actually maxing out the location’s capacity. We have booked a larger space this year at Suite 200, so no one will be squeezed out of this popular after-hours event! Another important note, this year the CONNECT party will benefit the Metropolitan Denver Dental Foundation (MDDF). All attendees will be eligible for some amazing door prizes and free drinks just for showing up! MDDF provides dental services to victims of domestic violence. The principal of “Smiling Again” is really hard to put into words until you have worked with this organization. Last year the organization was able to donate almost $1,000,000 in dental services, but sadly, this is just the tip of the iceberg and many victims are unable to be helped. Once again we will be utilizing the latest in technology with our RMDC mobile application for your smart phones. It is a great way to stay connected to all of the happenings at the convention and this year it will be better than ever.

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I invite everyone to join us on Thursday morning as we kick off the convention with a great speaker. Mr. Tim Gard will be presenting “Developing a Comic Vision.” Tim delivers a rejuvenating and immediately applicable message that teaches audiences to enhance productivity and enthusiasm in both professional and personal encounters. This is a great session for both doctors and staff alike. I would also like to take this opportunity to remind everyone that all sessions for this year’s meeting are again ticketed. The earlier you can register your office, the better. Not only do you save on registration fees, but you assure you and your staff of the courses you want. If during the convention you have any questions, we will have plenty of volunteers and staff available throughout the Convention Center to assist you. I look forward to seeing many of you at the Rocky Mountain Dental Convention 2013. Yours in good health, Brett R. Levin, DMD

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REFLECTIONS Crispy Bacon By Carrie Seabury, DDS

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eady yourself for a bold statement. There is nothing. Better. Than. Crispy Bacon. My quest to find a food source more satisfying - more delectable - more salty-licious than bacon has been fruitless. Bacon is versatile, readily available, and frankly, bacon really does make everything better. No other protein besides bacon can claim improvement on the turducken. That’s just a fact. Bacon has serious street cred and yet somehow remains humble and approachable. Bacon works hard for me and most importantly, bacon promises to save me should there ever be a zombie apocalypse. I speak the truth. This is my serious face. My game-on face. My Crispy Bacon face. My love for bacon has inspired me to celebrate my accomplishments by implementing a nod to The Bacon. I have decided to compare large victories in my life with the feeling of having a plate full of perfectly cooked crispy bacon winking at me. The day I found out I passed my dental boards? Now that was a Crispy Bacon moment. The day my son used the word please without being prompted? That certainly qualified as a Crispy Bacon moment. Some of the best TV moments revolve around Crispy Bacon. You and I both are acutely aware of Daisy Duke’s incredible talent of assembling a carburetor in the dark. This daunting accomplishment certainly invokes the power of The Bacon. I thought of Daisy the other morning when I

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was frantically changing out my car battery while the four kids inside (3 are mine – one was borrowed) patiently waited to be driven to school. Well, patiently may not be the right word. There were brothers fighting brothers inside that car. Garage door buttons were being recklessly pushed, pieces of chewed gum were being placed in the hair of the innocent…in other words…complete chaos was going down inside my Toyota. Needless to say, the clock was ticking. I gave myself 5.7 minutes to swap out my battery and all I have to say is bless the person who decided to use the same size nuts on the battery lead as the hold down. It saved me at

“When you really think about it, there are very few invasive procedures anyone else in the entire medical profession performs on conscious patients.” least 37 seconds not having to find a second wrench. As I slammed my car hood down in victory after hearing that satisfying zing of electricity when hooking up the positive lead, I knew. That sweet, sweet Crispy Bacon moment was coming to me just as soon as I turned the ignition key. Dentistry is no different than any other quest for the Crispy Bacon. If I may engage in a little self-indulgence, I would just like to mention that our job is hard. Super-hard. I recently attended an MDDS pediatric CE course taught by Dr. Ulrich Klein and he fluffed our feathers a bit when he mentioned how hard it is to complete the work we

do. Every day we perform microsurgery on conscious patients. When you really think about it, there are very few invasive procedures anyone else in the entire medical profession performs on conscious patients. Setting a broken bone, vaccinations and throat cultures are some of the worst of them and they all are finished within a few minutes at worst. Contrarily, we dentists are just barely getting started when administering our injections. We still have 30 minutes or more to help our patients through before the appointment is over. The rapport we share with our patients and the verbal skills we develop over the years to guide our patients through our dental procedures is amazing. We are involved in a profession that truly values trust, honor and service. As a patient, just to make it through the surgical intervention takes courage. There are noises, sensations and an element of the unknown that keeps our patients on edge. Add into this equation a potential patient history of survival of verbal, physical or sexual abuse, neglect, war or acts of violence, or other moments in life that may predispose a patient to lose a sense of trust. We can never truly know the battles our patients have faced. For all of these reasons and more, our patients deserve some Bacon for even making it through our front door. It is tremendously difficult to guide our patients through a dental procedure and keep the experience positive and light and worthy of the term “a good experience.” Yet, we do it every day. We exist in this profession solely for the opportunity to serve. Chalk another victory up for the dentite team.

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When we act from our hearts and make every recommendation with our patients’ best interests in mind, our patients can feel our best intentions. I think every moment a patient agrees to give you his/her trust should be celebrated. High fives and Crispy Bacon for the entire office staff. We all play an important role in helping our patients value their health. When delivering the best patient experience possible, there is more to it than acting with a pure heart. We each need to be on top of our game, embracing new technology and ideas to deliver state-of-the-art dental care. This is where the Rocky Mountain Dental Convention helps us all. Bacon cannot fry without the RMDC. As we come together every year for the RMDC, we learn new ideas through our CE courses and interaction with our colleagues and dental reps. Each person who works the show is there to bring us more Crispy Bacon moments. There is new technology and equipment to explore.

There are new clinical techniques to make procedures smoother for us and our patients. Furthermore, there are tips and ideas for managing the office and our lives so that our Bacon can shine. Without the convenience of the RMDC every year, most of us would miss out on all the opportunities to grow and crisp up our Bacon. The true advantage to taking the time out of your practice and coming down to Denver for the long weekend is the camaraderie you experience here. A dental conference in Denver is like no other. We are some of the warmest, friendliest people in the country – I think it’s all the Colorado sunshine injected directly into our bloodstream every day. Today why don’t you try to reach out to a neighbor in your class, an old friend you haven’t seen in a while, or a co-worker you have always wanted to know a little better…and talk to them about some Crispy Bacon!

BOOTH #133

W E C A R E A B O U T Y O U R S U C C E S S Dental practice transitions are about relationships. The relationship of the doctors and between the doctors and patients. We work to build those relationships so there is trust and integrity which results in a successful, smooth transition.

CTC Associates Chatterley Transition Consulting info@ctc-associates.com

mddsdentist.com

303-795-8800

www.ctc-associates.com

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MEMBER MATTERS New Members - Welcome! Dr. Brandon M. Braud Dr. Jennifer L. Clark Dr. Amir H. Dehghan Dr. Tricia A. Doukas Dr. Claire-Marie Ficsor

Dr. Christopher Frederick Dr. Rebecca H. Goldberg Dr. Melissa A. Goodpaster Dr. Melissa J. Hinze Dr. Josh Jackstien

Dr. Joshua Jenkins Dr. Clifford M. Jones Dr. Adriana S. Lamounier Dr. Somi M. Lim Dr. Aleksandr V. Lutskiy

Dr. James E. McLain Dr. Grady S. Randall Dr. Celeste C. Riggs Dr. Elizabeth R. Salazar Dr. Galvin A. Trogdon

Dr. Kory J. Wallin Dr. Philip M. Yen

MDDS New Member Event - Dive Lounge, Denver Aquarium

The last New Member Networking Event of the year at The Dive Lounge at the Downtown Aquarium was a great success! New MDDS members, Ambassadors, MDDS Board members and staff mingled amongst aquatic wildlife at the final event of the year. MDDS would like to thank the ADA for the grant initiative that funded this year’s events.

MDDS new members enjoying the aquatic atmosphere of The Downtown Aquarium

Mingling “Under the Sea” at The Dive Lounge

MDDS Ladies Night Out at the Vineyard

MDDS Ladies Night Out at the Vineyard held at Balistreri Vineyards in Denver, CO was an unforgettable evening filled with antipasta, wine and networking amongst fellow women dental professionals. Attendees received a private tour of the wine cellar from co-owner, Mrs. Birdie Balistreri! MDDS would like to thank the ADA for the grant initiative that funded this year’s events.

Mrs. Birdie Balistreri giving attendees a tour of the wine cellar at Balistreri Vineyards

SAVETHEDATE Thursday, February 7, 2013 BRING YOUR FRIENDS & FAMILY TO WATCH THE DENVER NUGGETS BEAT THE CHICAGO BULLS!

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Ladies Night Out attendees enjoying Balistreri Vineyards’ finest wines

MDDS NIGHT WITH THE

Hosted by:

REGISTER ONLINE at mddsdentist.com

Whooping cough: at the intersection of dentistry and infectious disease

2013

By Kathryn DeYoung, MS Resident Epidemiologist, Denver Public Health

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SCH EDU LE

t starts with a runny nose, a low fever, a bit of a cough. It looks like a cold. But after a couple weeks, the fever disappears and the cough can progress to a bark and such violent, uncontrollable coughing fits that a person can’t catch his breath, making a whooping sound when it is finally possible to breathe. A fit might end in gagging or vomiting. In an infant, these symptoms might be totally absent; she might just be unable to breathe. A teen or adult might have a mild chronic cough or a full-blown case. The cough can last up to 10 weeks and can be so severe it causes rib fractures. It is pertussis, or whooping cough.

February 28 Thommen Medical

Practice Building Implant by Implant Dr. Paul R. Farrell Oral and Maxillofacial Surgeon Reading, Pennsylvania April 11 BioHorizons

Complications in Implant Dentistry: Treatment Planning and Restorative Concepts to Minimize Failures and Improve Treatment Outcomes Dr. Aldo Leopardi, Prosthodontist Greenwood Village, Colorado June 20 Implant Direct

Effective and Efficient Abutment or Implant Level Protocols for the Partially Edentulous Patient

Denver Public Health has been very busy responding to the ongoing pertussis epidemic in Denver. In the course of this response, we have begun a more thoughtful consideration of who is really at risk for pertussis and needs to be warned about what whooping cough looks like and how to prevent it. As it turns out, one of those groups is dental care providers. We are concerned that dental care providers may have a unique potential to be exposed and to expose others to whooping cough without being fully aware of their vulnerability to the disease.

Dr. John S. Cavallaro, Jr., Prosthodontist Brooklyn, New York

Location: MDDS Building 3690 S. Yosemite Street Denver, Colorado 80237 Time: 5:30 PM to 8:30 PM

Only about 8% of adults have received the “booster” vaccine against pertussis, Tdap. Concern that immunity from the childhood DTaP series wanes more quickly than thought has prompted an urgent call for all adults and children 10 or older who have not yet received the Tdap to get it as soon as possible. To protect infants and children from exposure, it is especially vital that healthcare providers (including dental practitioners), pregnant/ post-partum women, friends or families of infants, and childcare workers receive the vaccine.

• Check that you and your colleagues have had the Tdap vaccine • Visit http://denverhealth.org/ to listen to a child with whooping cough. A child or adult with these symptoms may be ill with pertussis: o Cough for 1 to 2 weeks with no fever; o Severe coughing that may cause gagging or vomiting (infants may not cough, only gasp for air); o Gasping for breath after a coughing fit and a “whooping” sound • Untreated, people with whooping cough can spread the infection for up to three weeks. People with whooping cough should stay out of work, school, or child care until they have finished five days of antibiotics to reduce the risk of spreading the infection • If you have questions about preventing, recognizing, or responding to whooping cough, please feel free to call our public health nurses, Carol McDonald and Stephanie Stark, at (303) 602-3614

YEARS

FI R S T T H R E E E V E N T S

Since about June of this year, there have been an unusually high number of people infected with whooping cough in Colorado. What is traditionally a disease of infants has expanded in recent years until infection rates are just as high in 10-14 year olds as in those 0-4 years old. Anyone can get pertussis, though, and researchers have found that infants and children often get the disease from adults, who may not realize their chronic cough is pertussis. There have been over 200 cases in Denver this year, more than the last four years combined. There has now been one death from pertussis in Colorado this year and at least 16 in other states, mostly infants.

While we at Denver Public Health work to control whooping cough, here is what you can do at the intersection of dentistry and infectious disease:

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CELEBRATING

Complimentary light dinner at 5:30 PM. Lecture begins promptly at 6:00 PM. CE credits are available. Fees for 2013 are waived due to corporate sponsorship.

Please Note: Capacity is limited. If interested in attending, please call 720.488.7677 to reserve your place.

SCAN THIS CODE FOR THE FULL SCHEDULE OR VISIT: www.knowledgefactoryco.com/discschedule

C O NTA C T

TO R.S.V.P.

Aldo Leopardi, BDS, DDS, MS Prosthodontist /// P. 720.488.7677 /// F. 720.488.7717

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RMDC SPEAKER CARIES RISK ASSESSMENT FOR CLINICAL PRACTICE By V. Kim Kutsch, DMD Dental Caries Disease Model

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ental caries is a transmissible bacterial mediated disease of the oral cavity that leads to net mineral loss in the teeth resulting in white-spot lesions or cavitation and potential tooth loss. This disease is prevalent in all age groups and often is a chronic disease.1 Historically the disease model centered on two primary pathogens Mutans streptococci and Lactobacillus, however, additional pathogens are being identified every year and some 40 different bacteria have now been implicated in this disease .2,3,4 Dental caries is no longer a disease of a Mutans streptococci, it is a true biofilm disease. In recent years, our understanding of biofilms has increased significantly, and our appreciation for the complexity of this disease model has also increased. Current biofilm studies suggest dental caries is a pH dysfunction of the normal biofilm on the teeth.5 Prolonged periods of low pH in the mouth provides the selection pressure to favor cariogenic bacteria and at the same time is responsible for demineralization and net mineral loss from the teeth.6 These acidogenic/aciduric bacteria help maintain the low pH conditions they are adapted for. The pH also selects for similarly behaving bacteria in the biofilm, and the biofilm eventually becomes more acidogenic/aciduric and ultimately these pathogens predominate.5 At the same time these low pH conditions provide the environment that demineralizes the teeth. Dental caries is a challenging disease to treat, as bacteria in biofilms are strongly resistant to antibodies, antibiotics and antimicrobial agents.7 As a result, biofilm diseases do not readily respond to surgery, vaccinations, or antimicrobial strategies targeting just one or two species. In order to effectively treat dental caries disease, not only must we restore the teeth to function, but the dental biofilm make-up and chemistry needs to be restored to a health.6 In addition to being recognized as a biofilm disease that contributes to local hard tissue chemistry, the multifactorial nature of the dental caries disease model itself is becoming clearer. Recent studies indicate that dental caries may have systemic effects and cariogenic bacteria may be associated with bacterial endocarditis and peripheral inflammatory disease.8,9 Additionally,

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other systemic bacterial infections may arise from oral bacteria.10,11,12 Further studies have also identified several different genetic types that may genetically predispose an individual to dental caries.13-18 Clearly the diverse interaction of the multiple factors that contribute to caries pathology calls for a new approach to diagnosing and treating this disease as restoring teeth alone no longer fits this new scientific model. The Risk Assessment-Based Caries Management Model CAMBRA, an acronym for “Caries Management By Risk Assessment,” is an evidence-based approach that identifies and examines the individual dental caries risk factors for each patient and then focuses effective strategies for those specific risk factors. A six year retrospective university based study validated risk factors used in many caries risk assessment (CRA) forms using data from 12,954 predominantly adult patients.19 The factors studied were later organized into three categories; disease indicators, pathogenic factors, and protective factors. It is the balance of these factors that determine the expression of caries disease (demineralization) or health.20 This study not only validated the individual risk factors but also validated outcomes based on the assessments. It is interesting to note that those patients in this study who were assessed as high or extreme risk at baseline and received only restorative treatment, the percent that had new cavities on one year follow-up CRA appointments were 69.3 and 88.0 % respectively.19 In addition, four risk factors demonstrated such high odds ratios that they are now considered indicators of the disease. These factors include: visible cavitations, radiographic interproximal enamel lesions, active white-spot lesions, and a recent history of restorations due to decay in the previous three years. The study also identified risk factors highly predictive of dental caries such as visible plaque on the teeth, inadequate saliva, frequent snacking, and xerostomiainducing medications. Numerous CRA forms are available and should be a routine part of every dental examination. Specific risk factors for small children vary significantly from adults, and risk assessment forms specifically for children are also available.21 Coaching Behavioral Change While dental caries can be described as a pH

specific biofilm disease, for many patients it can just as accurately be described as a behavioral disease. Dental caries really comes down to three factors (or “usual suspects”) driving the disease for most patients: 1) Biofilm: either they have the wrong bacteria (predominantly cariogenic) in their biofilm, or they have too much bacterial load (fig. 1), 2) Destructive diet: either they have too much sugar in their diet or they eat/snack too frequently (fig. 2), 3) Saliva: either they don’t have enough saliva (fig. 3.) (medication induced xerostomia), or they have poor buffering capacity.23.24 Modifying the pathogenic biofilm or poor dietary habits for the most part involve lifestyle choices and require behavioral change. Addressing the behavioral component plays a significant role in successfully treating dental caries. Without addressing the causative role of behavior in the disease process, no intervention (restorative or chemical) will stand much chance of success. CAMBRA is an approach that identifies the specific risks, and dental professionals can make recommendations targeted to the patient’s specific risk factors to effectively manage the disease.25,26,27 The problem is that providing information or instructing the patient on what they “should or need” to do does not translate to behavioral change. Furthermore, short-term behavioral change without sustainability will not result in long-term health. Educating patients about their risk and making recommendations, is not enough. CAMBRA clinicians can better serve their patients by utilizing Motivational Interviewing techniques to help the patient identify problems and move them towards making behavioral change.28 The Motivational Interview is a process of identifying where a particular patient is in the stages of behavioral change. Do they recognize they have a problem, are they aware of it but not ready to do anything about it? Are they ready to make a behavioral change? Have they already been trying to change and are in a maintenance or relapse situation? The Motivational Interview philosophy helps identify where a patient is in terms of change. Wellness Coaching advances the knowledge from the Motivational Interview and helps create action.29 Wellness Coaching is a partnership between the practitioner and the patient. The coach (practitioner) helps the patient look at their desires, abilities, reasons and needs in

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RMDC Edition 2013

Caries Risk Assessment: A New System for Private Practice Thursday, January 24, 2013

Dr. V. Kim Kutsch is an inventor holding numerous patents in dentistry. As a clinician he is a graduate and mentor in the prestigious Kois Center and maintains a private practice in Albany, Oregon.

lives. The first step is to engage the patient, get them involved in the process.

Fig. 1 High caries risk patient with visible plaque on their teeth.

Traditionally dentists were trained to identify how many cavities a patient has, and identify the teeth and surfaces involved, as part of our restorative treatment planning. This approach goes straight from diagnosis to treatment without engaging the patient. The most important question is not how many cavities a patient has, but “why” do they have cavities in the first place. Only by correctly answering that question can we provide the patient with the effective disease management and lifestyle choices that leads to long term health. Targeted Strategies

Fig. 2 High caries risk patient with high frequency of sugar in their diet.

Fig. 3 High caries risk patient with medication induced xerostomia

making healthcare decisions. The patient needs to be aware of their own motivations for making a behavioral change, and work through an honest assessment of why they want to change, what they are realistically capable of and what they hope to accomplish. The coach asks powerful open ended questions that help the patient determine their focus and discover their own answers for their health goals. If behavioral changes are part of the strategic plan, it is always a good idea to coach the patient through making one behavioral change at a time. The coach is responsible to help direct, encourage and also hold the patient accountable during the process. Wellness coaching offers a very real solution to help patients make life long behavioral changes that creates wellness in their

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The next step is for the CAMBRA clinician to recommend specific strategies targeted for the patient’s individual risk factors. Typical strategies might include antimicrobial agents, pH neutralization, xylitol, fluoride and calcium phosphate, (insert products of choice) and lifestyle changes such as homecare, diet, eliminating destructive habits and combinations thereof. This can be a confusing task, as there are no standardized methods and protocols. However, it is important to make sure that whatever strategies are recommended, that there are sufficient materials provided to the patient to last at least 3 months, until their next re-care appointment. Changing biofilms and behaviors are not short term propositions, the professional needs to think long term for the strategies.30 When presented with new recommendations, especially if they are presented as the only option, it is a normal reaction to resist or push back. However, when presented with options that they get to choose from: 1) Declining Therapy, 2) Provisional Therapy, or 3) Recommended Therapy, patients are more likely to participate at some level. This approach provides the patient with clearly outlined information necessary to make a good health care decision for themselves, and engages the patient into the decision making process. Depending on which option the patient selects, it also makes the patient clearly self-aware of their current level of motivation. Furthermore, it also removes the task of “selling” the concept/products/strategies to patients. This simple change in approach leads to improved patient participation and adherence in treatment strategies. Summary Understanding the patient’s specific risk for dental caries give the clinician the opportunity to address the cause of their cavities, not just restore lesions. Utilizing a simple Caries Risk Assessment form that incorporates Motivational Interviewing and then adding Wellness Coaching principles into the

treatment phase, better insight to understanding patient’s attitudes, risk levels, and participation can be obtained and the clinician will be better prepared to help the patient improve their oral health. These simple changes open the door to successfully implement the caries risk model into clinical practice, which in turn provides the predictability and improved treatment outcomes for the practice. By addressing the barriers and making simple changes that take less time with greater consistency, more patients choose treatment. More healthy patients translate to more satisfied patients, increased patient referrals and greater practice success and satisfaction. References: 1. Bagramian RA, Garcia-Godoy F, Volpe AR. The global increase in dental caries. A pending public health crisis. Am J Dent. 2009 Feb;22(1):3-8. 2. Tanner AC, Mathney JM, Kent RL Jr, et al. Cultivable Anaerobic Microbiota of Severe Early Childhood Caries. J Clin Microbiol. April 2011. 49(4):1464-74. 3. Tanner ACR, Kent RL, Lif Holgerson P, et al. Microbiota of severe early childhood caries before and after therapy. JDR November 2011. 90(11):1298-1305. 4. Kutsch VK, Kutsch CL, Nelson BC. A clinical look at CAMBRA. DPR August 2007. 41(8):62-67. 5. Takahashi N, Nyvad B. The role of bacteria in the caries process: ecological perspectives. J Dent Res March 2011. 90(3):294-303. 6. Marsh PD. Dental plaque as a biofilm: the significance of pH in health and caries. Compend Contin Educ Dent March 2009. 30(2):76-8. 7. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999 May 21;284(5418):1318-22. 7. Fejerskov O, Kidd E. Dental Caries: The disease and its clinical management. Blackwell Munksgaard 2003 Oxford UK. Pp:4-5. 8. Nakano K, Nemoto H, Nomura R, Inaba H, Yoshioka H, Taniguchi K, Amano A, Ooshima T. Detection of oral bacteria in cardiovascular specimens. Oral Microbiol Immunol February 2009. 24(1):64-8.9. Nemoto H, Nakano K, Nomura R, Ooshima T. M olecular characterization of Streptococcus mutans strains isolated from the heart valve of an infective endocarditis patient. J Med Microbiol. 2008 Jul;57(Pt 7):891-5. 10. Gundre P, Pascal W, et al. Prosthetic valve endocarditis caused by Gemella sanguinis: a consequence of persistent dental infection. Am J Med Sci. 2011 Jun;341(6):512-3. 11. Kojima A, Nakano K, et al. Infection of specific strains of Streptococcus mutans, oral bacteria, confers a risk of ulcerative colitis. Sci Rep. 2012;2:332. 12. Wang R, Kaplan A, Guo L, Shi W, Zhou X, Lux R, He X. The influence of iron availability on human salivary microbial community composition. Microb Ecol. 2012 Jul;64(1):152-61. 13. Ozturk et al. J DENT RES.2010; 0: 0022034510364491v1gum disease found in genes. Journal Dental Research April 2010. 14.Wendell S, Wang X, Brown M, Cooper ME et al. Taste genes associated with dental caries. JDR November 2010. 89(11):1198-1202. 15. Werneck RI, Lázaro FP, Cobat A, Grant AV, Xavier MB, Abel L, Alcaïs A, Trevilatto PC, Mira MT. A major gene effect controls resistance to caries. J Dent Res. 2011 Jun;90(6):735-9. 16. Abranches J, Miller JH, Martinez AR, Simpson-Haidaris PJ, Burne RA, Lemos JA. The CollagenBinding Protein Cnm Is Required for Streptococcus mutans Adherence to and Intracellular Invasion of Human Coronary Artery Endothelial Cells. Infect Immun. 2011 Jun;79(6):2277-84. 17. Shaffer JR, Wang X, Feingold E, et al. Genomer-wide association scan for childhood caries implicates novel genes. Journal Dent Res December 2011. 90(12):1457-1462. 18. Tannure PN, Kuchler EC, Falagan-Lotsch P, et al. MMP13 polymorphism decreases risk for dental caries. Caries Research July/August 2012. 46(4): 401-407. 19. Domejean S, White JM, Featherstone JDB. Validation of the CDA CAMBRA caries risk assessment – a six-year retrospective study. CDA Journal October 2011. 39(10):709-715. 20. Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent. 2006 MarApr;28(2):128-32; discussion 192-8. 21.Ramos-Gomez F, Ng MW. Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols. CDA Journal October 2011. 39(10):7723-734. 22. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007 Oct;35(10):703-7. 23. Kutsch VK, Young DA. New directions in the etiology of dental caries disease. CDA Journal October 2011. 39(10):716-721. 24. Kutsch VK, Cady C. MIX Disease: Diagnosis and Treatment. Inside Dentistry July 2009. 5(7):80-83. 25. http://www.ada.org/sections/newsAndEvents/docs/topics_caries_instructions.pdf 26. Brocklehurst PR, AshleyJR, Tickle M. Patient assessment in general dental practice – risk assessment or clinical monitoring? British Dental Journal April 2011. 210(8):351-354. 25. Tellez M, Gray SL, Lim S, Ismail AI. Sealants and dental caries: dentists’ perspectives on evidencebased recommendations. JADA September 2011. 142(9):1033-40. 28. Weinstein P. Motivational interviewing concepts and the relationship to rrisk management and patient counseling. CDA Journal October 2011. 39(10):742-45. 29. Arloski M. Wellness Coaching: for Lasting Lifestyle Change. Whole Person Associates, Inc. Duluth MN. 2007. 30. Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res. 2012 Apr 3;46(2):118-129.

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RMDC SPEAKER

A NEW GPS By Greg Psaltis, DDS

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ot long ago I was driving on back roads of France, heading toward Brussels, Belgium from Verdun, France and found myself on small, two-lane roads with few signs. While the countryside was stunning, my route was entirely unknown to me. On the bright side, I knew where I wanted to go, so at least the end point was in mind. Like many of us today, when I am traveling in a new area of the country (or world) I have come to rely on my GPS. If I know where I’m headed, that amazing little device will tell me every turn, even when I’m at an intersection in the middle of farmlands. Without it I could probably find my way to Brussels, but the ease of its directions brought me directly and efficiently to my destination. Is it possible that a similar approach might assist dental professionals in moving along in their lives? What if the goals of one’s career were to have professional security up until retirement and more personal satisfaction? Perhaps a specialized GPS could help. Enthused following graduation from our professional training, we dentists embark on an exciting new career and are soon confronted with some surprising discoveries of the “real world.” School loans, set up fees for a new practice, overhead expenses, living expenses (without financial aid) and other things come to bear on us as our enthusiasm is high and our resources are low. It is an exciting, but imperfect world that we have entered. Years later, when our resources are high and our enthusiasm has waned, we look for ways to make it to the finish line with enough finances to ensure a well-deserved relaxed retirement. Somewhere along the line, things shifted. Looking back, we may wonder how we might have handled it all differently. The majority of dentists are somewhere in between these two extremes of professional life. The balance between enthusiasm and resources slowly builds as our practices do the same. Our bodies are still young and strong, our desire to serve others remains tantamount and life is good. From this period of our lives, it is difficult to imagine that anything could possibly derail us. Retirement is still so far away that we hardly give it a thought. We have it all under control. Which of these times is the best time to determine ways to ensure a meaningful life after our days of practice are behind us? When

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is the best time to decide how to maintain our enthusiasm? When can we be setting the stage for a strong financial foundation? Either extreme as well as that heady middle period provide roadblocks to many thoughts about a bigger picture. We are typically focused on the “now” and miss opportunities to “have it all.” As it turns out, every period of time is the best time to be focused on establishing professional security while enhancing personal satisfaction in our lives as dental professionals. As we move through our careers, it is possible to obtain the goal of professional security through a number of means. Fiscal responsibility, particularly in the current economic environment, is perhaps the primary goal of any young practitioner. The burden of debt not only weights heavily on our pocketbooks, but also on our mental state. The sense that we “must” go to work is often either created or expanded by the need to service our debts. This not only impacts our sense of professional security, but also our ability to enjoy our work. Management of our financial affairs, especially right at the moment that we feel we deserve some reward for all our years of study, becomes a significant challenge. It also becomes one of the biggest roadblocks toward security and satisfaction. Other means of establishing professional security include taking the individual responsibility off the shoulders of the dentist by establishing a genuine Team. Many people banter the word “Team” about when they actually have a staff. There is a huge difference. Team is not a label. It is a process and it is a commitment of highest degree. The expense, time and resistance (by employees and doctors) each provide ample reason to either abandon the efforts or to never begin. However, the benefits far outweigh these hurdles and once a real Team is in place, life becomes easier (and more enjoyable) for the dentist. Nobody likes to think about their own demise and few actually do it in realistic terms. There is probably nothing more devastating for a practice (and a family) than the unexpected disability or death of a dentist. While overhead insurance can cover the costs associated with running a practice, there is no insurance available that can breathe life into a practice without a dentist. Some dentists may rely on friends to help out in such an emergency, but a mutual aid group will ensure the viability of the practice following the death (or disability) of its owner. It is the best insurance that money cannot buy. On the other hand, while resources build and retirement begins to loom, that old “zip” that we once had may have begun to fade and drudgery may be the catch word of work. No longer encumbered

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RMDC Edition 2013

A New GPS Friday, January 25, 2013 by all the “have to’s” of a dental practice, it just doesn’t seem quite as much fun as it was back in the beginning. So how is it possible to keep that spark alive and reach the goal of personal satisfaction in the repetitive tasks that we have faced for years? The first method is to accept gratitude as a part of your remuneration of your practice. This may be a developed skill, but when dentists fully take in the compliments that are provided by patients in the form of comments, cards or letters satisfaction will certainly follow. When we pay attention to the multiple gifts we have rather than holding our focus on production and collections, it is a wonderful discovery that we are surrounded by riches. A second step is to truly connect with patients (and, in my case, their parents). Few of us fail to notice when any business person, be it a barista in a coffee shop, a checker at a grocery store or salesperson at a clothing store, gives us special attention. This usually results in a personalized experience that forms a bond that is potentially richer than the usual doctor-patient interaction. Sending personalized notes (I prefer handwritten), articles from the local newspaper or acknowledging gifts of all sorts enhance the human part of our connections with clientele. In my practice I routinely get pages of coloring books that have been artistically prepared for me by my young patients. In addition, I also get senior pictures and even wedding invitations. I believe this is the result of having connected with patients. This has the potential for enhancing satisfaction in a different way.

Dr. Gregory Psaltis has been a pediatric dentist for 38 years, the last 32 of which have been in private practice in Olympia, Washington.

When a practice becomes successful, it is often accompanied by a sense of it becoming a burden. Solutions for this are varied, but the basic premise is to seek out some help. If you have established a Team (as described above) this step will be much easier than if you have held onto the reins of your practice tightly. Finding a locum tenens, an associate or a partner are all ways that the pressure of being a solo practitioner can be assuaged. It requires thought, planning and then execution, but having another dentist to share the load will create more free time and decrease the sense of “always having to be at the office.” The fourth technique calls on us to make a conscious choice to put an emphasis on satisfaction as a specific goal. This requires no skills and no expenses—only a state of consciousness to be cognizant of the best parts of a practice. It requires that we no longer take things for granted, but instead take in the non-monetary rewards of our office. This may include a sense of self-satisfaction for the years of study to become a dentist, the pleasure of treating the Team to a fun CE trip or simply the joy of serving a patient in an unexpectedly positive manner. In summary, all practitioners have tools available to create a long-term sense of professional security and personal satisfaction in our work. None are difficult, but all require a degree of commitment, focus and awareness. Each of these may be seen as part of the routing on your personal GPS assuming the end point is already known. Dentistry affords us the opportunity to have abundant lives. If we can chart a course, the abundance is much likelier.

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RMDC SPEAKER

PLANNING THE SHADE PRESCRIPTION By Gerard J. Chiche, DDS

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hen the patient comes to consult for Esthetic Treatment, the consultation appointment is divided into a conventional evaluation with charting, periodontal, occlusal and radiographic surveys, diagnostic models and photographs and an esthetic evaluation involving an esthetic analysis and a focus on the patients esthetic requests. The media image displayed in many advertisings has a very strong influence in contemporary dental treatment. Increasingly, Fig. 1 today’s smile is part of a youthful dynamic appearance characterized by whiter teeth which often fall beyond the range of traditional shade guides. To that effect it is possible to identify two types of patients: Fig. 2 perfect-minded, or natural-minded. Patients in the first category will typically expect maximum regularity and alignment along with maximum brightness and a “general sparking Fig. 3 effect”. It will be critical to provide for these patients a straight dental midline, a regular smile line, often flatter than the curvature of the lower lip, symmetric central incisors, lateral incisors and canines along with symmetric gingival margins. (Fig. 1). Natural-minded patients will typically expect a general sense of regularity and alignment along with definite brightness but do not wish their teeth to be noticed at every turn. In any pleasing smile, pleasing tooth symmetry is found close to the midline, therefore the central incisors must be mostly symmetric with only minor irregularities (a central incisor may be more mesially inclined than the other, and the distal incisal angle of the central incisors may be bilaterally asymmetric). The main asymmetry will be provided between the lateral incisors. The canines will also provide minor asymmetry as their gingival margins

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and their cusp tips do not need to be leveled horizontally. The depth of the incisal embrasures should be of a natural depth in addition to providing a natural progression (Fig. 2 and 3). These pictures also illustrate the need to provide these patients with subtle polychromatic effects : incisal halo, streaks and increased cervical saturation. When planning the shade prescription, one must bear in mind that the most frequent shade variation from the basic shade of an anterior tooth is observed in nature at the incisal third. The next most frequent category observed is when the Fig. 4 shade distribution is nearly uniform, resulting in a monochromatic appearance. In the third category, the color deviation from the basic shade is observed at the cervical third mostly Fig. 5 and finally in the fourth group, the shade variation involves the middle aspect of the tooth. In order to give the patient an idea of what incisal effects are possible, the incisal aspect of the shade tab is discussed with the patient after the basic shade is selected. The patients’ reaction usually is to prefer incisal effects similar to the shade tab if they are natural driven, and to attenuate the effects to the maximum if they are perfect-driven. There are three typical scenarios that can be transmitted to the dental ceramist: Lightly Monochromatic Shade Design It is very common to find patients who are so displeased by the dark appearance of their teeth that they end up requesting very monochromatic and high brightness restorations (Fig.4, 5). The shade prescription is accordingly straightforward and uncomplicated and the dental ceramist will assume that the incisal effects are very tenuous and hardly noticed. Lightly Monochromatic Shade Design with Effects The typical incisal effects found on unworn incisors include 1. Halo effect, 2. Transparent incisal Border 3. Dentin Streaks or mamelons 4. Proximal translucency (Fig. 6 & 7). These are the typical shading effects of young, unworn incisors and impart a very pleasing effect to the tooth shade overall. The incorporation of these effects for the

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RMDC Edition 2013

Smile Design, Esthetic and Occlusal Techniques Saturday, January 26, 2013

Dr. Gerard Chiche is the Thomas P. Hinman Endowed Chair in Restorative Dentistry and the Director of the Center for Esthetic & Implant Dentistry at MCG School of Dentistry in Augusta, GA. He is the author of the textbooks: ‘Esthetics of Anterior Fixed Restorations’ and ‘Smile Design - A guide for Clinician, Ceramist and Patient’.

natural-driven patients yields this shade prescription. It is recommended that the clinician provides in such situations the same template each time so that nuances and variations recorded from patient to patient may be easier interpreted.

Fig. 6 & 7

Fig. 8 & 9

Lightly Polychromatic Shade Design There are situations where several shades and various degrees of discolorations coexist in the same mouth, or conversely there are situations where different ceramic systems are present and do not perfectly match with one another. In such situations, the rule is to insure for maximum patient acceptance of the restorations that the central incisors are kept a slightly higher value than the other anterior teeth. If the value of the central incisors ends up a slightly lower value due to some excessive translucency for example, then it is very likely that the patient will reject the final result, even with the best designed proportions, display and length. Therefore, in situations where the patient desires a natural appearance or when several different colors or ceramic systems are expected in the final outcome a lightly polychromatic system should be considered. Typically, a mild transition in shades will be produced whereas the central incisors have the highest value, followed by the lateral incisors and finally the canines. Whenever possible, this effect should be very soft. However, it allows to easily transition from a light central incisor to a dark canine which was not bleached (Fig. 8 and 9). It is very important in such transition to keep the value of the lateral incisor closest to the central incisor even if the canine is of a much lower value. In the following diagram example the value is lowered by mixing A1 shade incrementally into the B1 shade. The typical incisal and proximal effects can also be added to the prescription. * Dr. Chiche is Director Center of Esthetic and Implant Dentistry Thomas P. Hinman Endowed Professor Georgia Health Sciences University, College of Dental Medicine. Augusta GA.

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RMDC SPEAKER

THE CSI EFFECT: By Theresa S. Gonzales, DMD, MS

Redefining Dentistry’s Role in Forensic Sciences

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herever he steps, whatever he touches, whatever he leaves, even unconsciously, will serve as silent evidence against him. Not only his fingerprints or his footprints, but his hair, the fibers from his clothes, the glass he breaks, the tool mark he leaves, the paint he scratches, the blood or semen that he deposits or collects – all these and more bear mute witness against him. This is evidence that does not forget. It is not confused by the excitement of the moment. It is not absent because human witnesses are. It is factual evidence. Physical evidence cannot be wrong; it cannot perjure itself; it cannot be wholly absent. Only its interpretation can err. Only human failure to find it, study and understand it can diminish its value.” — Paul L. Kirk, PhD “Father of Criminalistics” Dr. Paul Kirk’s comments regarding the role of forensic science and evidence collection in law enforcement are the stuff of which popular television docudramas like CSI : Miami are made. Each week millions of Americans tune in to this popular show in what appears to be nothing more than an national infatuation with a “21st-century whodunit" complete with the requisite scientific validation. This glorification of the use of scientific principles to assist in crime solving has produced what some legal analysts refer to as the “CSI Effect.” “As television educated America about the role of forensic evidence in the law enforcement/justice system, the legal community found itself adapting as juries began finding reasonable doubt when the State did not produce “sufficient” forensic evidence. ‘The CSI Effect’ placed the legal community under a new burden of helping jury members distinguish the fictional aspects of television from reality. Additionally, expert witnesses must now explore new ways of presenting testimony that captivates the jury’s desire to be not only entertained, but also convinced that law enforcement properly collected evidence and that crime scene technicians properly performed all of the relevant types of forensic analyses.” Our cultural fascination with the forensic sciences has allowed the public to potentially overestimate the dental as well as the medical professional’s capabilities and capacities with respect to our precise role in law enforcement. Forensic odontology (often referred to as forensic dentistry) is but one of the many disciplines of forensic science and it is the one branch that requires unique dental expertise. The word forensics is derived from the Latin word forensis and it literally means “public or forum.” A second meaning of the word is associated with Epithelial Pathology: from A to Z/ Physical Examination of the Head and Neck for Dental Health Care Providers

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Thursday, January 24, 2013

“debate or argument." Generally, forensic odontology may be defined as that branch of forensic science that deals with the proper handling, examination and evaluation of dental evidence that is presented in the interest of justice. Forensic odontologists generally define their responsibilities along four main areas of concentration: 1) 2) 3) 4)

identification of human remains recognition and responsible reporting of abuse age determination assessment of bite mark injuries

No doubt, the legal community will continue to rely on the dental profession to provide expertise in civil and criminal proceedings. Regrettably, most undergraduate and even graduate dental school curricula do not provide appropriate levels of training in forensic applications of dental science. Education, experience and membership in professional organizations are necessary to ensure that dentists and dentistry remain committed to the scientific basis of the forensic sciences and in order for forensic odontology to continue to meet the standards of judicial review. Clearly, the field of forensic odontology encompasses many scientific areas which, if used properly, can make invaluable contributions to the resolution of social and legal disputes. If you have an interest in this branch of the forensic sciences, there are a number of ways to get involved. The simplest way is to talk to your local dental society to identify opportunities for participation in your area and potential mentors willing to help you acquire the skills necessary for effective participation.

Col. Theresa Gonzales, DMD, MS has just returned from Europe after completing a tour as the Commander of the Bavaria Dental Activity. For the past six years, she has commanded formations and deployed to Iraq with the 1st Medical Brigade as the Chief of Clinical Operations. Recently, she was selected by the Surgeon General as the Director of Communications for the Army Medical Department- the second largest command in the Army inventory.

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RMDC Edition 2013

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Examine a holistic approach to understanding patients’ current health conditions and possibilities for future health. Discuss using thorough diagnosis to help prevent the stress of premature failure and clinical surprises. Investigate when it’s safe to treat without making changes to occlusion versus when additional diagnosis, support and therapy become necessary. Compare options for treating patients with unstable occlusion and joints, including when and why to use appliance therapy, equilibration, orthodontics and restorative dentistry. The ultimate goal of this presentation is to help participants develop a system for diagnosing and differentiating treatment for occlusally stable and unstable patients in a practical way for general practice.

January 24th/Day 1: Advanced Treatment Planning: Esthetics, Occlusion, Joint, Airway and Worn Dentition Broaden your scope of diagnosis and the implications of your decision-making on your patients over their lifespan. The management of your restorative patients requires a global approach. Viewing your patients as more than just occlusal surfaces and incisal edges is integral to providing optimal dental as well as medical health and well-being. Investigate protocols for addressing your restorative dental patients with excessive occlusal wear, GERD, skeletal discrepancies, jaw or joint pain and snoring and sleep apnea through the use of patient-specific examples.

January 26th/Day 3: Creating the Exemplary Comprehensive Practice

January 25th/Day 2: Diagnosing Occlusal and Joint Health and Application in Everyday Dentistry

Learn proven techniques and systems that will bring your team into alignment and help increase your rate of comprehensive case acceptance. The ABC network show Extreme Makeover has raised patient’s awareness of advanced esthetic procedures and thousands of patients are seeking dental health and cosmetic improvement. Although today’s dentists have trained to accomplish advanced restorative and cosmetic procedures, unfortunately many are unable to turn knowledge into reality. Get more fulfillment in your dentistry by changing people’s lives through comprehensive care. Move your patients beyond patch and repair procedures that are just enough to stay within the insurance limits. This advanced seminar is designed for the dentists and staff in offices that use articulators and have an understanding of occlusion, utilize composite and porcelain veneer restorations, use digital photography and desire to perform more comprehensive dentistry in their daily practice. JAN

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By Maureen Roach, DMD

G

rowing up in Mexico City, Chef Richard Sandoval (right) and his family would gather at his grandmother’s table for large, lively meals. Chef Sandoval would join his grandmother in the kitchen as she prepared authentic Mexican feasts from scratch. From his grandmother, he learned to respect fresh, authentic ingredients and to create the vibrant flavors that turned family dinners into celebrated events. Meanwhile, his restaurateur father, owner of Madeiras and Villa Fiore in Acapulco, imparted lessons in service and restaurant management. These early influences inspired Chef Sandoval to enroll at the Culinary Institute of America. Upon graduation, he gained the attention of New Yorkers with his contemporary French restaurants, Savann and Savann East. Soon, though, he returned to his first love – the Mexican food of his childhood. In 1997 he channeled his passion into Maya, his flagship modern Mexican restaurant in New York. Chef Sandoval opened his second modern Mexican concept, Tamayo, in Denver in 2001. In 2003, Chef Sandoval and opera star Placido Domingo partnered at Pampano, which would become their first of many restaurants together. Located in midtown Manhattan, Pampano serves coastal Mexican cuisine. 2004 took Chef Sandoval back to Denver where he opened Zengo, his first Latin-Asian restaurant. His newest addition to the Denver foodie scene does not disappoint. Opening its doors in August of 2012, al Lado is a great asset to the riverfront area. From the moment you walk in, the cozy vibe, warm woods and cheerful staff make you realize it’s a place you could spend a fantastic evening. One could easily pony up to the bar for a few hours or grab a secluded table to enjoy an evening of good conversation accompanied by

wonderful food, drink and service. As we enjoyed our first glass of wine at the bar, resident Chef Clint Wangsnes (formerly of Zengo), greeted us and explained the features of the menu. The distinctly Latin style of Al Lado’s wide arrangement of options make it deliciously tough to choose. Thankfully, everything is the perfect size for sharing. Al Lado boasts a fantastically intriguing wine list, incredibly delectable small plates and, of course, a wonderful Latin flavor. Once seated at our table, we were immediately greeted by our server who was extremely knowledgeable in both food and wine pairings. As he put it “you simply can’t go wrong” and I couldn’t agree more. We started off with the tapas, all delicious, but there were definitely a few musthaves: the bacon wrapped dates and the croquets. Yum! Along those same lines, while the wine list is absolutely enticing, I would recommend starting out with the habanero sangria which has just enough of a bite to make you want a second! In addition to the “heavenly dates” and “creamy croquets,” I would be remiss if I didn’t mention the shishito peppers. The accompaniment of a roasted garlic aioli is perfect dip for these tasty morsels. Next up were the Cazueles (Spanish for cooking pot) – some fantastic choices here as well. Our thoughts went immediately to the lamb meatball with goat cheese, which proved to be an excellent choice. When paired with a great Argentina malbec, the flavors were simply remarkable. Finally, it was time for the cocas (Spanish flatbreads). We indulged in the hongos y tartufo which sports the delicious combination of mushrooms, spinach, truffle oil and goat cheese, all baked to perfection with just enough crisp to the crust. One of the added benefits to al Lado is their wonderful happy hour and nightly specials. Check out their website for more details. Happy eating my fellow foodies!

Mention you want to "Feed the Foundation" when making your reservation in January and 10% of tab goes to benefit MDDF! No dayArticulator restrictions! mddsdentist.com RMDC Edition 2012 26 your

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RMDC SPEAKER

BONDING AGENTS SUCCESS DEPENDS ON APPLICATION By Michael B. Miller, DDS

B

onding agents or adhesives, as the name implies, are products that allow us to adhere various types of dental materials to enamel, dentin, and even other dental materials. Unlike the old hydrophobic materials used to bond to enamel, virtually all of the current bonding agents are typically hydrophilic to some extent to be compatible with dentin. However, it is this need to be hydrophilic that has caused most of the problems when it comes to bonding. Therefore, success or failure with these products depends as much on how they are applied as which product you choose to use.

Note: To create the moist or wet status, many manufacturers will tell you to use your air syringe. Typical instructions will tell you to “dry lightly for 2-3 seconds” or some variation thereof. Our tests show that using air to create moist or wet options is not effective. From a clinical perspective, it is even more difficult. For example, if you are trying to “dry lightly” an MOD preparation, you may merely be blowing the excess water from one proximal box to another. Therefore, the blotting techniques we have developed have proven to be much more effective and easier to calibrate. In addition, when using the moist or wet option, you should apply the adhesive or primer immediately after blotting the tooth. If you wait even 15 seconds (especially if you are using the rubber dam), some of the moisture could evaporate, which could affect the performance of the adhesive.

Moisture Status of Preparation

After rinsing the phosphoric acid etchant, you need to know the optimal moisture status of the preparation. Our tests show that this can be one of the most critical steps during the adhesive process. However, the directions from many manufacturers either omit this description entirely or it is covered inadequately. Therefore, we test all bonding agents using three protocols:

Furthermore, if you choose to apply a product containing either chlorhexidine or glutaraldehyde to inactivate MMPs (matrix metalloproteinases that can break down the collagen scaffolding which is essential for stable bonds), use the Moist protocol prior to applying the product. Then follow our suggested technique (our tests have found the optimal way to apply each adhesive), treating the MMP inhibitor that you applied as if it were water.

• Dry

Method and Time for Applying the Primer/Adhesive

Air syringe is used to produce forceful air for 2-3 seconds for a small preparation or longer until the cavity is completely void of visible moisture, but not totally desiccated.

• Moist

Blot with a lint-free, dry 2x2 gauze, mini-sponge, or virtually any absorbent product that will not leave a residue on the tooth surface. The result should be a tooth surface with no visible moisture, but appears to have either a matte or slightly shiny appearance (depending on the character of the dentin and type of instrument used to prepare it). This protocol will leave necessary moisture in the demineralized dentin (created by the etching process). Clinically, you would have to cut 2x2 gauze (if used) into small sections or use other products such as an applicator tip or mini-sponge to siphon off the excess moisture in small areas. For large areas, such as a complete crown preparation, draping an intact 2x2 gauze over the preparation may be more effective and expeditious.

• Wet

Use the same type of blotting material described under Moist and dip it

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into distilled water. Then blot this wet material with a dry 2x2 to create a “damp” blotting material. Use this “damp” material to blot the cavity preparation, leaving tooth surface with a definite sheen of water on it, but be sure all puddles of water are removed.

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The manner by which you apply a primer or adhesive can vary from the simple “let sit” of some manufacturers to literally scrubbing it into the surface of the preparation. “Let sit” may be effective in the laboratory on flat test teeth, but it rarely works with the complex surfaces found in many preparations, especially vertical ones. “Scrubbing” is a relative term and the force by which it is accomplished is limited by the application instrument. In other words, the applicator tips that are usually supplied with bonding agents are rarely stiff enough to allow vigorous “scrubbing.” “Gentle agitation,” which refers to applying the primer/adhesive and then basically moving it around on the preparation surface to ensure that there is optimal contact in all areas, is in-between “scrubbing” and “let sit.” “Rubbing” is basically the same as “scrubbing,” but it is presumably accomplished in a less aggressive manner, although from a clinical perspective, trying to differentiate between “rubbing” and “scrubbing” is virtually impossible. Application time can also vary the effectiveness. Our tests found the best method and optimal time to apply the bonding agent. Be aware that the size of the preparation will affect the application time. While

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RMDC Edition 2013

Materials Friday, January 25, 2013

the stated times are application for small Class V preparations, you should extend the times for large Class IIs. In addition, don’t start your timer until the preparation is thoroughly wet with primer or adhesive.

Method of Evaporating the Solvent

The monomers in the primers or bonding resins are typically dissolved in solvents (usually ethanol, acetone, and/or water), which carry these monomers into the demineralized surface of the preparation. Etching with phosphoric acid creates this demineralized surface. These solvents, besides being the vehicle in which the monomers are dissolved, need to be hydrophilic since the demineralized dentin surface contains moisture to prevent the collagen network from collapsing. The solvents also tend to be “water-chasing.” This property refers to the solvent being attracted to the moisture content of the dentin. As the solvent “chases the water,” it literally brings the active monomers with it. Once this job is done, however, the solvent needs to be evaporated, since it can actually interfere with adhesion if it remains in the adhesive. Part of the reason for the interference is the dilution factor. In other words, solvents literally water-down the adhesive. But even more important is that the hydrophilic nature of a solvent can prevent the bonding of the hydrophobic materials such as composites and cements subsequently being placed. After application of an adhesive or primer, the excess is usually first removed by suctioning, being careful to allow a continuous coating to remain on the tooth. If you don’t suction the excess, there is a tendency to just blow the primer or adhesive from one part of the cavity to another section or onto the soft tissue, which can cause untoward reactions that are typically self-limiting but may provoke undesirable questions from the patient. After suctioning the excess, the solvent needs to be evaporated using air. The typical method is to place the tip of the air syringe about 1.0cm from the tooth and direct a gentle stream of air (like a breeze) at the preparation surface. Some adhesives, however, require a more forceful air flow, not only to evaporate the solvent, but also to keep the film thickness as minimal as possible so the layer of adhesive does not interfere with the complete seating of an indirect restoration. When using forceful air, be careful not to blow the primer or adhesive completely off the tooth. This can usually be done by starting the evaporation procedure with gentle air and proceed to forceful. We have determined the optimal technique for each adhesive. The result of this evaporation effort should be a layer of primer that appears dry (you can’t move it around with the air syringe) and the preparation surface appears shiny. This air-evaporation effort may take five or more seconds, depending on the size of the cavity.

Dr. Michael Miller is the co-founder, President, and Editor-in-Chief of REALITY and maintains a dental practice in Houston, Texas.

If the dentin surface is not shiny, it may not be sealed. Therefore, it seems prudent to apply additional adhesive and repeat the evaporation process. Typically, the reapplication is merely applying the material and immediately beginning the evaporation process — you don’t need to wait as you may have when you applied it initially. If, after the second application, the dentin surface is still not shiny, we recommend applying the adhesive one final time.

Light Curing the Primer/Adhesive

If this is the final component of the bonding agent (such as when you are using a single-component product), you would typically cure it at this time. The conventional curing time has always been 20 seconds. However, this may be overkill for some adhesives. We tested the optimal curing time for each adhesive. But be aware that even these times may need to be altered based on the distance from the tip of the light to the tooth surface. For some bonding agents used in the dual-cured or self-cured mode, in which an activator is mixed with the main component of the kit, you may need to wait until the restorative material or indirect restoration is placed to cure the adhesive or allow it to cure concurrently along with the dualcured or self-cured composite or cement.

Method of Applying the Bonding Resin

As this component does not typically contain any solvents and, indeed, is usually primarily hydrophobic, you do not have to apply air other than to thin out the layer. While this will work, overaggressive use of the air can lead to overthinning, which, in turn, can affect the performance of the bonding agent. You can alternately remove the excess by using the same applicator, but blotting it with a 2x2 each time you remove more excess. This is known as the “brush on, brush off” technique and works well.

Final Word

While new bonding agents tout various benefits, this article aimed to show it’s the details that determine success, not necessarily the product you use.

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EVENT CALENDAR March 19

JANUARY 2013

Metro Denver Dental Society: CPR & AED Training, a Two Year Certification Metropolitan Denver Dental Society Headquarters 3690 S. Yosemite St., Denver, CO 80237 6:00pm-9:00pm (303) 488-9700 For more info go to: mddsdentist.com

January 24-26

Metro Denver Dental Society: 2013 Rocky Mountain Dental Convention Colorado Convention Center 700 14th St. Denver, CO 80202 (303) 488-9700 For more info go to: rmdconline.com

March 21

FEBRUARY 2013

Metro Denver Dental Society: Sinus Course Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 (303) 488-9700 For more info go to: mddsdentist.com

February 12

Metro Denver Dental Society: MDDS Night with the Nuggets Pepsi Center 1000 Chopper Circle Denver, CO 80204 6:30pm (303) 488-9700 For more info go to: mddsdentist.com

February 20

March 28

Metro Denver Dental Society: CPR & AED Training, a Two Year Certification Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 6:00pm-9:00pm (303) 488-9700 For more info go to: mddsdentist.com

February 22

Metro Denver Dental Society: Basic Radiation Education for Unlicensed Dental Personnel Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 8:00am-12:00pm (303) 488-9700 For more info go to: mddsdentist.com

MARCH 2013 March 7, 8

Metro Denver Dental Society: Mastery of Modern Endodontics for the General Practitioner-Dr. John West Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 (303) 488-9700 For more info go to: mddsdentist.com

Metro Denver Dental Society: Prevention of Oral Disease-Ms. Andrea Wiseman) Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 6:00pm-8:30pm (303) 488-9700 For more info go to: mddsdentist.com

APRIL 2013 April 19 & 20

Metro Denver Dental Society: Botox and Dermal Fillers Training: Course I American Academy of Facial Esthetics - Dr. Louis Malcmacher Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 8:30am-5:00pm (303) 488-9700 For more info go to: mddsdentist.com

April 25

Metro Denver Dental Society: CPR & AED Training, a Two Year Certification Metro Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 6:00pm-9:00pm (303) 488-9700 For more info go to: mddsdentist.com

MAY 2013 May 16

Metro Denver Dental Society: MDDS 116th Annual Meeting Wings Over the Rockies Air & Space Museum 7711 E Academy Blvd. Denver, CO 80237 6:00pm-9:00pm (303) 488-9700 For more info go to: mddsdentist.com

May 24

Metro Denver Dental Society: Hands -on Course: State-of-the-Art Tips, Tricks and Hands-on Techniques in Implant Overdentures for Private Practice-Dr. Robert Vogel This will be a premier MDDS CE event presented by implant specialist Dr. Robert Vogel. Metropolitan Denver Dental Society Headquarters 3690 S. Yosemite St. Denver, CO 80237 9:00am-4:00pm (303) 488-9700 For more info go to: mddsdentist.com

JUNE 2013 June 13

CDA Annual Meeting CDA House of Delegates & Annual Meeting in Steamboat Springs at the Sheraton Resort 2200 Village Inn Court Steamboat Springs, CO 80477 All Day

June 20

Metro Denver Dental Society: MDDS CE Weekend Getaway The Ritz-Carlton, Bachelor Gulch 0130 Daybreak Ridge Avon, Colorado 81620

For more info go to: mddsdentist.com

JULY 2013 July 18-20

ADA New Dentist Conference Four Seasons Hotel Denver 111 14th St. Denver, CO 80202 All Day

BOTOX AND DERMAL FILLERS TRAINING COURSE I Presented by Dr. Louis Malcmacher and The American Academy of Facial Esthetics (AAFE)

Botox Training Courses for Physicians, Dentists, Nurses and all Licensed Healthcare Professionals Day One - Botox Training Day Two - Dermal Fillers Training

30

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RMDC SPEAKER

Understanding the Biology & Biomechanics of Implant Dentistry

By Dr. Michael Norton, BDS, FDS, RCS(ED)

RESPECTING THE BOUNDARIES

T

he intimate relationship between living tissue and artificial implant material is complex. Some of the factors that have been known or seen to influence outcome include:

• The bio-inertness, biocompatibility and/or biotoxicity of the implant material • The differential elasticity of the materials and tissues • The implant design • The primary implant stability • The manner by which the tissues attach to the material surface • The topography of the material surface • The presence of micromovement • The implant-abutment joint design (micromovement, microleakage & platform switching) The importance of osseointegration is not just about a biologic response to a given metal, but more importantly it is about functional longevity. This more than anything defines clinical success and thus it emphasizes the need for us to understand the mode by which osseointegration works, since we place implants not for their own sake but to support dental restorations over the long term. By the mid 1980’s ultrastructural studies on the bone to implant interface were being carried out with the help of scanning and transmission electron microscopy. The result of these studies was the categorical confirmation that a fusion between implant and bone did not exist. In fact there were always two distinct zones of organic material interposed between implant surface and bone. The width of these zones appeared to vary according to the implant material used and this suggests that the zonal width acts in some way as a marker of biocompatibility. The concept of a direct fusion was no longer tenable and other explanations for the clinical and experimental impact of osseointegration have been sought. In particular it became clear that if fusion was not the key to osseointegration, then macro-

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mddsdentist.com

and microscopic surface topography were essentially responsible for biomechanical retention.

Certainly it is easy to see how the macroscopic threading of an implant might aid resistance to axial forces, and with the recent advent of the tapered implant design it is also possible to maximize initial primary stability. Such primary stability reduces micro-movement, which has itself been implicated in the etiology of early implant failure. However it is imperative to understand that this mechanical stability only accounts for the first three weeks after which remodeling results in a drop in mechanical stability and at this point early onset oseeointegration becomes vital. Implant retention can be measured by two different modes of resistance; these are termed axial interfacial tensile strength and rotational interfacial shear strength. It can be assumed that resistance to rotation may be the result of increased mechanical bone-implant-interlocking by microscopic surface roughening or pitting, which would then suggest that the strength of the interface is dependant on the strength of bone and the proportion of bone at the interface, which is mechanically interlocked with the implant. This is easy to understand when one considers the resistance of bony threads between implant threads, and the force required to fracture those threads but perhaps less clear at the microscopic level. Utilizing this knowledge it is possible to make certain assumptions regarding the bone-to-implant interface. With the aid of mathematical principles, it is possible to derive a fundamental equation that mathematically determines the strength of an implant in bone. Determining the optimal shape and dimension of a pit on the surface of an implant for maximum bone interlocking could also be derived. The application of this mathematical equation is prefaced by knowledge that the strength of the interfacial tissues most close to the implant are weak and incapable of resisting shear. By contrast, mature bone

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RMDC Edition 2013

Dr. Michael Norton is a specialist in Oral Surgery with Understanding the Biology and Biomechanics of Implant Dentistry - Respecting the Boundaries a practice in London, England. He is the Associate

Thursday, January 24, 2013 would represent maximum mechanical strength, and the mechanical strength would therefore increase across the interface, which is known to be from 300-500nm thick for commercially pure titanium, and thus it could be assumed that the mechanical strength of the interfacial tissues increased over this distance. Clearly the surface roughness of an implant could be considered in terms of a variety of pits of varying shape and size. It was postulated that the depth of a pit would influence the proportion of mature bone able to grow into it and that for a pit depth less than the interfacial distance only weak tissues with little or no resistance to shear would be incorporated. However with increasing pit depth a plug of mature bone would be incorporated with increasing mechanical strength. For machine prepared titanium, the surface pitting was seen to be shallow and although the macroscopic threads are of course relatively deep and provide resistance to axial forces the rotational shear stress for such implants is relatively low by today’s standards, with early torque removal studies confirming a removal torque of 30 to 60Ncm. By contrast the rough coated and grit blasted implants have surface topographies characterized by pits of varying shape and dimension, allowing plugs of mature bone to grow into the pits and effect resistance to shear forces in particular, with torques typically >150Ncm often required to unscrew these implants from bone. Expanding this mathematical theme, it was also apparent that the proportion of mature bone interacting with the implant will be dependant on the number of pits on the surface, or pit density. These mathematical findings have been corroborated in extensive experimental studies which have shown that the ideal surface roughness should be of the order of 1.5¾m with recent evidence for the benefit of a superimposed nano-topography to aid an even more tenacious interfacial bond which may even have a bio-active component to it. In addition, it is widely known that bone cannot be maintained adjacent to a machined collar with bone loss typically occurring down to the first thread within the first six months of loading. One reason

Editor of the International Journal of Oral & Maxillofacial Implants.

postulated for this is the absence of a propitious load transmission in the absence of the interfacial interlocking described above. However, multiple studies utilizing a roughened implant surface with the addition of a coronal micro-threaded portion have consistently demonstrated insignificant marginal bone loss. Such a dramatic contrast provides weighty evidence for the impact of the biomechanical theory proposed. Of course there has been considerable speculation about the role of the implant-abutment connection with respect to marginal bone levels, with experimental studies identifying the horizontal and vertical position of the microgap as being an over-riding factor. The concept of platform switching may have both a biomechanical as well as biological impact on the this vital area with evidence that the load transmission through an external hex-top design without platform switching was less favorable than with platform switching such as through an internal conical joint. In addition to the above microleakage has been indicated as the source of a peri-implant inflammatory infiltrate, which may itself cause crestal bone loss. In clinical reality all of the above will play a part in stabilization of the marginal bone. Today there is a clear convergence in implant designs which support the statements made in this article, with a diversity of third generation micro-roughened surfaces, all of which creep ever closer to the top of the implant where there is now a routinely applied micro-threading. In addition, we are seeing a gradual shift towards internal connections, which would seem to create more propitious conditions for the preservation of crestal bone and are also known to provide a more rigid connection from a mechanical standpoint, thereby reducing screw joint failures, which are themselves associated with fistula formation and marginal bone loss. In combination with our greater understand for tissue handling, new clinical techniques such as immediate placement and immediate loading, these developments will continue to result in greater predictability from both a biological and mechanical perspective, as well as impacting upon healing times and the diversity of areas which can be treated, such as the posterior maxilla, with improved long-term clinical success.

Connect with Old Friends & Make New Friends at the

RMDC Friday Night Party!

Since 2005, thanks to the generosity of MDDS and its members who volunteer their time and talent, MDDF has helped others Smile Again and learn the importance of optimal oral health. Thanks to our Friday Night Friends, you could win a great prize, but you have to be there to win!

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CDAAnnual AnnualSession Session CDA

June 13-15, 2013 June

Steamboat Springs, Springs, CO CO Steamboat

www.cdaonline.org www.cdaonline.org

House of Delegates, CE, Family Friendly Activities, Golf, Networking, Rodeo... House of Delegates, CE, Family Friendly Activities, Golf, Networking, Rodeo...

RMDC RMDC Happy Hour &

Happy Hour & Networking Event

Networking Event Jan. 24, 2013 at 5:30 p.m. 2013 atCE 5:30 p.m. After a day of Rocky Mountain Jan. Dental24, Convention courses and tradeshow shopping, join your New Dentist colleagues After a day of Rocky Mountain Dental Convention CE courses (10 years or less out of dental school) for happy hour and and tradeshow shopping, join1550 your New colleagues networking at Katie Mullen’s: CourtDentist Pl., Denver CO 80202. (10 years or less out of dental school) for happy hour and networking at Katie Mullen’s: 1550 Court Pl., Denver CO 80202.

RSVP by Jan. 21 to jeanne@cdaonline.org

CDA State Lobby Day CDA State Lobby Day Feb. 15, 2013 Feb. 15, 2013 We need your Voice! Come meetyour your legislators We need Voice! at

this CDA-organized event at at the Come meet your legislators State Capitol. No training this CDA-organized event at the necessary. State Capitol. No training necessary. Contact Jennifer Goodrum for Contact Jennifer further details Goodrum for at jennifer@ further details cdaonline.org.

at jennifer@

RMDC SPEAKER New to Management? Avoid These Three Common Mistakes By Teresa Duncan, MS, FADIA, FAADOM

T

eam leaders in dental offices are often created by accident or out of necessity. Unless they are recruited specifically for the position, today’s dental office manager has been promoted from within the organization. The most common pathways are from dental assistant or receptionist to manager – many times with training as an afterthought. Doctors tend to assume that since the person is a long-term, loyal employee that they are more than prepared for the new responsibilities. But management requires new skill sets and new performance expectations. Many new managers learn their skills on the job. When you place a person into a new position with which they're not familiar they tend to bring habits from their old position along with them. As a result, new managers tend to make mistakes which could have been avoided through mentoring and guidance. By not only outlining expected duties but also suggesting behavior, a doctor can prepare the new manager for success. The first mistake made by many new managers is not reevaluating your friendship with existing team members. A new manager has often worked side-by-side with other team members for years sharing common experiences and common complaints. However, when you are leading a team you have to understand that those old allegiances need to be put aside. Newer managers tend to still prioritize their friendships with their coworkers because they have loyalty to them. But when you take a position of leadership your allegiance now belongs primarily to the office and then to the employees. This can be hard, especially when you are used to commiserating with other employees about work situations. The new job will require oversight of friends and this can be uncomfortable for a new manager. Once you become too close with employees it

becomes almost impossible to manage them. Many times office workers will see patterns of favoritism because they are used to you and Cindy being constant lunch buddies. Are you in the habit of going to happy hour and taking long lunches with your coworkers? I hate to tell you this but generally this will not work in your new managerial position. This includes not giving in to office gossip – yes, even if you did this last week. New position, new expectations! Prepare your team by establishing new boundaries around your position. Let them know that you won’t be able to take the lunches with them on a regular basis because you are learning new skills. Experienced managers will tell you that this is one of the hardest lessons to learn. It’s in our nature to want to be liked but your priority is the success of the team and the practice. The second mistake is continuing to perform the same job and just adding managerial tasks into the mix. I’ll bet that before the new tasks were assigned this was a full-time position. Add in running reports and strategic planning and we now have an overworked, unprepared manager. Delegation does not come easily to your typical office leader. Our first inclination is to always do the job ourselves because ‘it’s just easier and faster that way.’ Rather than retrain employees to perform routine jobs that we did without thinking, we continue to do the ‘easy’ tasks. Managers are much more effective when they are performing high level tasks such as report analysis, budget reviews and employee management. Entering insurance checks, scheduling appointments and answering the phone are easily delegable duties that will allow your new manager to focus on moving the practice forward. And what of the employees that are more than willing to take over tasks? If they’re not utilized they will begin to wonder why. Employees are at their best when they are motivated by empowerment and the idea of learning new skills. It’s human nature to want to expand our horizons. If you don’t offer new opportunities or empowerment to your employees, you risk demotivating them.

Foundations of Office Management Friday, January 25, 2013

Sponsored by The third mistake that I observe in new managers is the reluctance to ask for help. While I understand that no one wants to show that they are lacking in an area, I believe that the most growth can occur during this learning curve. A valuable manager will recognize when he or she needs more training. After all, we can see this in others so then why shouldn’t we see it in ourselves? At the very least a manager should take introductory courses in human resources and small business financial reporting. Leadership and systems implementations are the next skills to learn. It’s hard to master leadership – it is always a work in progress. Most great business leaders will emphasize that they learn from their employees every day. Asking for help is a great way to forge a strong relationship with your owner/dentist. Chances are that he or she did not take many business classes in dental school. Any classes or memberships can be shared between manager and dentist. Why not learn together? The doctor may also have no idea that you need training in areas such as insurance or accounts receivable management. Managers who have been with their employer for more than 10 years will gladly tell you that they’ve been able to teach their dentists a few things about the business. What makes them valuable to the dentists is that the information was shared. The manager that doesn’t share information does not help their office. Learn with your doctor and brainstorm together – this is what makes a strong management team. Taking on more responsibility is a wonderful opportunity. You now have the chance to take your practice to the next level – you’ve been given the keys! Will you read the roadmap and ask for help or will you forge ahead blindly? I hope that you reach out for support and learning. We are never finished with our education and no doubt your new position will offer situations and conversations that will be unexpected. You’re not alone – ask for help and manage your practice to future success.

Ms. Teresa Duncan is a Fellow and Educator for the Association of Dental Implant Auxiliaries and the American Association of Dental Office Managers. Teresa received her Master of Science degree in Healthcare Management.

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RMDC SPEAKER

Discovering Your Seven Me’s By David Weber

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s I lecture across the country, many times I divide Nthe crowd up by job titles and group all the doctors, hygienists, assistants, front office, etc. into different areas. Then I ask “What is the one thing that drives you crazy at work?” Virtually every group comes up with the same answer, “The people.”

is going on) or is it in control intentionally. I want folks to discover a whole new way of looking at themselves and their interactions with others—at work and at home. The skill of “Frog-Kissing” is the key to making progress on purpose in all of your relationships. It means to intentionally speak words that are uplifting and affirming to others. There is so little of that being modeled in today’s society where around every curve we are being bombarded with “in your face” confrontation and down-right ugliness coming out of everyone’s mouth. From reality TV, to radio talk-shows, to road rage we rarely see healthy communication. Here’s the bottom line: clearly words matter. They are powerful. And what matters most is how we use them. We can use them to tear down and destroy. Or, we can use them to build up, encourage and affirm.

Whether it is getting along with coworkers, patients, labs or vendors, it seems our interactions with others can be quite challenging at times. And the same thing can be said of our personal lives as well. I believe that when you boil everything in life down to the barest essentials, the only thing that truly matters is relationships. Whether it’s parent/child, husband/wife, doctor/staff, teacher/student, or any other relationship… and what we say has great impact on those relationships. Everyone wants strong, positive, mutually beneficial relationships. So why are they so hard to develop? Why do so many spouses have such a hard time communicating with each other? Why does the generation gap feel more like the Continental Divide? It is because we don’t realize how complex relationships are…how many different “people” are involved. I believe that there are actually seven versions of ourselves living inside of each and every one of us. Let me clarify: I am NOT talking about multiple personalities or a demonic possession issue (I’ll leave those topics to trained psychologists and Stephen King). It might sound a little off the wall at first, but I think we all have seven concepts of self that together help define who we are as a person. I call them the Seven Me’s. Now, they look different in every one of us because we are all different, but every person reading this article has the following seven people residing in them:

The Me I Think I Am The Me I Really Am The Me I Used to Be The Me Others See The Me I Try to Project The Me Others Try to Make Me The Me I Want to Be

Whichever Me is in charge determines what words we use…and that determines the trajectory of the relationship.

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Don't forget about the MDDF Presentation Center

Here is where relationships get crazy -- not only does every person have these Seven Me’s in them, but each one of the Me’s wants to be in charge and influence the interaction. So here’s the challenge: when two people are communicating, there is not just two people, there are seven in one person and seven in the other—a whopping 14 people are trying to interact! It’s no wonder relationships are tough! So who’s in charge? Ahh! That’s the fun part! Most people have never thought about these Seven Me’s running around inside them like a bunch of rowdy kindergartners. But each individual can determine which of the Me’s to give the reigns to. Believe me, one of those Me’s is in control of every situation … but is it in control by default (because you are not realizing what

Some Day's You're the Pigeon, Some Days the Statue!: Part 1 Friday, January 25, 2013

As an MDDS member, you have free access to the MDDF Presentation Center. MDDF has giant toothbrushes, puppets like Ollie Z. Mutt with movable typo-dents, coloring/activity sheets, story books, videos and so much more. Please call Amy at (303) 957-3272 for more information.

February 1, 2013

Mr. David Weber is President and CEO of Weber Associates. He is an international speaker, author, and trainer.

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CLASSIFIEDS Job Board Part Time Dentist Provides care in the following disciplines of general dental practice: Diagnosis, preventive dentistry, periodontics, removable prosthodontics, endodontics, fixed prosthodontics, oral surgery, and orthodontics. Helps provide inhouse dental training. Helps evaluate and supervises hygienists, dental assistants, and other assigned personnel. Items for Sale or Wanted Dental chairs for sale Chairs include base plate, attached 3 drawer unit with keyboard slider, delivery system and flat screen mount, HP mini tower, HP L1710 monitor, and doctor/assistant chair. Delivery in Metro Denver included. Call Billie 720-881-7404. DENTAL CHAIR Official AVALANCHE TEAM 1-OF-A-KIND Official Avalanche Dental Orthodontic Chair Autographed by the entire 20032004 team. Fully functioning, excel cond. On display since purchase direct from Pepsi Center locker room. Contains 29 Original Signatures of the Greats: Sakic, Forsberg, Foote, Blake,Hejduk,Tanguay,Konowalch uk, more. closeup photos: frjden@aol.com 720-2734428 & MDDS online. Real Estate Aurora, Colo. Professional dental office space consisting of 1003 sq. ft. available for lease. Some existing dental equipment, currently in suite, may also be available to purchase making for an affordable, smooth and quick practice start up. Suite is partitioned, plumbed, and wired for three dental operatories. Ideal location with great traffic visibility and easy access. Call Dr. Trompeter at: 303-688-3838, (C: 720-244-1523) or e-mail at trompeternotes@ msn.com DENTAL OFFICE SPACE: Arvada/Westminster, 1 story professional building complex. 1,100 sq. ft. professional office. Fronted by busy Old Chicago restaurant and adjacent professional massage therapy practice. Modern, well-designed and attractive unit with 4 Tx rooms dental equipment installationready with cabinetry, gas lines, plumbing, electrical in place. Plenty of storage & Dr. private office with private entrance. Great drive-by & walk-by exposure with ample dedicated parking. New carpet tenant finish allowance. Contact: Jim True at 303-425-9200

Dental Office Space Arvada Spacious 1850 sq. ft existing dental space in owner occupied professional building in the area of 80th Ave and Wadsworth blvd. Office has 4 dental ops, large business office, staff lounge, private bath, lab area and private office. The space will be available late spring or early summer 2013. Contact Dr. James Gallagher D.D.S. at 303-424-4048 GENERAL DENTAL PRACTICE: Coming 2013! GP Northern Colorado, Metro-Denver, New Specialty practices and more! Go to www. sastransitions.com for new listings as they come forward! Susan 303-973-2147 or SAS Dental Practice Brokers susan@sastransitions.com GENERAL DENTAL PRACTICE: Denver, Colorado Established 764 active patient base, long time hygienist and front office manager to stay with practice. Great Acquisition or Satellite Practice Downtown Denver! Motivated Seller! Susan 303973-2147, susan@sastransitions.com SAS Dental Practice Brokers! www.sastransitions.com GENERAL DENTAL PRACTICE: Mountain Town, Colorado This is a dream practice in a dream location! Ski, Golf, Hike, Bike, and more! Easy access to Denver! Established state of the art practice. Great potential for growth. Own the condo too! Susan 303-973-2147 or susan@ sastransitions.com SAS Dental Practice Brokers www.sastransitions.com GENERAL DENTAL PRACTICE: Rural, Colorado Become the dentist you always planned to be! Perfect for New Grads/GPR and Returning Military dentists! Excellent Satellite Practice! Owner is Retiring but will support a smooth transition! Susan 303-9732147, susan@sastransitions.com SAS Dental Practice Brokers! www.sastransitions.com General Practices for Sale: Practice listings along the Front Range in Denver, Boulder, Longmont, Loveland, Fort Collins, Centennial, Aurora, Littleton, Colorado Springs, Lamar, Evergreen area and Eagle County. For more information on current practice opportunities, including an overview of each practice, please visit our website www.ctc-associates. com or call Larry Chatterley and Susannah Hazelrigg with CTC Associates at (303)795-8800.

Practices for Sale: Listings in Colorado: Denver, Centennial, Boulder, Arvada, Parker, Colorado Springs, South I-25 corridor, Central & Western Colorado, Grand Junction and WY & KS. For more information and listing description(s), please visit our website: www.adsprecise.com; new listings added frequently; Peter Mirabito, D.D.S., Jed Esposito, M.B.A., ADS Precise Consultants 855-461-0101. Practice Sales, Practice Appraisals, Partnerships & Buy-In’s. Specialty office space available for space sharing in the DTC area. Ideal for an endodontist or oral surgeon to establish a satellite practice in one of the most desirable areas in the Denver Metro area. Build-out is quite new. The office build-out and equipment are state of the art. Ceiling mounted surgical microscopes are available. The class A medical building is very accessible and has ample parking space. For further inquiries, please email DTCofficespace@gmail.com. There is flexibility in how this space sharing arrangement can be set up. Please let us know what your requirements are in terms of number of ops, days of the week and hours of the day. Announcements & Services Aurora Oral Imaging, LLC We pride ourselves in customized service for doctors and patients alike. We are conveniently located off I-225 & Parker Road in the Ponderosa Professional Plaza, 14991 E Hampden Ave Ste 340, Aurora, CO 80014. Visit our website at www.auroraoralimaging.com for expedient scheduling or call 303-690-5100 for appointment times not offered online. Dyno-Tech Dental Lab, Inc. At Dyno-Tech Dental Lab, we are in the business of helping dental health professionals create beautiful, natural looking smiles. We custom design amazing dental restorations using state of the art technology and techniques for truly outstanding results. Visit us at www.800labguys.com or call (800)Lab Guys/(800)522-4897 HIRE A BROKER YOU CAN TRUST! Now is the time to Sell, Buy or Transition Your Practice! Less Cost to Sell! Great Motivated Buyers! Excellent Interest Rates! Pick from the Best Pool of Applicants! www.sastransitions.com Susan Spear, Practice Transition Specialist / Licensed Broker SAS Transitions, Inc. SAS Dental Practice Brokers 303.973.2147 susan@sastransitions.com

Check Out the New MDDS Online Classifieds! The new MDDS online classifieds are up and FREE for members. Find a new home for that unused equipment, or the perfect new team-member for your practice. You can also purchase your Articulator classified online now as well!

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RMDC Edition 2013

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Renovating or Relocating? Construction Build-Outs: CONSULT*DESIGN*BUILD* You build your practice, let us build the rest. Practice Build-Out & Tenant Alterations. Quality General Contracting & Construction Mgmt. with Integrity, Attention to Detail & Expertise. Preconstruction services-space evaluation. www. atkconstruction.us Contact Adriene King @303.668.2694 or email: king@ atkconstruction.us Transition Services: For more information on how to sell your practice or bring in an associate, or for information on buying a practice or associating before a buy-in or buy-out please contact Larry Chatterley and Susannah Hazelrigg with CTC Associates at (303)795-8800 or visit our website for practice transition information and current practice opportunities www.ctc-associates.com.

WATCH DENTAL LINE 9 ON CHANNEL 9

Tuesday, January 15, 4:00pm – 5:30pm Thursday, January 17, 6:00am – 7:30am

MASTERY OF

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ENDODONTICS FOR THE GENERAL PRACTITIONER Lecture - Thursday March 7, 2013 9:00am – 4:00pm Hands-on - Friday March 8, 2013 9:00am – 1:00pm mddsdentist.com

An example of successful obturation of a difficult canal. Endodontic skills of Cleansing, Shaping and 3-D obturation learned in this course will allow immediate application in the participant’s practice and the achievement of outstanding results such as this.

Change the way you practice Endodontics: Presented by John West, DDS, MSD

Lecture: Mastery of Modern Endodontics for the General Practitioner: “What, When, Why, & How?” Hands-on: Mastering Endodontic Mechanics: “What & How to Do it When?” Articulator

REGISTER TODAY at mddsdentist.com or call (303) 488-9700

RMDC Edition 2013

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“I

am so grateful for the opportunity to work with Carr Healthcare Realty. They met with the landlord, negotiated the new lease on my behalf, AND saved me a lot of money by cutting our lease rate and negotiating additional incentives! The fact that I didn’t have to take time away from my patients to deal with the lease particulars was much appreciated. Thanks for making the whole process so easy!” Christopher Hahn, DDS Mile High Endodontics

At Carr Healthcare Realty… We provide experienced representation and skilled negotiating for dentists’ office space needs. Whether you are purchasing, relocating, opening a new office, or renewing your existing lease, we can help you receive favorable terms and concessions. Every transaction is unique and provides substantial opportunities on which to capitalize. The slightest difference in the terms negotiated in a lease or purchase can impact your practice by hundreds of thousands of dollars. With this much at stake, expert representation and skilled negotiating are essential to receive the most favorable terms.

Colin Carr President

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Christian Gile Principal Denver Metro

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Roger Hernandez Colorado Springs Southern Colorado

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Kevin Schutz

Boulder • Northern Colorado Western Slope • Wyoming 970.690.5869 kevin@carrhr.com

If your lease is expiring in the next 12 – 18 months, allow us to show you how we can help you capitalize on your next lease or purchase.

Lease Negotiations • Office Relocations • Lease Renewals • Purchases