2021

Zircon Lab / 2021

Zirconia – Separating Fact From Fiction

ABSTRACT


The use and popularity of both zirconia and lithium disilicate have increased dramatically over the last several years (Fig. 1). In fact, if current trends hold1 it is entirely possible that that the escalating use of both zirconia and lithium disilicate will soon lead to the demise of traditional PFM’s. This article will focus specifically on zirconia.

Zirconia has many positive attributes not the least of which is high strength. In fact, the flexural strength of monolithic zirconia crowns can be anywhere from five to well over 10 times that of conventional PFM’s.2-4 Likewise, the fracture toughness (ability to resist crack propagation) of zirconia is significantly higher than both lithium disilicate and PFM restorations.5 In addition,
zirconia can be bonded or conventionally cemented, is very wear-friendly to opposing tooth structure when properly polished, is compatible with CAD-CAM technology, and can be used in the monolithic form to maximize strength or as a supportive substructure and layered with various ceramics to optimize esthetics. This article will focus on just what zirconia is, its advantages and disadvantages, recent improvements in optical properties, misconceptions some may have, how to optimize the zirconia surface prior to placement, and various cementation options.

What is Zirconia?

Zirconia is often referred to as “white metal” or “white steel”. This terminology may have originated with the introduction of razor-sharp zirconia knives used as cutlery with blades that are typically harder and more corrosive resistant than those of their steel counterparts (Fig. 2). Of course, zirconia is not steel. In fact, it is not even a metal. Zirconia is the oxide of the element zirconium (element 40 in the periodic table). While the element zirconium is a tough hard silvery white metal (Fig. 3) its oxide, the zirconia we use in dentistry, is not. Zirconium is not found in nature in its pure elemental form. It exists combined with other elements forming minerals such as zircon (ZrSiO4) and baddeleyite (mostly ZrO2). These and other minerals are mined, refined, and purified through a number of complex physical and chemical processes to produce zirconium oxide powder (ZrO2) (Fig. 4). This powder (a polycrystalline ceramic) can be shaped, pressed, and fully or partially sintered to create zirconia pucks and blocks (Fig. 5) that can be milled using CADCAM technology to create zirconia dental restorations and supporting frameworks.

Types of Zirconia

Zirconia exists in three distinct temperature and pressure dependent crystalline configurations or phases (monoclinic, tetragonal, and cubic). At normal temperatures and pressures zirconia exists in the monoclinic crystalline form. While this is the most stable configuration of zirconia it lacks the physical properties required for dental use. When heated to approximately 1170°C the monoclinic powdered form of zirconia will coalesce into a solid (sintering). During this process the zirconia crystals undergo a phase transformation from the monoclinic to the tetragonal crystalline configuration (Fig. 6). This form of zirconia is very strong, biocompatible, corrosion resistant, can be milled, and has the physical properties necessary for use as a dental restorative or supporting structure. When further heated to approximately 2,100°C another phase transformation occurs and the tetragonal crystals transform to the cubic crystalline configuration forming a very hard, translucent, and somewhat brittle

Zirconia Conundrums

One of the problems with the tetragonal form of zir- conia used in the fabrication of dental restorations is it is not inherently stable and readily converts back to its weaker, more stable, and lower energy state monoclin- ic crystalline form. Various dopants such as yttrium oxide (Y2O3) and aluminum oxide (Al2O3) are add- ed in very small amounts to stabilize the tetragonal crystalline lattice as well as modify optical properties. This so called “yttria-stabilized zirconia” is in fact, not entirely stable. It is actually “metastable” meaning that given the right conditions the tetragonal crystals can convert back into their monoclinic configuration.

On a small scale this is actually a desir- able property as it makes zirconia resistant to crack propagation via a property called transformation toughening. Simply stat- ed, as a crack is initiated on the zirconia surface and begins to propagate there is a localized conversion of the tetragonal crystals around the advancing crack front back into the monoclinic form. This re- sults in a localized volumetric expansion of the crystals (around 4%) surrounding the crack essentially compressing and sealing the defect and mitigating further crack advancement. So, on a small scale the metastable nature of zirconia can be a positive attribute due to transformation toughening.

However, on a large scale it can be a negative as excessive tetragonal to monoclinic phase transformation can weaken overall assembly strength po- tentially leading to catastrophic failure. Indeed, in the early part of this centu- ry thousands of Prozyr zirconia femoral heads (used in hip replacement surgery) were recalled due to numerous instances of spontaneous fracturing of the zirconia femoral heads within 27 months of place- ment (expected lifespan was at least 10 years). The failures were attributed in part to minute changes in processing tempera- tures during manufacture that resulted in excessive tetragonal to monoclinic phase transformation over-time.9-11 These fail- ures highlight the importance of using zirconia produced by reputable manufac- tures (all zirconia is not created equally).

To take full advantage of the physical properties of zirconia it makes sense to use them as full contour monolithic res- torations whenever possible. That is, to avoid layering or pressing ceramics over zirconia (as is often done to optimize esthetics) because the layering ceramic, along with the interface between the zir- conia and layered ceramic, are weak links in the restorative assembly. In addition, monolithic zirconia restorations that can be milled full contour keep costs low as no additional time is required for layer- ing by a ceramist. While high strength monolithic zirconia restorations make sense, esthetics can be an issue in the an- terior regions of the mouth where the in- herently high value and stark white color of some monolithic zirconia restorations, coupled with a lack of translucency and fluorescence, can make them unsuitable when optimal esthetics is required. The esthetics of monolithic zirconia has im- proved significantly in recent years with the introduction of so-called “translu- cent” zirconia. Manufacturers employ a number of techniques to improve the translucency of zirconia including reduc- ing grain size, reducing alumina content, modification of processing and pressing techniques, altering sintering times and temperatures, and manipulating dopant levels to increase the percentage of the more translucent cubic crystals relative to the more opaque tetragonal crystals.

Sandblasting Zirconia Prior To Placement

It is the author’s strong opinion that the zirconia surface should be particle abraded (sandblasted) prior to placement no matter what type of conventional or resin-based cement is used. There is significant sup- port in the literature for this recommen- dation.15-18   While  there  is  some  concern that sandblasting has the potential to in- duce surface and subsurface cracks and/or

defects that could reduce physical proper- ties19,20, the author is unaware of any stud- ies that demonstrate this to be a clinical problem assuming appropriate blasting pressures, particle types, and particle sizes are utilized. In fact, some studies found that sandblasting actually increases the flexural strength of zirconia (due to trans- formation toughening).12,21 Sandblasting zirconia is useful in terms of cleaning the target surface of impurities, increasing surface roughness and surface area, raising surface energy, improving the bond to zir- conia primers and adhesives, and generally optimizing the surface prior to bonding or conventional cementation.22 Having said this, the term “sandblasting” is very am- biguous. Sandblast with what exactly? At what pressure and distance? The general consensus among researchers and opinion leaders is that traditional high strength zirconia (3-4 mol% yttria concentration) can be safely and effectively sandblast- ed with 30-50 micron aluminous oxide (Al2O3) using a blast pressure of 1.5-2.8 bar (approximately 20-40 psi) from a dis- tance of 1-2 cm and for a duration of 10-20 seconds.18,23,24 In addition, some research- ers recommend the nozzle head be held at an angle of approximately 60 degrees.24 When dealing with translucent zirconia (5 mol% yttria concentration) that has a reduced capacity to undergo transforma- tion toughening, blasting pressures should be in the lower range (approximately 20 psi) to minimize any surface damage that could lead to a reduction in physical prop- erties. Burgess and McLaren have sug- gested using 50-micron silica glass beads as an alternative to harder aluminum ox- ide particles when sandblasting translu- cent zirconia.25 Their testing showed no reduction in the physical properties when glass beads were used. Additional testing is needed to confirm and refine optimal protocols for sandblasting both translucent and high strength zirconia.

As far as when to sandblast, the au- thor prefers to sandblast the intaglio sur- face of zirconia restorations after try-in and any adjustments, and just prior to

conventionally cementing or adhesively bonding the restoration into place. In this regard, the author strongly recom- mends that dentists invest in a quality chair-side sandblasting unit (i.e. Micro- etcher II, Danville Materials) and dust cabinet with a built-in fan filtration unit (i.e. Microcab, Danville Materials). If the dentist does not have a sandblaster then the author recommends having the dental laboratory sandblast the resto- ration just before shipment. Of course, this requires a high degree of faith that the dental lab is sandblasting the zirconia correctly. Once the zirconia restoration is ready for placement dentists have several important decisions to make: 1) Should the restoration be conventionally cement- ed or adhesively bonded into place? 2) Should a separate zirconia primer such as 10-Methacryloyloxydecyl Dihydrogen Phosphate (10-MDP) be applied at some point after sandblasting? 3) Is it necessary to clean the zirconia surface before ce- mentation with alkaline solutions such as Ivoclean (Ivoclar) or ZirClean (BISCO)?

Are Alkaline Cleaning Solutions Necessary Prior to Zirconia Primer Application?

It is the author’s strong opinion that if you want to predictably and durably bond to zirconia  with  resin-based  cements  then it  must  be  sandblasted  and  a  zirconia primer placed. The primer can take the form of a separately applied solution that contains a phosphate ester zirconia prim- er such as 10-MDP (i.e. Z-Prime/BIS-

CO, Monobond Plus/Ivoclar, Clearfil Ceramic Primer Plus/Kuraray, various universal adhesives22, etc.) or by using a resin cement that incorporates a zirconia primer directly in its chemical makeup (i.e. PANAVIA SA Cement Plus Ku- raray, Unicem 2/3M ESPE). A recent study found that 10-MDP zirconia primers chemically interact with the zir- conia surface by both hydrogen and ionic bonding mechanisms.26 This chemical interaction requires that terminal phos- phate groups in zirconia primer mole- cules such as 10-MDP (Fig.8)can freely interact with reactive sites on the zirconia surface. Zirconia has a remarkable affin- ity for phosphate ions.27 This affinity ex- tends not only to the phosphate groups in zirconia primers but also to phosphate groups and ions that are inherent in sa- liva. When zirconia restorations are tried in and the intaglio surface is contaminat- ed by saliva, the phosphate ions from the saliva bind to, and occupy, the same reac- tive sites that zirconia primers require for chemical interactions. This competition for reaction sites significantly decreases the efficacy of zirconia primers and it is necessary to “free-up” these sites so zir- conia primers can function optimally. This can be accomplished by sandblast- ing the restoration after saliva contami- nation and/or the use of strongly alkaline cleaning solutions such as Ivoclean (Ivo- clar Vivadent) or ZirClean (BISCO). It should be pointed out that vigorous rins- ing with water, or the use of acetone and alcohol, is not effective in cleaning zirco-

nia surfaces that have been contaminated with saliva.28 Products such as Ivoclean and ZirClean essentially work by hav- ing a higher affinity for phosphate ions than does the zirconia itself. In effect, the cleaning agent chemically scavenges phosphate ions from the zirconia surface and in so doing frees up reaction sites that now become available for chemical inter- action with subsequently placed zirconia primers. If the dentist is sandblasting the zirconia restoration themselves (after it is tried in and just prior to placement), then the use of a separate cleaning agent is not necessary (but still an option) as the sandblasting alone is sufficient in terms of freeing up reaction sites. If the den- tist does not have a sandblaster, and had the dental lab sandblast the restoration before shipment, then the restoration SHOULD be treated with a cleaning solution such as Ivolean or ZirClean (af- ter it has been tried in and prior to prim- er application). To reiterate, studies show that the best way to treat saliva-contam- inated zirconia surfaces is by sandblast- ing and/or the use of strongly alkaline cleaning solutions such as Ivoclean or ZirClean.29,30 Two last important notes:

1) While phosphoric acid (H3PO4) is an effective cleaning agent for saliva-con- taminated silica-based ceramics (such as stacked porcelain and lithium disilicate), it is contraindicated for cleaning zirconia surfaces. This is because, just as in the case of saliva, the phosphate ions from the phosphoric acid remain bound to the zirconia surface (even after rinsing) and tie-up reaction sites required for chemical interaction with zirconia primers. 2) While silane is an effective primer for sili-effective for priming zirconia sur- ate ester primers such as 10-MDP).

Cementing and Bonding Zirconia Restorations

The fact is there is not one specific universal protocol to use when it comes to the placement of zirconia restorations. The optimal way to treat both the zirconia and tooth surfaces prior to placement is con- tingent on many factors including, the specific clinical conditions, how retentive the preparation is, the nature of the conventional or resin-based cement being used, the minimum occlusal thickness, whether the dentist or the lab sandblasted the zirconia, the type of zirconia being placed (conventional vs. translucent), and esthetics (will the color of the cement affect the esthetic result). As previously discussed and as a general rule, the author recommends that the in- taglio surface of all zirconia restorations be particle abraded (sand- blasted) and a zirconia primer placed (typically a phosphate ester such as 10-MDP). However, this is not true in every situation and the use of a separate zirconia primer is actually contraindicated or not necessary with some materials. As an example, Ceramir C&B (DOXA Dental) is a “bioactive” glass ionomer/calcium aluminate hybrid cement that is very hydrophilic in nature. Hydrophilic sur- faces generally interface well with other hydrophilic surfaces (“like likes like”) but are generally less or non-interactive with hydropho- bic surfaces. For example, water (hydrophilic) does not mix well with oil (hydrophobic). Properly sandblasted zirconia has a high energy hydrophilic surface. Once a zirconia primer is placed the hydrophilic surface becomes hydrophobic (Fig.9). This is advan- tageous when using methacrylate-based resin cements that are also hydrophobic but can be a detriment with hydrophilic non-resin containing materials such as Ceramir C&B. Indeed, there are a number of anecdotal reports of zirconia crowns loosening or falling out when a zirconia primer was used prior to cementation with Ce- ramir C&B. For those dentists using Ceramir C&B, the zirconia surface should still be sandblasted to optimize surface conditions, but a zirconia primer should NOT be used.32 Likewise, conven- tional glass ionomer cements (i.e. Fuji II/GC, Ketac CEM/ 3M ESPE) do not require the use of a separate zirconia primer.

However, zirconia primers (i.e. Z-Prime, BISCO, Monobond Plus, Ivoclar) have been shown to increase bond strength of zir- conia to both RMGI33,34 and methacrylate based resin cements.35 RMGI (resin-modified glass ionomer) cements have many pos- itive attributes including good physical properties, low solubili- ty, some chemical bond to tooth structure, low film thickness, fluoride release, anti-microbial activity, good long-term clini- cal track record, and low incidence of postoperative sensitivity. Perhaps the biggest clinical advantages of RMGI cements is that they are very easy to mix, place, and clean. In fact, cement cleanup is generally much easier compared to resin cements, and this fact alone makes RMGI an attractive cementation option. Indeed, according to a 2018 survey of 1,026 dentists, RMGI cements (i.e. Rely X Luting Plus/3M, FujiCEM 2/GC) are currently the most popular cement type used in North America36 (Fig.10).  The  author  personally  considers  RMGI  to  still  be one of the best cementation options for high strength zirco- nia assuming the preparations have proper resistance and re- tention form and a minimum occlusal thickness of 1 mm or more. Even though studies appear to support the application of a separate zirconia primer after sandblasting to enhance the bond of RMGI to zirconia, the actual clinical relevance and benefit of this extra step is unclear and open for debate. The author’s  personal  preference,  at  least  at  this  time,  is  to  apply a separate zirconia primer (Z-Prime, BISCO) after sandblast- ing when cementing zirconia restorations with a RMGI. The author also recommends a warm air dryer be used to evaporate

primer solvents from the zirconia surface after primer application. Warm/dry air is simply very effective at removing solvent carriers and by “heating up” the substrate one can speculate that reaction rates will be accelerated, molecular interactions become more frequent, and greater num- bers of chemical bonds are formed.

In situations where there is a lack of resistance and retention form, esthetics is an issue, or maximum adhesion is re- quired, then self-etching self-priming resin-based cements (i.e. RelyX Unice- m/3M ESPE, Maxcem/Kerr, Bis-Cem/ BISCO, G-Cem/GC) or resin-based cements used in conjunction with a den-

tin bonding agent (i.e. Duo-Link/BIS- CO, RelyX Ultimate Adhesive Resin Cement/3M ESPE, Multilink/Ivoclar) are preferable over conventional ce- ments. Resin-based cements have a dis- tinct advantage over RMGI and other conventional cements when it comes to bonding restorations on, or in, minimal- ly retentive preparations as they bond more durably and predictably to both tooth tissues and zirconia. In addition, they may be a better choice when dealing with translucent zirconia or zirconia res- torations with minimal occlusal thick- ness as resin-based cements allow better stress distribution when loaded, may in-

hibit crack formation, and generally op- timize overall assembly strength.25 On the downside, resin-based cements can be difficult to clean, are more technique sensitive, and require extra steps when used in conjunction with a separately placed bonding agent. While dual cure self-etching self-priming resin cements are popular with dentists because they do not require a separate bonding agent be placed on the tooth, dentists should be aware that the highest bond to tooth structure is achieved by the use of res- in cements used in conjunction with a separately placed bonding agent.

In fact, some studies have found that even the self-etching/priming cements (such as Unicem 2) that are designed to be used without a separate bonding agent per- form better, in terms of bond strength to tooth structure, when a separate bond- ing agent is placed on the tooth first.37-39 There is some ambiguity as to the neces- sity of using a separate zirconia primer with some resin-based cements. This is because some self-etching resin cements such as Panavia SA Cement (Kuraray) and Unicem 2 (3M ESPE) already con- tain a phosphate ester zirconia primer inherent in their formulations. This may preclude the need for a separate dedicated zirconia primer. Indeed, some of these materials have shown promise bonding to both tooth tissues and zir- conia without using a separately placed adhesive or primer.40,41

CONCLUSION

A misconception held by many dentists is that “you cannot bond to zirconia.” The fact is you can bond very predictably and durably to zirconia surfaces using a com- bination of sandblasting, a phosphate ester primer such as 10-MDP, and an appropriate resin-based cement42-46 (Figs. 11-14).

The optimal way to treat zirconia and tooth surfaces prior to placement of zirconia restorations is contingent on many factors including, the specific clinical conditions, how retentive the preparation is, the nature of the conventional or resin-based cement being used, the minimum occlusal thickness, whether the dentist or the lab sandblasted the zirconia, the type of zirconia being placed (conventional vs. translucent), and esthetics (will the color of the cement affect the esthetic result). Proper management of both the zirconia substrate and tooth tissues is crucial for predictable and du- rable clinical outcomes. As a general rule the intaglio surface of all zirconia resto- rations be particle abraded (sandblasted) and a zirconia primer placed (typically a phosphate ester such as 10-MDP).

However, this is not true in every situation, and the use of a separate zirconia primer is contraindicated or not necessary with some materials. In this regard manufac- turer instructions and recommendations should be followed precisel for optimal results. It is incumbent on all clinicians to familiarize themselves with optimal cementation options and pro hen placing zirconia restorations.

About Dr Gary Alex, DMD

Dr. Gary Alex DMD - Zirconia Headshot

Dr. Alex attended Penn State University on an athletic scholarship where he graduated with a degree in Biology in 1977.  He then took advanced level graduate courses in chemistry and biology before working at Jefferson Hospital in Philadelphia.   He attended Tufts University Dental School where he earned his DMD in 1981.  He has taken thousands of hours of continuing dental education over the last 35 years with an emphasis on occlusion, adhesion, comprehensive dentistry, materials, and esthetics.

Dr. Alex has researched and lectured internationally on adhesive and cosmetic dentistry, dental materials, comprehensive dentistry, and occlusion.  He is an accredited member of the American Academy of Cosmetic Dentistry and past president of the AACD New York Chapter.  With a background in chemistry and adhesive technology, he is a consultant for numerous dental manufacturers and member of the IADR (International Association of Dental Research).  He has written and had published numerous scientific articles and papers and regularly conducts and participates in scientific studies on materials and adhesives.  He has studied occlusion extensively with Dr. Peter Dawson (Center for Advanced Dental Study) and the late Dr. Bob Lee (Lee Institute) and is a member of the AES (American Equilibration Society).  He has been the director of “PAC Live Ultimate Occlusion” and “Aesthetic Advantage Occlusion and Comprehensive Dentistry” programs.  He is co-founder of the “Long Island Center for Advanced Dentistry” which provides the advanced continuing education training for dentists through lecture and hands-on programs. Dr. Alex is on the editorial board of, and has had a number of articles published in, the highly respected and peer-reviewed publications “Inside Dentistry“, “Compendium”, “Journal of Cosmetic Dentistry”, and “Functional Esthetics and Restorative Dentistry”.  Dr. Alex is involved with a number of continuing education programs and regularly conducts hands-on programs and lectures on adhesion, porcelain veneers, direct and indirect restorations, materials, and occlusion.  Dr. Alex maintains a busy fee for service practice in Huntington, NY, that is geared toward comprehensive prosthetic and cosmetic dentistry.

Zircon Lab is America’s leading dental lab. We are partnered with dental offices nationwide and are consistently growing. As America’s highest quality dental lab with the most competitive pricing, the highest caliber of product, expert craftsmanship, and fastest delivery, we set the dental industry standard. After choosing Zircon Lab to be your dental lab of choice, you can trust our dental product will be unmatched by any competitors.

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  46. Tanis MC, Akay C, Karakis D. Resin cementation of zirconia ceramics with different bonding agents. Biotechnology & Biotechnological Equipment 2015;29(2):363-367.
Dental Learning / Technology - 04/08/2021
Dentist,In,Coverall,Pointing,At,Green,Screen,Display,During,Coronavirus

Cloud-Based Dental Software Helps Practices Adapt to The New Normal

Since the American Dental Association began tracking the impact of COVID-19 on dental practices in March 2020, there has been a slow and steady climb towards normalcy. 

But we’re not there yet, based on research from January 2021. According to the survey, 32.3% of practices were open and back to business as usual. 66.7% were open but experiencing lower patient volume than usual. Clearly, the road ahead could be long for many practices.

During the early days of the pandemic, many dentists felt overwhelmed as they weighed their options, seeking information on the new regulations for PPE, FFCRA, FMLA, and more. When they received approval to re-open, they had to determine how best to keep their patients, staff, and themselves safe while running a profitable business. This entailed reevaluating their entire workflow, including the practice management software.

Cloud-Based Dental Practice Management Software Front and Center

Unlike other medical segments, dentistry has been slower to adopt cloud-based software. While it is fair to say that the majority of dentists believe that the cloud is the future, approximately 85% were still hanging on to their server-based software as COVID-19 hit in Spring 2020. With limited access to their system and patient data during the shutdown, more practices than ever considered the benefits of the cloud, and many made the move.

Curve Hero™, Curve Dental’s cloud-based dental practice management software, experienced a significant spike in product demos during COVID-19. During the first few months of the pandemic, nearly three times as many practices moved to Curve’s cloud-based platform than normal. In February 2021, Curve announced that over 33,000 dental professionals used Curve Hero, far more than any other cloud-based provider.

Remote Access to Data Helped Curve Hero Customers Get a Jump Start on Recovery

Early on, Curve customers found how much easier it was to open their practice’s doors to their patients while using the Curve Hero platform. Practices made digital forms available to patients whose information automatically went directly into their Curve Hero database. Office staff informed patients of the practice’s COVID-19 protocols in advance of appointments which increased confidence in their commitment to keeping everyone safe. Billing went through the Patient Portal, eliminating the need to handle and return credit cards at the front desk. This “low-touch/no-touch” experience made a very challenging process far more manageable and safe than practices using traditional server-based systems.

What New Customers Said After Switching to Curve Hero  

Going into the demo, dental professionals knew that cloud-based software allowed them much easier access to patient data than their server-based system. But they discovered many more benefits available with Curve Hero. Typically, dentists and office managers are reluctant to change software because of the anticipated disruption to their practice due to the data conversion process, a potential lengthy learning curve, and time-consuming training.

During product evaluations, they learned that Curve makes it significantly easier to switch software by having proven processes in place to make the transition as smooth as possible. Curve collaborates with the dental office from start to finish — during the initial setup through data review and final assembly. Curve has successfully completed more than 4,000 data, file, and image conversions from well over 90 practice management software products, both server-based and cloud-based. Watch Dr. Jesse Ritter explain his Curve Hero conversion experience in this video.

Web-based training means your team doesn’t have to travel. Staff adopts the software quickly because Curve separates each training session into small digestible bites. Plus, your staff has access to Curve Community, a rich library of information to remind them of what they learned or act as a quick training refresher.

Curve’s New Patient Engagement Feature Makes Practices Even More Productive

Recently, Curve added Curve GRO™, a patient engagement feature that simplifies and streamlines communications by having everything in a single system. Powered by a robust campaign engine, Curve GRO automatically manages patient reminder campaigns and updates the schedule when the patient confirms. For patients who may need to change their appointment or ask questions, GRO delivers 2-way conversational texting. For patients who do not respond to the reminder campaigns, GRO can automatically create tasks in the Smart Action List, allowing the staff to collaborate in real-time to triage patient outreach. A rules-based campaign engine combined with the Smart Action List is significant for dentistry because it creates automation, enforces best practices as determined by the practice administrator, and delivers an auditable trail of all activity that occurs.

Disasters Aren’t Planned. They Just Happen.

Well before COVID-19, dental practices have had to deal with unexpected events like fires, floods, data breaches, and more. If your data is contained on a server in your office and disaster strikes, you could be out of luck. There are so many good reasons to move your practice to the cloud starting with protecting your data. In addition, as we learned during the early stages of COVID-19 with the mandatory office shutdown, the ability to access data remotely to triage dental emergencies and manage rescheduling, billing, and payments were extremely beneficial to Curve customers and their patients. The cloud is by far your best option to protect your business from the unexpected.

About Curve:

Founded in 2004, Curve Dental provides web-based dental software and related services to dental practices within the United States and Canada. The company strives to make dental software less about computers and more about user experience. Curve’s creative thinking can be seen in the design of software that is easy to use and built only for the cloud. Visit www.curvedental.com for more information.

Zircon Lab is America’s leading dental lab. We are partnered with dental offices nationwide and are consistently growing. As America’s highest quality dental lab with the most competitive pricing, the highest caliber of product, expert craftsmanship, and fastest delivery, we set the dental industry standard. After choosing Zircon Lab to be your dental lab of choice, you can trust our dental product will be unmatched by any competitors.

Dental Learning / Dental Marketing / Education / Technology - 03/11/2021

The influence of soft-tissue volume grafting on the maintenance of peri-implant tissue health and stability

Abstract

Background

To investigate the influence of soft-tissue volume grafting employing autogenous connective tissue graft (CTG) simultaneous to implant placement on peri-implant tissue health and stability.

Material and methods

This cross-sectional observational study enrolled 19 patients (n = 29 implants) having dental implants placed with simultaneous soft-tissue volume grafting using CTG (test), and 36 selected controls (n = 55 implants) matched for age and years in function, who underwent conventional implant therapy (i.e., without soft-tissue volume grafting). Clinical outcomes (i.e., plaque index (PI), bleeding on probing (BOP), probing depth (PD), and mucosal recession (MR)) and frequency of peri-implant diseases were evaluated in both groups after a mean follow-up period of 6.15 ± 4.63 years.

Results

Significant differences between test and control groups at the patient level were noted for median BOP (0.0 vs. 25.0%; p = 0.023) and PD scores (2.33 vs. 2.83 mm; p = 0.001), respectively. The prevalence of peri-implant mucositis and peri-implantitis amounted to 42.1% and 5.3% in the test and to 52.8% and 13.9% in the control group, respectively.

Conclusion

Simultaneous soft-tissue grafting using CTG had a beneficial effect on the maintenance of peri-implant health.

Introduction

A major goal of implant therapy is to ensure long-term peri-implant tissue health and create appealing esthetics. To obtain these therapeutic endpoints, soft-tissue grafting procedures performed either simultaneously with or after implant placement have become an indispensable part of contemporary implant dentistry [1].

From a biological point of view, a lack of or reduced height (< 2 mm) of keratinized mucosa (KM) around the implants was shown to jeopardize self-performed oral hygiene measures, which subsequently increased the likelihood of soft-tissue inflammation [1, 2]. As a consequence, soft-tissue grafting procedures aimed at increasing keratinized tissue have been shown to markedly improve peri-implant soft-tissue inflammatory conditions and were associated with higher marginal bone levels compared to the control sites [3]. Moreover, from an esthetic perspective, the presence of KM > 2 mm was demonstrated to be a preventive measure for the occurrence of peri-implant soft-tissue dehiscences [4].

Changes in peri-implant soft-tissue height, particularly on the facial aspect, are a critical factor that may compromise the overall esthetic result of implant-supported restoration [5]. A thin mucosa (also known as a soft-tissue biotype) at the time of implant installation was found to be a crucial component that correlated with facial soft-tissue recession [6,7,8]. In fact, to attenuate the undesirable changes of the soft-tissue margin, soft-tissue volume augmentation at the time of implant placement was also suggested as a preventive measure [9, 10]. On the contrary, currently available data evaluating procedures to increase mucosal thickness did not show any significant effects on bleeding scores, but higher interproximal marginal bone levels over time when compared with control sites [1]. Due to a lack of reporting, an evaluation of the prevalence of peri-implant disease was not feasible [1].

Therefore, the aim of the present cross-sectional analysis was to assess the influence of soft tissue volume grafting on the peri-implant tissue health and stability.

Materials and methods

The present investigation was designed as an observational, cross-sectional case–control study evaluating the clinical treatment outcomes of implants inserted simultaneously with (test group) and without (control group) soft-tissue volume augmentation. All patients had received the same implant brand (Ankylos®, Dentsply Sirona Implants, Hanau, Germany) in a single university clinic (Department of Oral Surgery and Implantology, Goethe University, Frankfurt) and were recruited during their yearly maintenance visits.

Patients were included in the study once they were informed about the investigation procedures and gave their written informed consent. The procedures in the present study were in accordance with the Declaration of Helsinki, as revised in 2013, and the study protocol was approved by the local ethics committee (registration number: 78/18).

Patient selection criteria

The following inclusion criteria were applied for patient selection:

– Patients with > 18 years of age rehabilitated with at least one Ankylos® implant;

– Patients with treated chronic periodontitis and proper periodontal maintenance care;

– Non-smokers, smokers and former smokers;

– A good level of oral hygiene as evidenced by a plaque index (PI) < 1 at the implant level; and

– Attendance of yearly routine implant maintenance appointment.

Patients were excluded for the following conditions: the presence of combined endodontic–periodontal lesions; systemic diseases that could influence the outcome of the therapy, such as diabetes (HbA1c > 7), osteoporosis and antiresorptive therapy; a history of malignancy, radiotherapy, chemotherapy, or immunodeficiency; and pregnancy or lactation at the last follow-up.

Surgical protocol

Soft-tissue biotype was assessed preoperatively based on the probe’s transparency at the mid-facial aspect and categorized as thin when the probe was visible and thin when it was not visible. Two-piece platform-switched implants were placed 2–3 mm subcrestally according to the manufacturer’s surgical protocol. Implants in the control group exhibited a thick soft-tissue biotype and therefore underwent a conventional placement protocol (i.e., without soft-tissue volume grafting; Fig. 1a).

figure1
Fig. 1

Implants in the test group presented with a thin soft-tissue biotype, and therefore, a connective tissue graft (CTG) harvested from the hard palate was simultaneously applied on the facial aspect via tunneling technique (Fig. 1b and Fig. 2). All surgeries were performed by one experienced oral surgeon (PP).

figure2
Fig. 2

Implant and implant-site characteristics

The following study variables were assessed for the test and control implant sites: (1) implant age (i.e., defined as time after implant placement), (2) implant location in the upper jaw, and (3) implant diameter.

Clinical measurements

The following clinical parameters were registered at each implant site using a periodontal probe: (1) plaque index (PI) (Löe et al., 1967); (2) bleeding on probing (BOP)—measured as presence/absence; (3) probing depth (PD)—measured from the mucosal margin to the probable pocket; (4) mucosal recession (MR)—measured from the restoration margin to the mucosal margin; and (5) keratinized mucosa (KM) (mm)—measured on the buccal aspects of the implants.

PI, BOP, PD, and MR measurements were performed at six aspects per implant site: mesiobuccal (mb), midbuccal (b), distobuccal (db), mesiooral (mo), midoral (o), and distooral (do). KM measurement was performed at three aspects per implant site: mesiobuccal (mb), midbuccal (b), and distobuccal (db).

The presence of peri-implant diseases at each implant site was assessed as follows [11]:

  • Peri-implant mucositis defined as the presence of BOP and/or suppuration with on gentle probing with or without increased PDs compared to previous examinations and an absence of bone loss beyond crestal bone level changes resulting from initial bone remodeling.
  • Peri-implantitis defined as the presence of BOP and/or suppuration on gentle probing, increased PDs compared to previous examination, and the presence of bone loss beyond crestal bone level changes resulting from initial bone remodeling.

Radiographs (i.e., panoramic) were just taken when clinical signs suggested the presence of peri-implant tissue inflammation (i.e., the presence of BOP). To estimate the bone level changes at the respective implant sites, these radiographs were compared with those taken following the placement of the final prosthetic reconstruction (i.e., baseline).

Investigators meeting and calibration

Prior to the start of the study, a calibration meeting was held with each examiner (KO, AB, AR) to standardize (pseudonymous) data acquisition and the assessment of study variables. For the calibration of the examiners, double measurements were performed with a 5-min interval of the assessed clinical parameters in 5 patients with a total of 15 implants. The calibration was acceptable when repeated measurements were similar > 95% level. The documentation of demographic study variables, implant sites’ characteristics, and clinical measurements were documented using a generated standardized data extraction template.

Statistical analysis

The statistical analysis was performed using a commercially available software program (SPSS Statistics 27.0: IBM Corp., Ehningen, Germany). Descriptive statistics (means, standard deviations, medians and 95% confidence intervals) were calculated for mPI, BOP, PD, and MR values. The analysis was performed at the patient and implant levels. The data were tested for normality by means of the Shapiro-Wilk test. Comparisons of clinical parameters between the test and control groups were performed by employing the Mann-Whitney U test. Linear regression analyses were used to depict the relationship between mean BOP, PD, and MR values and KM scores. The alpha error was set at 0.05.

Results

Patient and implant sites’ characteristics

The test group included 19 patients (13 women and 6 men) with a total of 29 implants, whereas the control group included 36 patients (20 women and 16 men) with a total of 55 implants. Mean patient age in the test and control groups was 46.24 ± 18.48 and 62.21 ± 14.41 years, respectively. The mean implant functioning time was 4.16 ± 2.06 years for the test group and 7.19 ± 5.25 years for the control group. All implants in the test group revealed a diameter of 3.5 mm with an equal distribution between all regions investigated. In the control group, the most frequent diameter was also 3.5 mm (85.5%), with a predominant implant location in the region of the lateral and central incisors (Table 1).Table 1 Patient and implant site characteristicsFull size table

Clinical measurements

The results of the clinical measurements are presented in Table 2. In general, test and control groups were commonly characterized by low median PI scores at both patient (0.00 vs. 0.21; p = 0.093) and implant levels (0.17 vs. 0.17), respectively.Table 2 Clinical parameters (mean ± SD, median and 95% CI)Full size table

Marked differences between test and control groups were noted for median BOP scores, reaching statistical significance at the patient level (0.0 vs. 25.0%; p = 0.023).

Similarly, the test group was associated with markedly lower median PD values at both patient (2.33 vs. 2.83 mm; p = 0.001) and implant levels (2.33 vs. 2.83 mm), respectively.

Both groups revealed comparable median MR values at both patient (0.0 vs. 0.0 mm; p = 0.76) and implant levels (0.0 vs. 0.0 mm), respectively (Table 2).

Prevalence of peri-implant diseases

The frequency distribution of peri-implant diseases in the test and control groups at patient and implant levels is summarized in Tables 3 and 4.Table 3 Prevalence of peri-implant disease (patient level)Full size tableTable 4 Prevalence of peri-implant disease (implant level)Full size table

According to the given case definitions, 66.7% of the patients in the control group and 47.4% of the patients in the test group were diagnosed with peri-implant diseases. In the test group, the prevalence of peri-implant mucositis and peri-implantitis amounted to 42.1% and 5.3%. In the control group, the corresponding values were 52.8% and 13.9%, respectively (Table 3).

At the implant level, the prevalence of peri-implant mucositis and peri-implantitis amounted to 44.8% and 3.4% in the test group, and 52.7 and 9.1% in the control group, respectively (Table 4).

Regression analysis

Cross-tables depicting selected independent variables (PD, MR, and BOP values) and local factors (i.e., KM and Implant age) in both test and control groups are summarized in Tables 5and 6.Table 5 Test group (n = 29 implants). Cross-tables of BOP/PD/MR values and (1) KM and (2) implant age (months)Full size tableTable 6 Control group (n = 55 implants). Cross-tables of BOP/PD/MR values and (1) KM and (2) implant age (months)Full size table

In the test group, the linear regression analysis failed to reveal any significant correlations between KM and the independent variables investigated.

In the control group, a significant correlation was noted between KM and MR values (R2 = 0.155; B = − 0.072; p = 0.003) (Tables 5 and 6).

Discussion

The present cross-sectional analysis aimed at investigating the influence of soft-tissue volume grafting employing autogenous CTG simultaneous to implant placement on peri-implant tissue health and stability. Based on the clinical parameters investigated, it was noted that the patients in the test group revealed significantly lower BOP and PD scores when compared with those of the control group. This was associated with a lower prevalence of peri-implant diseases, particularly of patients diagnosed for peri-implantitis. In this context, it must be emphasized that the latter assessment was based on recently established case definitions and considered previous examination data [11].

Basically, the present results do not confirm the findings of a recent systematic review and meta-analysis, since soft tissue grafting procedures by means of CTG were not associated with any significant differences in BOP or PD values as compared to control treatments [1]. The analysis was based on a total of 6 randomized (n = 2)/controlled clinical (n = 4) studies reporting on a total of 260 systemically and periodontally healthy patients over a mean follow-up period of 57 months [9, 12,13,14,15,16]. Except for one study [17], the implants were placed immediately and soft tissue grafting was accomplished either at implant placement [9, 12, 15], or after a healing period of 3 months [13, 14, 16]. At test sites, the range of mean BOP values was 20–35% at baseline and amounted to 20–56% at follow-up [14,15,16,17]. The corresponding values at control sites were 21–40% at baseline and 33–46% at follow-up [1]. A total of five studies [9, 13,14,15,16] failed to identify any significant effects of soft-tissue volume grafting on mean PD values. In particular, at test sites, the range of mean PD values was 2.50–3.45 mm at baseline and amounted to 3.67–4.09 mm at follow-up. At control sites, these values were 2.50–3.20 mm at baseline and 3.20–3.97 mm at follow-up [1]. One study focusing on immediate implant placement with simultaneous soft-tissue volume grafting reported on significantly lower PD values at test sites when compared with control sites [12].

The meta-analysis failed to reveal any significant differences in either plaque, BOP, or PD scores (i.e., changes or endpoint values) between test and control groups. However, significantly less marginal bone loss over time was observed with the use of CTG [n = 2; WMD = 0.110; 95% CI (0.067; 0.154); p < 0.001] when compared to sites without grafting [1].

The discrepancy noted between the present analysis and the aforementioned systematic review may, at least in part, be explained by the fact that the included studies [9, 12,13,14,15,16] did not consider BOP or PD as primary outcomes measures. Accordingly, the power of these studies may not have been sufficient to rule out potential differences between groups. Moreover, it needs to be emphasized that none of the evaluated studies [9, 12,13,14,15,16] used case definitions for the evaluation of the occurrence of peri-implant diseases [1].

The present study did not consider to routinely take radiographs during follow-up, but just limited the indication to those patients exhibiting clinical signs of peri-implant tissue inflammation [18]. Accordingly, the influence of soft-tissue volume grafting procedures on marginal bone level changes could not be assessed.

When further evaluating the present data, it was also noted that, in contrast to implants of the test group, control sites revealed a significant correlation between KM and MR values. In this context, it must be emphasized that a major drawback of the present study was the lack of a quantification of the horizontal mucosal thickness (i.e., biotype) during follow-up. That was due to the fact that the assessment of the biotype is challenging at diseased implant sites, since the inflammatory lesion is inevitably associated with an increase in mucosal thickness [19]. As a consequence of the notable prevalence of peri-implant diseases in both groups, it may have been impossible to estimate true changes of the biotype during follow-up.

Nevertheless, the findings of the regression analysis corroborate the results of previous studies also indicating that at implant sites exhibiting a healthy peri-implant mucosa, a thick tissue biotype was associated with a lower frequency of facial soft-tissue recessions (i.e., MR values) over time when compared with sites exhibiting a thin biotype [6, 20].

In conclusion and within its limitations, the present study has indicated that simultaneous soft-tissue grafting using CTG had a beneficial effect on the maintenance of peri-implant health.

Obreja, K., Ramanauskaite, A., Begic, A. et al. The influence of soft-tissue volume grafting on the maintenance of peri-implant tissue health and stability. Int J Implant Dent7, 15 (2021). https://doi.org/10.1186/s40729-021-00295-1

Zircon Lab is America’s leading dental lab. We are partnered with dental offices nationwide and are consistently growing. As America’s highest quality dental lab with the most competitive pricing, the highest caliber of product, expert craftsmanship, and fastest delivery, we set the dental industry standard. After choosing Zircon Lab to be your dental lab of choice, you can trust our dental product will be unmatched by any competitors.

Dental Lab / Dental Learning / Education - 03/11/2021

New CAD/CAM milling with 3D printing technique for dental restorations

By Pirkko-Liisa Tarvonen
University of Eastern Finland, Finland

Statement of the 3D Printing Problem: 

Dental caries remains as one of the main health problems globally. Direct filling technique with composite has several shortcomings. Especially large fillings in lower posterior teeth are challenging. Accuracy of the additive CAD/CAM (computer-aided design and computer-aided manufacturing) technique called 3D printing makes it suitable for manufacturing of several dental applications, like surgical guides, aligners as well as dental and facial implants.

Rayo 3D Tooth Fill - Dental 3D Printer

The Rayo 3D Tooth Fill is a novel technique developed by Finnish professors and experts for dental restorations by digital imaging and 3D printing on a single visit to a clinic. Based on an in vitro study carried out in University of Eastern Finland, Kuopio, Finland, the accuracy of 3D printing technique overcomes that of milling technique in the fabrication of dental inlay and on lay fillings. Other major advantages compared to current solutions include lower cost, possibility to layering and tailoring properties, suitability for existing filling materials and material use efficiency. Additional clinical investigations are planned to carry out during 2019 to confirm the findings.

3D Printing Methodology & Theoretical Orientation: 

A questionnaire was sent to 3,777 Finnish dentists in 2018 to study the use of chair side dental CAD/CAM milling technology and to evaluate the attitudes towards 3D printing-based applications for fabrication of dental restorations among Finnish dentists. Findings: More than a third of the respondents reported using dental chair side CAD/CAM milling technique, most of them on a weekly basis. The respondents with former experience of chair side CAD/CAM technique reported that they would consider using 3D printing for filling manufacture if a better survival rate could be achieved, even though the price of the filling would be higher than traditional direct filling.

Conclusion & Significance: 

The results indicate that 3D printing-based applications for fabrication of dental restorations attract interest among Finnish dentists. Technology has played an important role in the evolution of dentistry by bettering work conditions both in dental offices and in dental laboratories. And one notable advancement is CAD/CAM dentistry. This simply refers to the construction of veneers, implant abutments, crowns, and inlays, on lays, fixed partial dentures and full- mouth reconstruction. Also, we can use CAD/CAM in orthodontics. But in dentistry specifically CAD/CAM restorations is high and they have a natural appearance because the ceramic blocks emulate enamel.

The measurements and fabrication are precise of life measures are getting increasingly significant; scans are faster and easier than conventional impressions because wax-ups, casting, firing, and investing are eliminated. Hence, clinician-based measures of treatment need don’t account for patient perceptions or opinions.

CAD/CAM is a major technological advancement, it is important that the dentists’ technique is suited to CAD/CAM milling. This includes: correct Though CAD/CAM is a major technological advancement, it is important that the dentists’ technique is suited to CAD/CAM milling. This includes: digitizing or scanning, a contact probe reads the anatomy of the model by following the contour of the physical structure. In non-contact scanning, with a continuous preparation margin generally, advantages of CAD CAM restorations over the conventional one, we will definitely place CAD CAM restorations on top.

They provide us quality restorations with quick and easy fabrication. Scanning of intra oral tissues takes less time than conventional impression, charged -coupled devices are also used. In addition to the specialized clinic management software, inventory control, etc., or hardware such as the use of lasers in cosmetic dentistry or intraoral scanning, recently the importance is given to the apart from laser light, optics and charged -coupled devices correct tooth preparation with a continuous preparation margin tooth preparation application of CAD / CAM technology in the field of prosthetic. After the removal of pathologically altered tooth structure, it is necessary to achieve restoration that will be most similar to the anatomy of a natural tooth. Applying CAD / CAM technology on applicable ceramic blocks obviously, this technique doesn’t require any physical contact with the model, but precision in recording the details is required and if the chair side system is available, the patients can get their restorations in one appointment. Quality of these restorations has been demonstrated in so many studies.

About the Author

Pirkko-Liisa Tarvonen has a specialist degree in Dental Public Health from the University of Turku, Finland, and a PhD degree from the University of Eastern Finland. She acts as Dental Marketing Director at Rayo 3D-Toothfill Ltd and as University Lecturer at the University of Helsinki and at the University of Eastern Finland. As a voluntary project coordinator for ten years she has had a remarkable contribution in the support of primary dental care and dental education in the Democratic People’s Republic Korea.

Zircon Lab is America’s leading dental lab. We are partnered with dental offices nationwide and are consistently growing. As America’s highest quality dental lab with the most competitive pricing, the highest caliber of product, expert craftsmanship, and fastest delivery, we set the dental industry standard. After choosing Zircon Lab to be your dental lab of choice, you can trust our dental product will be unmatched by any competitors.

Dental Learning / Dental Practice Tips / Education / Uncategorized - 03/11/2021

TikTok Key to Dental Marketing Success

If you would like to promote your products to a younger audience, there’s no doubt that TikTok provides a fantastic chance to get this done. With over 500 million global consumers, it’s amazed many with its rapid expansion. To get the most out of TikTok, you have to understand what you’re doing, and this guide will describe the best method to approach it.

Know the TikTok Platform

Just jumping on into the TikTok platform maybe not understanding precisely what you Do will turn away users so that you have to scrutinize it before getting involved. Have a peek at the most well-known movies on TikTok and workout why customers are drawn to them.

Also, you need to know how to interact correctly with TikTok users. If you receive this wrong, then you’ll drive away users in droves. You must understand that TikTok is about pleasure and amusement. There are a lot of mini music movies which do nicely in addition to entertaining films also.

There’s not any location on TikTok for pushy messages. From the United States that the vast majority of consumers are between 16 and 24 years old, and they’re not interested in sales pitches. You’ve got to be imaginative in the manner that you join to TikTok users.

Your Content Needs To Be Interesting

You Need to Be Ready to create quite fun Content for TikTok. You may create quite inexpensive videos with a significant effect on the platform when you become accustomed to doing so. TikTok users aren’t expecting high-quality Hollywood fashion videos, so it is possible to record in your smartphone, which is going to be wholly acceptable.

It is Ideal to keep it simple and never attempt to be overly bright. Produce light-hearted movies that exhibit your products utilized in a fun manner. TikTok users are going to love this and feel that you’re genuine and will trust you.

Utilize Hashtag Challenges

Many manufacturers and associations have experienced Lots of success with hashtag challenges. You produce a branded hashtag then use this to market a battle where consumers participate by making their videos with your hashtag.

A Fantastic example of that was that the hashtag challenge made by Guess Jeans. They struggled to request TikTok consumers to make videos of themselves wearing their Guess clothes” their way.” Their hashtag has been #inmydenim.

Utilize Influencers

There happen to be influencers on TikTok, which have enormous Followings of countless. This is a superb way to expand your brand to achieve the stage. Not many influencers will be prepared to work together with you. Your brand and fashion should match theirs, or they’ll turn you back down.

Influencers have to be comfier with your products. If they enjoy them, then they’ll be inclined to showcase them for your viewers. Please do your homework and use external resources to check on possible influencer bios until you devote to working with them.

TikTok Advertising

Lately, TikTok established its advertisements program. Here you can cover For various ad types that are in short type video format to expand your reach. There are four kinds of TikTok advertisements:

1. Native Advertisements (in feed)

2. Hashtag Challenges

3. Brand Takeovers

4. Branded Lenses

These advertisements strategically You’ll Have the Ability to achieve Out to numerous TikTok users. There are all targeting options that you narrow down Your viewers, and those may enhance over time. Time will tell how successful TikTok advertising is.

By the way, do you want to learn more about (TikTok)? If so, go to my website and obtain my GUIDE.

And do you want to read more blog posts like this about similar topics? If so, go here https://www.makemoneyonlinehappy.com/shop to read more of my articles

Article By Jean Taylor
Source: https://EzineArticles.com/expert/Jean_Taylor/478703

Uncategorized - 02/02/2021

3 Ways To Detect A Bad Dentist

Finding a good dentist is paramount to ensuring the health and longevity of your teeth and gums. Unfortunately, not all dentists are the same, and though there are intensive training requirements and strict regulations governing patient care, some bad dentists still exist. So how do you distinguish a good dentist from a bad dentist? Ultimately, if you have a good rapport with your dentist, you feel s/he respects you, and you trust her/him, then you have probably found yourself a good dentist. Nevertheless, these signs of a bad dentist are all clear indications that you should consider finding someone new.

Disorganized

We all learn never to judge a book by its cover, but if you enter a dentist’s office that is disorganized and cluttered you should treat this as a warning sign. First and foremost, medical environments should be sterile and hygienic and a messy office may be your first indication that things are not properly cleaned. Moreover, disorganization may be the sign of poor business and management skills. Your dentist’s waiting room should be tidy and well-organized, swept, dusted, and free of debris. Exam rooms should appear sterile in addition to organized. Staff members and dentists should wear gloves at all times when working with clients.

Complicated Bills

Before you choose a dentist, it is in your best interest to understand their billing procedures. Unnecessarily complicated billing policies are another sign of a questionable dentist. Will you be charged for cancelled appointments even with advanced notice? Does your dentist offer payment plans? Will the dental office bill directly to your insurance provider? Ultimately, you want to find a dentist that can work with you so that you can get the appropriate dental care, and their billing policies should be clear and straightforward.

Professionalism

Does your dentist take personal calls during your office visit? Does s/he delegate advanced tasks to office staff that may not be qualified for the procedure? Does the dentist suggest exorbitantly expensive treatments for seemingly minor problems? There are many signs that your dentist may be acting unprofessionally, and in the end you sometimes have to trust your judgement. For example, imagine a situation where you switch dentists and your new dentist tells you have several major dental problems to which your previous dentist never alerted you. Perhaps your first dentist was unprofessional, but you should feel comfortable asking for a second opinion when things don’t add up. Moreover, during your dental visits, you should expect your dentist to be focused on you, his client. This means that s/he does not allow their attention to be disrupted by non-work related matters. If you find yourself questioning your dentist’s professionalism, you should seek someone new.

When it comes to finding a dentist, the most important thing is that you feel comfortable in her/his office. You should trust your dentist and the advise s/he gives, and you should never be made to feel a burden for asking questions about treatment alternatives.

If your dentist displays any of the above signs, it might be time to switch. Visit Signal Hill Dental Centre for trusted Calgary dentists.

Article By Alex Pupkin
Source: https://EzineArticles.com/expert/Alex_Pupkin/464140

Uncategorized - 01/28/2021

Benefits of Offering a 401(k) For Your Dental Practice

There are many reasons why you may not already offer a 401(k) plan through your dental practice; concerns about cost and complexity of running a plan, questions regarding whether your practice is even big enough to need a 401(k), and worries about fiduciary responsibilities are all common reasons employers cite when asked why they don’t offer a retirement benefit to employees [1]. But here’s the reality: there are 401(k) providers in the market that specialize in operating small business plans and design their services around alleviating the concerns small business owners have. Whether you have one employee in your practice or 100, there are cost-efficient 401(k) plan options out there that can be customized to fit your business needs, help minimize your administrative duties, and limit your fiduciary responsibilities.

Not to mention, as the head of your practice, your employees are counting on you to help them financially prepare for the future. You’re also going to need to replace some—if not most of—your own pre-retirement income when you reach retirement age, and offering a 401(k) plan for your practice is one of the most advantageous ways to do that.

Top three reasons employers don’t offer a 401(k) plan statistic
  • Think company is not big enough (54%)
  • Concerns about cost (42%)
  • Employees not interested (18%)
401(k) plan access for employees of small businesses

Only 60% of small businesses offer a 401(k) or similar retirement plan to employees, yet 81% of workers agree that retirement benefits offered by a prospective employer are a major factor in their final decision when job hunting.

  • Tax deductions for the employer

There are a variety of tax deductions and credits dentists can take advantage of when starting up a 401(k) plan for their practice. If your practice hasn’t had any type of retirement plan for at least three years or you are starting a 401(k) plan for the first time, your practice may be eligible to receive a tax credit that covers up to 50 percent of the startup and administrative costs, up to $5,000 per year, for the first three years of the plan.* Plus, any matching contributions made to employees on behalf of the business are a deductible expense, up to 25 percent of total participant compensation. 

  • Attract and retain top talent

It’s no secret that many American workers expect to be offered a retirement plan to save in as part of their comprehensive benefits package. In fact, doctors may be missing out on top talent by not offering some type of retirement benefit to employees of their practice; more than 8 in 10 workers agree that retirement benefits offered by a prospective employer are a major factor in their final decision while job hunting [1].

  • Plan design options allow for flexibility to fit business needs

A 401(k) plan offers added flexibility in plan design compared to other retirement plan options, allowing employers to add Safe Harbor provisions, profit sharing options, etc. Plus, 401(k)’s offer enhanced contribution options for owners and other highly compensated employees—which may be especially intriguing for dentists who run their own practice—as well as payroll integration options to help streamline benefits processes. 

  • Help your staff (and yourself) financially prepare for retirement

Experts recommend saving 10-15 percent of gross income for retirement, but that can be hard to do in an Individual Retirement Account (IRA) or other types of retirement plans that have low contribution maximums. One major benefit of 401(k) plans is that they boost the highest contribution limit among any type of retirement plan, allowing plan participants to save up to $19,500 in 2021, plus an extra $6,500 in catch-up contributions if they’re age 50 or older. 

Learn more about the hidden benefits of 401(k) plans

Five things to look for in your practice’s 401(k) provider

Dental practices can vary in size quite drastically, which may leave some doctors feeling like they aren’t qualified to run a retirement plan for their employees. But studies show that most 401(k) plans for dental practices actually contain fewer than 25 participants—and even further, about two-thirds of those plans contain ten or fewer [2]. Clearly, practices of any size can offer a 401(k) plan for employees, but it’s important to find a provider who specializes in small plans and can help take some of the responsibilities of being a plan sponsor off of your plate. Here’s what to look for:

  1. Flexibility in plan design

We’ve already mentioned how 401(k) plans allow for maximum flexibility in plan design, so make sure you choose a 401(k) provider that offers the features you’re looking for. Whether you want to add Safe Harbor provisions or are considering various matching contribution options, your 401(k) provider should be flexible in helping you design a plan that fits your practice’s needs.

2. Upfront pricing

You and your employees should feel comfortable while investing in your future—and hidden fees can make participants and plan sponsors alike uneasy. Your 401(k) record keeper should provide completely transparent and upfront pricing, so you and your employees know exactly what the plan’s fee structure is before any contributions are processed. 

3. Easy-to-use website

One of the most important parts of a successful retirement plan is participation, so your 401(k) provider should make it as easy as possible for participants to get enrolled and start contributing. Participants should be able to sign up and manage their account online, and the website should be easy-to-navigate so participants and plan sponsors can find necessary forms and account information.

4. Knowledgeable and helpful Customer Care team

Chances are you’re not a retirement professional—and certainly, you aren’t solely focused on running your practice’s retirement plan. Your 401(k) provider should offer access to a Customer Care team that’s available to help you and plan participants navigate the path to retirement readiness. Some providers, like PAi Retirement Services, will even go as far as offering first year end plan support and perform applicable non-discrimination testing on behalf of the plan sponsor.

5. Financial education available

Investing and financial jargon can be overwhelming, so many employees in your practice may not know where to start when it comes to investing and saving for their future. Choose a provider that offers robust financial education and support for both plan sponsors and plan participants—and a plan, like PAi’s CoPilot Prime 401(k), that includes personalized education, fast setup, and easy plan management. With CoPilot Prime, you can focus on running your business while PAi focuses on running the retirement plan, giving you more time to do what you do best: take care of your patients and grow your practice.

With actively managed accounts, fiduciary protections, and access to an award-winning Customer Care team, CoPilot Prime offers a viable option to dentists considering starting a 401(k) plan for their practice. To learn more about CoPilot Prime or the other CoPilot retirement plan options available, contact PAi Retirement Services at 800.236.7400, Option 1.

Sources:

[1]19th Annual Transamerica Retirement Survey, Transamerica Center for Retirement Studies, 2019.

[2] 401(k) Benchmark Report, ALM Intelligence, 2018.

* Requirements for this credit include:
– Has less than 100 employees
– At least one non-highly compensated employee must be participating
– Employer must not have sponsored a qualified plan in the last three years
Dental Practice Tips - 01/21/2021

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