The concept of a reduction coping is to create more space for the restoration after the laboratory receives the impression or cast of the prepared teeth. This additional space may be required to accomplish the goals of the case for esthetic or functional reasons.

The additional space allows for:

• Adequate space to make the tooth morphology changes requested.
• Increasing the thickness of the restorative material to improve its strength.

The coping can be fabricated out of:

• Acrylic/resin
• Cast metal

There can be a significant cost difference when a casting is made to due to the material and alloy expense, and the fabrication process. It may be worth considering the additional expense, as a cast metal coping will fit more precisely than one made from acrylic or resin.

Reduction copings are the most effective when the area of the tooth that needs to be reduced involves only the incisal edge, cusp tip, or one surface of the tooth. The modification of the preparation should never extend closer than 1mm to the finish line.

The coping is placed onto the tooth, and the amount of the tooth that extends through the opening is what will be reduced. A bur is used to reduce that portion of the tooth and slightly more, rounding all the edges and corners. This minimizes the chance that the restoration will not seat completely. Two examples where a reduction coping is most effective are:

• When there is an inadequate tooth reduction in incisal length to achieve the goals of the case.
• When the labial surface of one tooth protrudes further labial than the adjacent tooth or teeth, and the expectation is to have straight and aligned restorations. A reduction coping would be indicated for the protruded tooth in order to achieve the goal of the case, as the final outcome is significantly more predictable if all the restorations have a similar thickness.

The one surface on which it is difficult to use this process is the palatal aspect of the maxillary anterior teeth. It is difficult to replicate the palatal concavity that can be created in the laboratory using a reduction coping. If there is inadequate occlusal reduction, it may be necessary to re-prepare the teeth and take a new impression or modify the incisal edges of the mandibular anterior teeth to create more space.

Reduction copings can be used effectively in some cases to avoid rescheduling a patient to modify the preparations and re-impress. Consult your laboratory on a case-by-case basis to determine when it can be used to give the laboratory and clinician a more predictable outcome.

After all, when you buy a new iPad at the Apple store, the person serving you does not ask you to make an appointment to return in six months to assess your electronic product needs. In that way, dentistry has a built-in relationship advantage.

But as with most competitive advantages, it only works if you really use it. Every patient that emerges from the chair either has treatment to be addressed or needs to come back for regular recare.

This means that every patient who leaves your office should walk out with an appointment to return.

This is something you must track and review at each day-end. Are all the patients you saw today appointed for their next visit? If the answer for anyone is no, follow up with these three questions:

1. Did we try scheduling them? Was the next step unclear in the chart? Did a phone call or other patient distract us? Or did the person just slip out the door before we could get their commitment?

2. If we did have a conversation, why didn’t they appoint? Was it because they didn’t have their calendar with them? Were they not prepared to commit to a specific date right now? If so, when will they know? In other words, even the patients who can’t commit to an appointment should have an appointment to make an appointment.  If they don’t, only one question remains …

3. Who is going to call the patient this evening? This is not something you should let slide. Give the patient a call while it is fresh in your mind—and in theirs. Get their commitment on when they are coming back, or at the very least, get their commitment on when exactly when you will reconnect to confirm their return.

Your patients are the lifeblood of your business. And it’s how adept you are at keeping them coming back that determines the pulse rate of your practice.

The researchers have shown that the teeth of rats treated with low daily doses of BPA could be damaged. Analysis of the damage shows numerous characteristics that are common with a recently identified pathology of tooth enamel that affects roughly 18 percent of children between the ages of six and eight.

These results have been published in the American Journal of Pathology. 

Bisphenol A is a chemical compound used in the composition of plastics and resins. It is used for example to manufacture food containers such as bottles or babies’ bottles. Recent studies have shown that this industrial compound has adverse effects on the reproduction, development and metabolism of laboratory animals. It is strongly suspected of having the same effects on humans.

As the release states, this effect has also been observed within a development window of no more than 30 days post-birth in rats, thus demonstrating a range of sensitivity to exposure.

Analysis of these teeth showed numerous characteristics that are common with a tooth enamel pathology known as MIH (Molar Incisor Hypomineralization) that selectively affects first molars and permanent incisors. Children affected by this pathology present with teeth that are hypersensitive to pain and liable to cavities. It is interesting to note that the period during which these teeth are formed (the first years of life) correspond to the period during which humans are most sensitive to bisphenol A.

Among the earliest observations made was the appearance of “white marks” on the incisors of rats treated with endocrine disruptors, one of which was bisphenol A (BPA). The researchers decided to define the characteristics of incisors of rats treated with low doses of BPA and to compare these with the characteristics of teeth in humans suffering from MIH.

Macroscopic observation of marks on both series of teeth showed similarities, in particular fragile and brittle enamel. Microscope observation of the enamel showed a significant reduction of the Ca/P and the Ca/C ratios in affected teeth. This leads to mineral depletion, making the teeth more fragile and more liable to cavities.

Finally, analysis of the proteins present in the tooth matrix of rats showed an increased quantity of enamelin, a key protein for enamel formation, and a buildup of albumin leading to hypomineralization. Analysis of the expression of key enamel genes highlighted two BPA target genes: enamelin and kallicrein 4.

According to Babajko, “Insofar as BPA has the same mechanism of action in rats as in men, it could also be a causal agent of MIH.”

You want to have more time to spend on the things you love and with the people you love, but you can’t afford to take more time away from work. You want to increase your income for more flexibility, but you are already maxed out on the number of hours you can or cannot put in at the office. This is where so many people start to feel trapped and frustrated.

There is a way out of this trap. In fact, it is the ONLY way out of this trap. It is the secret that has been mastered by those people who seem to have life figured out—the ones who always seem to be getting the most from their time, money, and relationships. They have optimized the value of their time.

It may seem obvious, but it is astonishing how many people who are feeling trapped in life don’t focus on this all-important escape route. After all, you can never buy more hours in a day, but you can always improve the value you get from the hours you have. Time is the most precious commodity you have; increase its value, and you will see the improvements in all areas of your life.

This doesn’t mean you simply increase what you charge (although a review of your fee structure might be one area worth examining). As I discussed in a previous article, a few well-chosen strategies in key areas can make all the difference.

I am confident that I could walk into just about any dental practice that is “treadmill” busy and, just by introducing some important scheduling tactics, create a notable increase in hourly productivity. And once you make real strides in things like treatment planning and case acceptance, you start to see how reaching new levels of competence in these areas is not just rewarding at a clinical level, it also means getting more from each hour you spend in the operatory. Getting more from each hour means more fulfillment, options and ultimately, freedom—it means getting more from life.

Trial appliance:
Typically, with this protocol a patient is asked to wear an acrylic appliance for three months, as a way to evaluate if the desired vertical dimension could be tolerated. The rationale behind this method is that the patient will experience pain if the vertical dimension is not acceptable.

However, except in a few patients with temporomandibular joint problems, altering vertical dimension does not produce pain. Although the appliance may be very useful to determine other elements of treatment or to aid in muscle deprogramming, it does not provide specific information regarding vertical dimension.

Measurements using the cementoenamel junction:
Another method to determine vertical dimension that has been described is to measure from the cementoenamel junction or gingival margins of the maxillary central incisors to the CEJ or gingival margins of the mandibular central incisors. This distance is then compared to the 18-20mm average distance seen in a dentition of unworn teeth and a Class I occlusion. If this distance is less than 18mm, it probably indicates a loss of vertical dimension and is, therefore, a rationale for increasing the VDO.

The primary flaw in this approach is that the anterior teeth do not establish the VDO; the length of the ramus and the eruption of the posterior teeth establish it. Measuring the distance between the CEJ or gingival margins merely represents the amount of anterior tooth eruption, not the vertical dimension of occlusion. Indeed, it is possible to have an extremely diminished CEJ-to-CEJ distance in the anterior and a perfectly normal vertical dimension of occlusion.

This situation commonly occurs in patients with severe anterior tooth wear and no posterior tooth. Most clinicians examine the worn anterior teeth and decide to open the bite to gain space for restoration, when in fact the patient could be treated at the existing vertical dimension by intruding the worn anterior teeth or crown lengthening them to correct the gingival levels. As a general rule, it is highly unlikely that the patient has lost vertical dimension if the posterior teeth are present, unworn, and in occlusion. If space to restore the anterior teeth is lacking, it is also likely that orthodontics or crown lengthening would allow the patient to be treated without the need to treat their posterior teeth.

Transcutaneous electrical neural stimulation:
A third method to determine vertical dimension that has also been used for decades is transcutaneous electrical neural stimulation (TENS). With this approach, electrodes are applied over the coronoid notch and a mild, cyclic electrical current is generated to stimulate contraction of the muscles of mastication by way of the cranial nerves. The surface electrical activity of the temporalis, masseter and digastric muscles is recorded electromyographically, and a jaw-tracking device evaluates the position of the mandible relative to the maxilla.

A baseline electromyographic reading is taken before any muscle relaxation. The TENS unit is then programmed to relax the muscles of mastication and the electrical activity of the muscles is again evaluated. Neuromuscular rest is achieved when the elevator muscles are at their lowest level of activity without an increase in the electrical activity of the digastric muscles. This neuromuscular rest position is thought to be the starting point for the building of the occlusion. The operator closes up from this position for the “new” amount of freeway space, effectively using the combination of neuromuscular rest and freeway space to determine the new occlusal vertical dimension.

The primary flaws in this approach relate to the neuromuscular adaptability of patients. As described earlier, the resting electrical activity of muscles, like the freeway space, relapses to pre- treatment levels within one to four months post-treatment. Moreover, this approach often results in a more open vertical dimension than the patient’s existing vertical dimension, which can lead to the need for extensive restorative dentistry and extremely large teeth simply to accommodate the vertical dimension dictated by the TENS device.

For instance, let’s try a thought experiment. Let’s say that you are working four-and-a-half days a week for 48 weeks a year (that’s 216 revenue-earning days) and you’re feeling stressed. But what if you came into the office just four days a week? That’s 24 more days to yourself right there. And then what if you gave yourself another 11 days off and tacked them on to each statutory holiday weekend? Now you have 35 more days off a year, you basically have a long weekend every week, and a mini-vacation every month or so. That is an awful lot of stress relief.

So how do you pay for that extra time off? Let’s go through the numbers. If you were earning $800,000 in revenue in those 216 days, that means bringing in just over $3,700 a day. Take away those 35 days and that leaves you with 181 days to do it, which translates to just over $4,400 a day.

In other words, what is standing between you and a dramatically improved lifestyle comes down to generating around $700 a day more.

I’m not saying that is insignificant—achieving an increase of $100 an hour is challenging. But it is a challenge I have seen countless dentists meet or exceed by adopting a few proven strategies. Improvements in diagnosis and treatment planning that lead to greater case acceptance, improvements in the mix of cases you see and how they are appointed, a review of your fees, is how incremental changes translate into an exponential difference in lifestyle.

Ask yourself what would make your life in dentistry ideally fulfilling. Is it more time off? More rewarding cases? An increase in net income? Then sit down and work out in real terms what it would take to achieve your dream. You may be surprised at how close you are right now.

Scientists and oral health care providers have known for decades that bacteria are responsible for periodontitis, or gum disease. Until now, however, they hadn’t identified the bacterium.

“Identifying the mechanism that is responsible for periodontitis is a major discovery,” said Yizu Jiao, a postdoctoral fellow at the U-M Health System, and lead author of the study appearing in the recent issue of the journal Cell Host and Microbe.

Jiao and Noahiro Inohara, research associate professor at the U-M Health System, worked with William Giannobile, professor of dentistry, and Julie Marchesan, formerly of Giannobile’s lab.

At the release states, the study yielded yet another significant finding: the bacterium that causes gum disease, called NI1060, also triggers a normally protective protein in the oral cavity, called Nod1, to turn traitorous and actually trigger bone-destroying cells. Under normal circumstances, Nod1 fights harmful bacterium in the body.

“Nod1 is a part of our protective mechanisms against bacterial infection. It helps us to fight infection by recruiting neutrophils, blood cells that act as bacterial killers,” Inohara said. “It also removes harmful bacteria during infection. However, in the case of periodontitis, accumulation of NI1060 stimulates Nod1 to trigger neutrophils and osteoclasts, which are cells that destroy bone in the oral cavity.”

Giannobile, who also chairs the Department of Periodontics and Oral Medicine at the U-M School of Dentistry, said understanding what causes gum disease at the molecular level could help develop personalized therapy for dental patients.

“The findings from this study underscore the connection between beneficial and harmful bacteria that normally reside in the oral cavity, how a harmful bacterium causes the disease, and how an at-risk patient might respond to such bacteria,” Giannobile said.

The thing is, there is a big difference between the person who says this because they are constantly time-broke and the person who is saying, “I am loving life so much, there is not enough time to do all the things I love.” One is feeling pressured and limited; the other is feeling rich with choices.

In other words, it’s not worthwhile to say you don’t have enough time. Nobody does. But it is instructive to observe how the most successful people spend theirs. And what you find very often with people who seem to get the most from their time is that they are very strategic about the time they put in. Just as we all recognize that you have to spend the money in the right way in order to make money, they know that you have to spend time wisely in order to generate the best return.

In some parts of life we recognize this instinctively. The couple that often complained of not having enough time when they were childless suddenly find themselves devoting endless hours to the precious new addition to the family. A patient who comes in asking for a complete restorative makeover in time for an upcoming wedding somehow is worked into a tight schedule. When the value is right—for you and for them—you find the time.

The question then becomes: Are you finding that time and making the right investments when it comes to your own professional development? Because when you think about what will make you a more successful dentist (and therefore a choices-rich person), it comes down to two things: Doing better at what you know and finding out about what you don’t know. It’s a commitment to ongoing discovery, and it takes time. But it is the time you spend in those 12 to 20 days a year that goes a long way to determining how you will feel about the rest of the time in your life.

So try not to think in terms of “not enough time” and start thinking about “how can I spend the right time on the right things?” After all, you can’t buy more time, but you can invest in better choices.

White spot lesions (WSL) are common during or after orthodontic treatment. Managing these lesions is a challenge. The following are best practice recommendations based on current research.

Most studies report the incidence of new clinically visible WSL occurring during orthodontic treatment to range between 30 to 70 percent of patients. Upper anterior teeth, especially maxillary laterals, are most commonly affected.

Prevention is key: Remineralization and restorative treatments for WSL are possible; but they either result in less than ideal cosmetic outcomes or they are too aggressive. Therefore, it is better to rely on prevention as the primary management strategy.

A. Identify risk
The following conditions indicate that patients are at high-risk:

• Existing WSL
• Poor oral hygiene and/or diet
• High DMFT
• New lesions that start during treatment

B. Plaque control
Effective motivation techniques tailored to the patient, use of disclosing solution and using an electric toothbrush are helpful in improving plaque control.

C. Fluorides and other adjuncts

• Prescribe 15000ppm Fl toothpaste. Compliance is better than Fluoride rinse.
• Application of Fl varnish as frequent as every six-weeks. This is effective in preventing and reversing early demineralization.
• Prophylaxis every three months
• MI Paste: Before going to bed smear over teeth with help of a brush or apply with a fluoride delivery tray.
• Xylitol: Chew on xylitol gum three to four times a day. It increases salivation, which helps in reminerlization, and it causes reduction in the level of S.mutans.
• Chlorhexidine rinse: Once a day rinse for a week, repeated every month. It helps reduce the level of caries producing and pH reducing bacteria in the mouth.

D. New methods
The following emerging adjunctive therapies have shown promising results. More independent research is needed.

Probiotics: They help shift the oral microflora balance towards higher pH producing caries free bacteria.

CariFree: A proprietary product that claims to help restore the pH balance in the oral environment.

Carbamide peroxide: Applying this has shown to improve the pH of the oral environment. Also an added benefit is whiter teeth, which would get easy acceptance with patients.

Resin sealants: A proprietary resin material, Pro Seal is applied on the enamel before bonding brackets. Protects it from demineralization effect. For high-risk patients this can be used, especially for upper anterior teeth. It is a bit cumbersome to clean off and polish the teeth after de-bonding though.

References:
• A Review on Prevention and Treatment of Post-Orthodontic White Spot Lesions – Evidence-Based Methods and Emerging Technologies. Bergstrand F, Twetman S. Open Dent J. 2011;5:158–62.

• A contemporary review of White Spot Lesions in orthodontics. Heymann GC, Grauer D. J Esthet Restor Dent. 2013 Apr

• White-Spot Lesions in Orthodontics: Incidence and Prevention. Airton O. Arruda, Scott M. Behnan and Amy Richter

Vivek Mehta DMD, FAGD, Visiting Faculty, Spear Education. Follow him on Twitter @Mehta_DMD. 

We are all masters of telling stories that explain the past: “I’m just not getting the right patients.” “My practice is in a bad location.” “If only I could become insurance-free.” “I wish my team would ‘get it’.” We find all kinds of ways to rationalize behavior and explain away results. It’s a defense mechanism, a way of protecting our ego. But these aren’t the kind of stories that contribute to success.

If you want to grow and advance, you have to stop being a master of explaining what is, and become a master of explaining what can be. That is really at the heart of what it means to be a visionary, and it is a skill that anyone can develop. After all, you’re programming your life with self-talk so it makes sense to tell yourself the things you need to hear.

Let go of what has happened. Don’t expend mental energy constructing elaborate explanations or “what-if?” scenarios of what might have been. Ask yourself if the story you’re telling yourself right now is creating the right context for what you need to do, and if it isn’t, change it.