Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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243 Dental: Trends & Future with George Freedman : Dentistry Uncensored with Howard Farran

243 Dental: Trends & Future with George Freedman : Dentistry Uncensored with Howard Farran

11/30/2015 2:00:00 AM   |   Comments: 0   |   Views: 477

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AUDIO - HSP #243 - George Freedman

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VIDEO - HSP #243 - George Freedman

• Major trends in clinical dental materials

• Major trends in dental technology

• Major trends in dental education delivery and formatting : new education technologies and preferences are altering access and consumption of information 

• Major trends in the evolution of patient treatment options

• Trends in the evolution of the dentist – patient interaction

• New clinical standards : in the next 12 months, in the next 5 years



Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian Academy for Esthetic Dentistry and a Diplomate of the American Board of Aesthetic Dentistry. He is a Visiting Professor at the MClinDent programme in Restorative and Cosmetic Dentistry, BPP University in London. His most recent textbook, “Contemporary Esthetic Dentistry” is published by Elsevier. Dr Freedman is the author or co-author of 12 textbooks, more than 700 dental articles, and numerous webinars and CDs and is a Team Member of REALITY. Dr Freedman was recently awarded the Irwin Smigel Prize in Aesthetic Dentistry presented by NYU College of Dentistry. He lectures internationally on dental esthetics, adhesion, desensitization, composites, impression materials and porcelain veneers. A graduate of McGill University in Montreal, Dr. Freedman is a Regent and Fellow of the International Academy for Dental Facial Esthetics and maintains a private practice limited to Esthetic Dentistry in Toronto, Canada.



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Howard: It is a huge honor today for me to be interviewing my buddy, George Freedman. Gosh, I think I've known you since day 1. It's gotta be going close to 30 years. George is founder ...

George: Don't say that. It makes me feel old.

Howard: No, you feel old because we're old enough to remember your names George, that "Georgie, porgie, pudding, and pie, kissed the girls and made them cry." That's what makes us old that we know music rhyme.

George: I see. Okay.

Howard: Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian Academy of Aesthetic Dentistry, and a diplomat of the American Board of Aesthetic Dentistry. He's a visiting professor at the MClinDent Program in Restorative Cosmetic Dentistry at the BPP University in London. His most recent textbook, Contemporary Aesthetic Dentistry is published by Elsevier. Is the how you pronounce that? Elsevier?

George: Elsevier.

Howard: Elsevier.

George: Originally a Dutch company.

Howard: Dr. Freedman is the co-author of 12 textbooks, more than 700 dental articles, and numerous webinars, NCD and is a team member of reality. Team member reality ... what's his name out of Houston?

George: Michael Miller.

Howard: Michael Miller. And his wife, the orthodontist? What's her lovely name?

George: Ingrid Castellanos.

Howard: Oh yeah. I love both of those guys.

Dr. Freedman was recently awarded the Irwin Smigel Prize in Aesthetic Dentistry presented by NYU College of Dentistry. He lectures internationally on dental aesthetics, adhesion, desensitization, composites, and impression materials and porcelain veneers. A graduate of McGill University in Montreal, Dr. Freedman is a regent and fellow of the international academy for dental facial aesthetics and maintain a private practice limited to aesthetic dentistry in Toronto, Canada with your wife, correct?

George: That is correct.

Howard: And tell them who your very famous wife is.

George: Faye Goldstep who also lectures extensively, and writes a lot. The reason that she maintains her maiden name is so people won't associate her with me. 

Howard: And we just all had dinner a couple of weeks ago at Joyce Bassett's house who is the first woman, female dentist president of the American Academy of Cosmetic Dentistry and that's where I talked you into doing this podcast. But Joyce won't do it because she's shy and bashful. 

George: Somehow I don't think so.

Howard: She is. I know, I know. She's gregarious in person, but when you turn on a camera she gets stage fright. 

Today we're going to talk about major trends in clinical dental materials, major trends in dental technology, major trends in dental education, delivery, and formatting. What's hot and what's not in dentistry today, George?

George: Dentistry has been evolving very rapidly over recent decades, and it's often a challenge to dental professionals to keep up with all the developments that are occurring simultaneously in many areas of the field. It is important for the practitioner to identify important trends within the profession such that they can really maximize the time that they spend in learning and maximize the benefit of the money they spend on upgrading.

Let's take a look at clinical dental materials. I have ... today I'm not using any materials that I learned about in dental school. In fact, even dentists who graduated only 5, 10 years ago many not be using very many of those materials. Developments of dental materials tend to be evolutionary, though, rather than revolutionary. In order to be able to identity important current and future trends, the easiest technique is to examine recent directions in research. Go to the IADR, go to the International Dental Salon, and extrapolate them into the coming years, because this is usually the direction that it goes. For example, amalgam restorations, popular for more than a century, have largely been replaced by tooth-colored materials in the span of twenty years. Dental professionals seeking to improve patient treatment are searching for restoratives that can positively impact upon the health of the remaining tooth structure over extended periods of time, preferably the entire lifetime. 

We're seeing the introduction of bio active restorations that beyond just replacing decayed and missing tissue with a non-reactive material, interact with tooth surfaces to discourage bacterial activity and to strengthen the restorative interface. These bio active materials represent both the near and the intermediate future. 

If we go into specific areas of restorative materials, bonding agents, most important for dentistry, first introduced in the 1970s, have gone through seven major formative generations. Each successive adhesive generation has been more predictable and less technique [inaudible 00:05:21] than the previous one. Thirty years ago, the resin practitioner was really faced with a variable chemistry set of materials to mix and match in very specific sequences in developing micro mechanical bond between the tooth and the restoration. Remember, these are not chemical bonds that we are working with in dental adhesion. They're micro mechanical bonds. 

Today the dental bonding standard is the seventh generation, single component, single step, dental adhesive. Easy, fast, tooth-friendly and totally, totally predictable. This is what we're looking for, where we cannot possibly, even inadvertently make a mistake. What can go beyond single-step adhesives? Well, let me throw out my first future dental material of this discussion. Very simple: a zero-step adhesive. How would you like to see a zero-step adhesive? We have no steps. We've gone from 4-steps to 5-steps to 3-steps, 2, 1. A zero-step. 

Howard: Is this where you use the light saber?

George: Well, more or less. The technology, interestingly enough, is already available. It's being used in the one-step, resin cements where the adhesive is already incorporated into the cement. Why not incorporate the same materials into the restorative materials? In that fashion, we will not have any bonding. Now, why does this not happen? Largely because the bonding industry is a multi ... multi, multi million dollar dental business over the world and companies are afraid to eliminate this particular area. The next major evolution of dental adhesives, the 8th generation, will see the elimination of this treatment process as a separate step. That's the first area in dental materials. 

Howard: So the 8th generation bonding agent will be ... means that it's gone and now it will be in the resin. 

George: No bonding. People who are experts in dental bonding will have nothing to talk about. It will be like the Harvey. Remember Harvey the invisible rabbit that we had in a movie 40-50 years ago with Jimmy Stewart? This is, I think the 8th generation bonding agent should be called Harvey because it's going to be invisible. It's going to be there, it spirit, but not at all there physically.

Howard: George, is it over simplistic to say that the only reason we need bonding agents is because the resins contract and if they ever made a bonding agents that didn't contract .. I mean a composite material that didn't contract or maybe even ever so slightly expanded, then there wouldn't even be a need for adhesive bonding anyway? 

George: The problem is more than just expansion and contraction. The problem is to a great extent the fact that the materials, the resin materials, don't really interact well with tooth materials. The materials that do interact with tooth structure, the glass ionomers, the pure glass ionomers, are not good in terms of wear in the long-term. If we want to get a really strong resin that can last for 10, 20, 30, years and we want it somehow affix it to tooth structure, we need to have an interface. That interface has to be able to interface on the one side, interact with the tooth structure and on the other side, with the resin material. That's what bonding agents do. They're not just cushions for expansion and contraction, they're actually also dual interfaces which allow the incorporation of two dissimilar materials into a single material.

Howard: Who are you predicting will come out with the first direct poster composite that you won't need any bonding agent?

George: I can't tell you who it would be, but the companies that have the one-step resin cements that do not require bonding agents are the ones that are most likely to be fast-tracking this at this time.

Indirect dental restorations are another area, they must be affixed to the remaining tooth structure somehow. The early looting cements were rather problematic, soluble oral fluids, irritating the vital tooth structures like our zinc-phosphate. Un-aesthetically opaque, white in color, and difficult to mix properly. You had to really learn how to do it.

Since 1990, resin cements have become dental standards. The early ones were difficult and problematic to mix and required many separate steps. In recent years the auto-mix, 1-step resin cements have simplified the final indirect restorative phase completely. While some of these materials are reactive with tooth structures, they do not chemically bond to all restorative materials. Soon, the incorporation of silanes and other ceramics and metal catalysts into the chemistry of the 1-step resin cements will securely adhere indirect restorations to tooth preparations developing a true monobloc. That way, again, you get the crown, you have the tooth, you put the cement in between, the tooth is wet with water not with saliva and four, five, six minutes later, just make sure you remove the excess. 

These materials are already here now, to a certain extent. The incorporation of silanes and other bonding agents which will work with zirconia and alumina are what's missing in the cements.

Again, who will be the first, there are a number of companies. I suspect when we see one we will see five or ten, because much of the development of dentistry is "me too." As soon as one company comes out with it, literally takes the first big step, everybody else follows and says, okay, yeah, we're here, too.

Howard: I agree. Lee Lacocca had the only minivan for one year and then the next year, all nine major car companies rolled out a mini van.

George: There you go. 

Now, there's also major transcendental technology, and this is probably even more advancing and more radical than the advances of materials nowadays. The progress in dental technology has been revolutionary as well as evolutionary. We have acquired and adapted relevant equipment from various segments of the medical field for the most part, as well as developing new methodologies from within dentistry. If we wish to predict the technological direction of dentistry, it's simply a matter of looking at the proven medical gadgetry and to imagine it's focused application in the oral cavity. If you look at what medicine is doing today, you sort of see what we'll be doing in five or ten years from today. Typically medical innovation precedes its dental counterpart anywhere from 5 to 20 years. 

Why does it take us so long? Because the dental market is much smaller than the medical market and it's less profitable for companies to develop that methodology and technology for the dental field. Dental radiology, for example, has changed very little since the times of Regan, about 125 years ago. The introduction of digital radiography reduced patient radiation exposure, added the ability to be able to manipulate diagnostic images, and simplified data storage. In less than 25 years, digital radiology has redefined dental diagnostics. 

As we move confidently and more affordably toward mainstream tomography, the dentist will begin to view both health and disease very differently. The next decade will see the arrival of 3-dimensional diagnostic standards where the 2-dimensional X-ray, either analog or digital is basically passe and we're looking at 3-dimensional examination. We don't have to guess which root is infected, we don't have to guess where the problem lies in the bone, we know because we're looking at it 3-dimensionally. The practitioner will have the opportunity to specifically locate the disease and examine the generalized health status using 3-dimensional modeling. Rather than 3-dimensional [inaudible 00:13:54] position on a 2-dimensional film or screen requiring the educated guess I mentioned before, tomography enables us to the most conservative direct diagnoses and treatment possible. This is here today, it's only going to get better. It's also going to get cheaper. Today ... Let's say 5 years ago we're looking at $250,000 for a tomograph. Today it's half of that. In another three or four years I suspect we'll be in the $25,000 or less range. Basically, making it possible for every practice to have a tomograph. 

The rise of oral cancer in groups not previously considered to be at risk: young non-smokers, non-drinkers, and females, is rather alarming. If we do a rapid visual scan of the cavity during routine examination, it may expose suspicious tissue, or some here that may have begun at the surface. Unfortunately many precancerous epithelial cells and lesions occur below the tissue surface at the base of the membrane. You can't find them. You can't see it. These subsurface abnormalities are invisible to the naked eye until they grow through the epithelial layer at which stage the best opportunities for early discovery and treatment have been lost. The recent combination of high-powered LED lights and innovative filtration utilizes natural tissue florescence to identify clinically invisible anomalies. Cancers and pre-cancerous epithelial lesions down to the base membrane can now be identified and mapped. Now follow it up with a biopsy and treatment. Technique is not invasive, not unpleasant. As such it is well accepted by patients and sets the standard for diagnostic techniques of the future. 

Where is this in the future? It's not, it's here. It's here today. We have a number of products out on the market, but the uptake by the dental profession is somewhat limited. There aren't a lot of these units available. You can't really tell very much in a three-second scan of the oral cavity when you're looking through and there's prophy paste and also some other stuff, blood, saliva in there. But with one of these diagnostic devices, like the DOE, Dental from Dentlight and from Velscope units, you can immediately tell if there's an abnormality. It doesn't mean that it's cancer, but you can immediately tell what it is, that's it's a problem that you should look at further.

One of the things that drives our practices is carrier detection. It's the cornerstone of the dental practice. The earlier the decay can be identified, the earlier and more conservative the treatment for it. The traditional methods for examining tooth surfaces and confirming dental carries are neither effective or beneficial to the patient. While the overhead operatory light illuminates the dentition well, the practitioner has two basic options. If the surface it is white it is healthy, if the surface is dark it is decayed. There's no allowance made for carries that have been arrested and for discolored but healthy tooth surfaces. That's the old style.

Often times the explorer was jabbed into suspected carries to determine the hardness of the tooth surface and its extent of decay. You and I were taught to do this in dental school, Howard. Not only was this very uncomfortable for the patient, often illiciting howls of protest, it was also iatrogenic, serving to spread disease very effectively from one tooth to the other. The introduction of fluorescence detectors has vastly changed the parameters of carries screening and today totally non-invasive techniques. Visualize the tooth surface in the mode to locate problematic areas and an analysis mode to pinpoint the severity of the lesion and the need for treatment which can be visible and distinct colors. This diagnostic modality focuses dentists onto areas that require treatment and quantifies the disease status. Tooth restorative interfaces are typically very difficult to evaluate for breakdown as amalgam and composites can confuse the visual interpretation of the practitioner. Fluorescence carries detection eliminates the doubt fully. In the near future the blending of innovate carriers detectors and small field tomography will yield diagnostic capacities that are unimaginable even today. 

The carries detection that I'm talking about, it's available today. It's the future. But, in north america, literally hundreds, at most a thousand or two, have this. Less than 1% of the practitioners have equipped themselves with these fantastic tools that should be in everybody's practice. 

Dental lasers have also revamped minor surgery in the dental practice. Benefits of this technology were evident many years ago but lasers themselves were cumbersome, large, difficult to use, and far, far too expensive. My fist dental laser cost $53,000 and later on lasers were over $100,000. The diode revolution transformed the playing field, you've seen lasers cost under $10,000 and often under $5,000. Wow, What a difference. Floor model lasers became countertops, hand held. Complex protocols are totally simplified to presets, and prices tumbled from a mini-mortgage to that of a hand piece. Literally, as Faye Goldstep says, the laser is the soft-tissue hand piece. Laser utilization mainstream from hundreds to tens of thousands of dentists. The lower prices, the easier use, just make them more practical. The advantages of laser procedures extend into every branch of dentistry from orthodontics to prosthedontics to endodontics and the proactive impact of these minimally invasive technologies is just beginning to be felt in preventive dentistry. 

When I've got a subgigival margin, I can restore it allowing blood or provicular fluid to seep in, knowing that that restoration will never work in the long-term, or I can dry it out, keep it dry with a laser in the matter of a few seconds and get a perfect subgingival margin, which is better, of course. That is by far the better way to do it.

We've already seen laser used to treat hard tissues such as enamel, dentin, and bone. These directions are likely to expand to an area where much of the surgical energy that is used for oral treatment will be light beam rather than rotational. Imagine that. The drill will not be a drill, it will be a light beam. In terms of hard tissue lasers, that do remove hard tissue, there's one that's going to be introduced at the Greater New York meeting that's going to be in the $50,000 range. Every single other one has been over 100, so the prices are just tumbling. That is going to be AMD, the Picasso folks are introducing that hard tissue laser and it's, price-wise, definitely interesting. We'll see the units while we're in New York and go from there.

Light media therapy can be more focused, it's less harmful to the immediately adjacent tissues, and offers a more rapid and improved healing. It's readily predicable that the combination of tomographic diagnosis will be used in the near future to guide precisely intervention where we're working internally at the apises and so on. Even not using our hands, using dentist-positioned robotic units, as is common in medical surgery in the treatment of dental disease. 

Photo-activated technologies may be in their infancy but research is pointing to great benefits for both patients and dentists. Typically, these techniques are highly proactive and minimally invasive for tissues both hard and soft. The general concept is that various wavelengths of light can stimulate desired responses in natural tissues. Or, alternatively, targeted tissues can be seeded with specific receptors that in turn are activated by a light beam. There's a lot of cancer therapy that is following this direction

Specific wavelengths can be focused at the tissue surface or perhaps below the tissue surface to encourage healing by stimulating beneficial responses and leading to the resolution of inflammation, a big problem in dentistry. Future enhancements include delivery modes and targeting technologies that will further refine this highly desirable treatment approach. This is being used a fair bit in Europe and is just starting to come to North America. It's certainly an area to watch.

Dental impressions, as recently as my time in dental school, involved rubber base. I don't know if you remember that.

Howard: Yes, I do. I do.

George: Inaccurate alginites and a whole host of memorably unpleasant techniques, both for us and for the patients. The great progression to polyvinyls polyethers, enhanced polyvinyls and precise alginate derivatives have all made dental impressions pleasant for the patient and predictable for the practitioner. Over the past decade, dentists have begun to scan prepared teeth optically rather than impressing them physically. Today this is widespread modality. Initially it was very expensive, the scanners were exorbitant, but these technologies are now friendly, within financial reach. Unfortunately, many of them are priced at the level of how much many the dentist can save by not doing a conventional impression rather than the cost of the technology itself. When we have more competition in this area and more companies vying for the market, it will allow the price to come down to where it should be, which is probably between $5,000 and $10,000 for a scanner, which will really make it practical in the dental practice. The predictable trend is that optical impressions, readily obtained and transmitted to the lab online will entirely replace traditional impressions in the near future. 

Now, having discussed a few areas, not by any means all the areas of innovation but certain areas that just grabbed my attention, I would like to talk about dental education. It is something that is mandated for all of us and really, we should be doing it. That's part of our life as professionals. We shouldn't be stuck on the day we graduated. We should be continuing to expand our knowledge base as science and technology goes forward for the benefit of our patients and a little bit more quietly for the benefit of ourselves, as well. In using technology we become more efficient, more practical, more productive and that's always good for the practice and the bottom line. 

Education is always changing. It is highly responsive to the need of those interested in acquiring new information and their current learning preferences. They'll be changing habits in education and the provision of education will follow them. Education is also highly dependent upon the techniques and the settings of those in a position to provide this new information and their current preferences. Continuous learning is, or should be, the very basis of every practitioner's professional commitment to dentistry. Typically, at any given time, approximately 30% of dentists are actively seeking to advance their knowledge. They read magazines, books, attend conferences and lectures, they participate in hands-on and extended programs. They, in turn, are in a position to offer their patients the best and most current treatment options. Unfortunately, the 30% seems to be the same group of dentists over time. You see the same faces at meetings over and over. 

What about the other 70%? Where are they getting their education? I'm not even going to address that. Fortunately, licensing laws and regulations require all practitioners to be relatively up-to-date with knowledge, targeting the remaining 70% who are less proactive in their educational activities.

Educational patterns are changing for a variety of reasons. In the recent past, education was the exclusive domain of academics. Academic teaching institutions and dental conferences. Over the past 2 decades focused organizations such as the American Academy of Cosmetic Dentistry, American Society for Dental Aesthetics, and others have focused on leading edge topics and techniques far more quickly than was possible within academia and education that was simply not available elsewhere. This attracted individual who were interested in providing specific treatment modalities to their patients. The rise of specialty and quasi-specialty meetings in cosmetics, orthodontics, implants, sleep apnea, etc. has been a testament to dentists seeking to expand their practice horizons. The larger meetings are likely to continue to decline slowly until they reinvent their message to the practitioner as they tend to every 10 or 20 years. The smaller, more focused, more information addressive meetings are likely to maintain their attendance within their special interest groups and possibly grow. 

Other factors, non-dental in origin, are also having an impact on dental education. Travel to meetings is more difficult, more time consuming and more costly. Taking extensive time away from the practice is cost-prohibitive, as well. In addition, many of the presentation offerings, meetings, are of marginal interest to the clinical dentist and may be repetitive of knowledge already acquired. And may be a mandated talk, etc., of no interest to anybody except for the bureaucrats. Dental manufacturers and distributors, long with the bank rollers of dental education, are also having a more difficult time participating and paying for the vast proliferation of dental meetings that you see in every state, every country, every city. 

The rise of web-based education has again, changed the playing field. Howard, you're very familiar with this, you've been one of the leaders for many, many years. Firstly, the quality of online programming, not subject to peer-review and evaluation, is very uneven. You have good, you have great, and you have bad. Excellent programs are found side-by-side with time wasters and there's little, if any, standardization. The other concern with online education is that the providers may have specific selling points and marketing objectives. This should not be a problem as long as the relationship is clearly identified, which all too often it is not. The cost of taking these program ranges from the ridiculously expensive to totally free. The true value for the dental practitioner is virtually impossible to pinpoint until they have already gotten the education. Thus, the online education arena is a potential mine-field for the unsuspecting dentist. Fortunately, there's a system of organization, definition, and valuation that is come to online programming. 

For the first time, University-based certificate, diploma and masters programs are being offered entirely online. These are comprehensive, long-range programs that compare favorably with the attributes of their live-attendance certificates, masters and such programs and more. Typically, their faculty members are leaders in their fields, offering the latest materials and techniques. There are more and more relevant lecture sessions, the literature reviews of searches are more focused and detailed and are examined for up-to-dateness on a regular basis. Treatment planning exercises have been transformed successfully to online platforms. In many disciplines, clinical cases are required from the participants, some in step-by-step detail showing exactly how good the practitioners command is of particular technique. Most important to clinical dentist, all of the education is available online at any convenient time. 

Practitioners do not have to give up their practices for 2 or 3 years or even valuable chair time. Almost all of the educational processes can be completed at the discretion of the attendees at their convenience in the comfort of their practices or homes. Up until now, the only missing link in online education was the personal exchange between teachers and students. Today, the availability of online e-tutorials and VOTS, "virtual online teaching" or "virtual over the shoulder teaching" has filled a gap. High quality simulators that are affordable for individual dentists enable private hands-on education for practitioners within their own office. Since physical location equipment requirements are lessened, the cost of these University-based certificate, diploma and masters programs are more favorable. We're looking at costs for masters in the $50,000 area from beginning to end and a variable time to complete it. This is easier for the dentist to cover while in full-time practice. Overall, online education is easier and more convenient to the dentist, but the dentist must select the right program for their own needs and purposes.

The impersonal large-classroom format of dental education is largely passe. Dentists are demanding a meaningful, personal contact with their educators to make learning time more relevant to their own practices. The value of engaging the instructors in one-to-one discussion cannot be overstated. Thus, smaller, more focused educational events are increasingly popular with the profession. Participants engage with a single instructor for the entire day, not or perhaps a part thereof. As they become more familiar with the delivery format and the though process of the teacher, the process of information transfer to the dentist and the small audience increases in effectiveness. 

Where there's opportunity to immediately try the material and technologies discussed in a hands-on setting the learning experience is further enhanced. At one time dental lectures could get away with presenting beautiful pictures of birds, flowers, sunsets and their cars as a significant part of their allotted time. Now, as dentists have more choice in sourcing their education, they demand that teaching be focused, specific, up-to-date, and relevant to their clinical practice. More stuff and less fluff accurately describes the successful dental educational presentation.

There's also major trends in the evolution of patient treatment options. The major direction for patient treatment all involve 3 underlying concepts. Proactive: diagnosing and treating problems early or before they start; minimal: treating problems as conservatively as possible; and comfortable: ensuring that the patient-consumer has a pleasant or relatively pleasant overall experience. These concepts apply to the traditional pursuits of the dental practice such as direct and indirect restorations, endodontics, orthodontics, implants, everything. Dentists who do not offer and promote these parameters to their patients will find themselves far less busy than they would like to be. 

There are novel areas where this can take responsibility if they choose to do so. Treatment of TMJ, sleep apnea, bad breath, peri-oral-dermal treatments, smoking cessation, nutritional counseling, among others are areas where the dentist can break in. Of course, there are a lot of people competing for this area and in some areas other specialist have made sure that dentists do not have access to these treatment modalities. Each of these treatment area extensions can have a major positive impact on the dental practice. Just think of all the benefits that tooth whitening brought to the profession over the years. 

One real cause for concern is the pressure on the dental profession and the surprising willingness of certain dental professional bodies to allow devolution of dental services and responsibility to groups that are not properly trained for these tasks. The pressure is on the politicians who enact these rules as financial and electoral. They see dentists as rich and powerful and it's a group that is easy to bring to their knees because it's a small group and very nonvocal, very unpolitically involved. In fact, most dentist are small business people who are making a comfortable living, but not getting rich. The current costs for dental education are so high that many young practitioners will spend a significant part of their working lives paying off their academic debts. Organized dentistry and its elected leadership must serve to protect the public and the members of the profession by opposing and preventing the devolution of unsupervised services to the less trained and the less capable. No matter how politically attractive that might be to people who can do it from a political perspective. 

Now, patients get more excited about certain treatment options than others. Tooth whitening and porcelain veneers, cosmetic dentistry, have been extremely popular and have propelled the recognition and the acceptance of dental treatment body more than all the other facets combined. The use of dental appliances for sports and more comfortable sleep have increased public awareness and familiarity with the dental profession and dental treatments. 

The role of implant dentistry is more than two decades old, yet this modality is just beginning to hit its upward curve. Major barrier to the extensive use of implants to restore missing teeth and lost function has been price. The big five, six hardware manufacturers just put the prices so high that many patients were priced out of the market. The technical and clinical problems were solved long ago. The unrealistically high expense of the implant hardware combined with the early noncompetitive positioning of the surgical and laboratory fees served to limit patient acceptance and utilization. Now as implant hardware costs have plummeted because of competition, the patents expiring and more and more companies in the field, dentists and technicians are competitively seeking to find reasonable remuneration levels for implant associate procedures, patients are benefiting and increasing numbers are choosing this excellent treatment modality. Once the market has essentially developed its own appropriate treatment fees, implants are going to be the norm rather than the exception in the replacement of missing teeth. 

One also has to wonder what treatment choice ramifications will be for a patient with a badly broken-down tooth in the near future. When the cost of an endodontic treatment plus post and core, plus crown are equivalent or less than the cost of an extraction, implant and implant crown, which will be the most conservative and longer lasting option, and which will be more popular as a patient selection? I think we're going to see over the near future a major decrease in endodontics, especially heroic entodontics, and a major increase in implants for these very situations.

The most dramatic trends in patient treatment options will occur as a result of combining existing and new technologies to make dental practice better, faster, and easier. We have seen this with the increasing utilizations of implants for denture stabilization. This is greatly underused. People who do use it are making a lot of money. They're very busy. Don't forget that the dental population, at least the entire population, is about 30% endenturist in most areas of the country. The people who are seeking the denture stabilization with the smaller implants, the immediate implants are also the baby boomers who have a lot of money. The money is there, the intent is there, just that many dentists have not recognized this as a good part of their practice. It's very lucrative.

Currently the use of 3-dimensional tomography to accurately plan implant placements facilitates placement. Comprehensive jaw movement analysis, precisely records the state and the mobility of the mandible joint to optimally design prosthetic treatment in a fully functional and comfortable position. Adding sensors and actuators to dental sleep appliances will improve the patient's nocturnal rest and waking hours. The age of synthesis, putting independent scientific and clinical knowledge together, is upon the dental profession.

A couple of more areas trance the evolution of the dentist-patient interaction. Unfortunately, practice success has always depended on the interaction between the dentist and the patient, and the staff, of course. This is unlikely to change in the near future or the far future. However, the dentist-patient relationship has been changing for many years and is likely to evolve more rapidly in the new future. The patient today is largely informed, but not always well-informed. The information readily available on the internet is rarely vetted for accuracy or fact. 

In fact, misinformation is much more likely than real understanding. Patients, however, assume that they are knowledgeable and will often confront the dentists with their knowledge gleaned from the experts on the internet. It is essential for the practitioner to correct the patients misinformation but without offending or belittling the patient. This is something that can be a difficult task on occasion. It is far better and easier to have an effective educational program available for patients in the reception area and in treatment rooms and while waiting for procedures. This proactive transfer of information may offset some of the incorrect data that has been gathered by the patient and may lead to questions that will ultimately encourage appropriate and additional incremental treatment. 

Increasingly, the dental team is focusing the patient's home care by recommending specific maintenance procedures. For example, patients who do not respond to flossing, that's the vast majority, are often more amenable to something called water flossing. Water flossing is something that we were told in dental school, 40 years ago, was a joke. We saw an article just 4 years ago which totally turned that on its head and it seemed that there were a lot of potential benefits. We started using waterpik or water flossing at home and we liked it so much. Basically it was more effective than flossing, although we used the two of them together, that we started recommending them to the patients. Patients, number 1, responded much more positively to it, and number 2, they were also keeping their mouths cleaner. We're now recommending this as a major fan to our patients and dentists who want to make sure that their patients maintain their oral cavities properly would be wise to do the same.

Individuals with halitosis and/or long term periodontal disease due to poor oral hygiene may accept medicated rinses on a regular basis. Those with excessively dry mouth are actively seeking oral moisturizers and there are a number of those on the market. We are the gateway to that as dental professionals. More and more home applied therapies are available under recommendation of the dental team. The successful practitioner will use every possible device to improve the patient's oral health in the long periods between re care appointment. This is when we don't see the patient, when the patients only sees themselves and we have to give them every possible tool to make that work. 

What are some of the new clinical standards in the next twelve months? In the next five year? 

In the next twelve months we are likely to see a major restructuring in the dental implant segment. The cost of implants to the dentist and patient and a significant increase in their popularity and utilization. The percentage of dentist sending optical impressions directly to the lab will grow. Bio active restorative materials will be the latest and the greatest in restorative dentistry. More restorative materials will be self-adhesive heralding the advent of the 8th generation, or no adhesive at all. The relationship between oral health and systemic health will become more firmly established in the public's mind, encouraging better oral healthcare and more dental consultation, and for the forward looking dentist, more patients, more business. 

Over the next five years, even greater changes are expected, the diagnostic and surgical technologies required for implant placement will make the process so predictable that most general practitioners will choose to embrace the surgical procedure rather than to send it out to specialists. Oh well. We'll keep the money and treament in our pockets rather than sending it to somebody else. Dentists will not only take impressions optically, but will use 3D modelling and printing to create the required shade-matched crowns and bridges within minutes right in the practice. iN fact, many of the cab camps today are already obsolete. 3D printing is the way to go in the future. Just a few days ago saw filling material that is printed, depending on the cavities shape and size that has been scanned in, and the printed restoration is actually antibacterial. 

Who knows what the future will bring? It will be good, but we're not entirely sure of what it's going to be. Remineralizing and regenerating restorative materials will build nature-mimicking structures that closely resemble natural teeth. A variety of systemic diseases will be treated orally by the dental practitioner. More importantly, we, as dentist, will become the gateways to the diagnosis of systemic diseases through oral tests that we can administer. 

The past 100 years have demonstrated a rapid, rapid growth in dental technology and even more rapid development of dental materials. The past few decades have offered quantum leaps in the restoration oral health, function, and aesthetics. By simple extrapolation, the future is golden for the dental profession. It is an exciting time to be a dentist.

Howard: George, that was ... You're the Beethoven of density, buddy. You just played an entire concert. That was amazing.

George: Thank you very much.

Howard: I'm so glad that we met up at Joyce Basset's dinner the other night and I was able to twist your arm to give me an hour of your most precious time.

George: You never need to twist my arm. Just ask.

Howard: All right. 

I would also love to interview your wife. Do you think Faye would be up for this? 

George: Yes, she is. Contact her and she'll be happy.

Having been married happily for 5 years out of 38, I know better than to make decisions for her, but I know she would be thrilled to work with you.

Howard: And how is your daughter doing?

George: SHe's doing fine. She's actually in charge of distributing canine toothpaste.

Howard: For dogs?

George: For dogs. Yeah. In Canada. 

Human toothpaste costs 3, 4 dollars, 2 dollars. The premium ones are $10-15. Dog toothpastes start at $25. It's amazing. She has the best one on the market. It's a product that is very, very good. It's called Pet Smile. It makes your Pet Smile. You don't have to brush your dog's teeth. Just get the material in their mouth, and they'll have fewer visits to the vet for tooth cleaning because the whole pellical deposition on the tooth is interrupted. It will keep dogs healthier, happier, and with fewer tooth cleaning appointments which are not only possibly risky, but they're also expensive.

For example, how much do you charge for a cleaning? $150 to $200?

Howard: Yeah.

George: Do you know how much vets charge for a cleaning?

Howard: How much?

George: $500 to $800 dollars. I'm giving up my human dental license and I'm going to become a vet. 

Howard: You know, George, if she runs into anybody, both of her parents are world-famous dentists. If she runs into a dentist vet or ... either a vet that does dentistry or a dentist who does veterinary whatever. I have never podcast interviewed and I've never made an online CD course with veterinary dentistry. If you run into any names, that would be really, really fun and exciting.

George: You know, veterinary dentistry is a really "ruff" business. 

Howard: Why is that? Oh, "ruff," as in "ruff, ruff" the dog. Is that what it was? A pun?

I loved it.

But really, she might run into one. She might run into someone. If she does, turn me on to the lead. Every time I see an article of some dentist doing a root canal on a lion in a zoo I always find that incredibly fascinating. 

Also, I wanted to ask you, my last question is how much money would I save if I traded you my four boys for your only daughter. Can we negotiate this?

George: Daughters are a lot more expensive than sons. I have to tell you that. 

Howard: But I've got four sons. Do you think that would be an even trade or you think I would even lose money?

George: You would probably lose money on the deal. But I'm happy to entertain it.

Howard: OK. Thank you so much for you time George, that was an amazing hour.

George: Pleasure and thank you for the opportunity.

Howard: All right. I'll see you in New York.

George: In New York. Are you coming to the IUDFE.

Howard: Yes.

George: Good. Have you nominated anybody?

Howard: I have not.

George: Well, do you know any deserving dentists who are leaders in their profession who have contributed who do interesting stuff, because you're a fellow of that group, right?

Howard: Yes. Okay. I will work on that.

George: Okay. Take good care.

Howard: You have a great day. Bye.

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