Post on 12-Feb-2020
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TODD SNYDER, DDS, FAACD, FIADFE
Accredited Fellow, American Academy of Cosmetic Dentistry
Fellow, International Academy for Dental Facial Esthetics
Member of The American Society For Dental Aesthetics
Former Faculty, UCLA Center For Esthetic Dentistry
Todd Snyder, DDS, FAACD, FIADFE, ASDALaguna Niguel, CA
Aesthetic Dental Designs®
doc@tcsdental.com
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PATHOLOGY DRIVEN DIAGNOSTICS
Are you still diagnosing with this??
50%
accurate
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RADIOGRAPHIC ANALYSIS
Since 1896
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Portable X-Ray Units
DIAGNOSE
Is it thru conventional radiographic analysis?Approximately 25% demineralization must occur to see a cavity on a conventional radiograph.
Equates to 40-60% demineralization on the tooth surface. Radiographs miss 70-80% of
occlusal cavities.Digital radiographs provide the ability to manipulate image size and appearance.
67%
accuracy
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Fiber Optic TransilluminationMicroLux Kavo DiaLux 2300L
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Fiber Optic Transillumination
Fiber Optic Transillumination
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DRIVES
Thru intraoral photographic interpretation?
How do you diagnose decay??
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FLUORESCENT TECHNOLOGIES
What fluoresces in fluorescent-based technologies?
• Bacterial porphyrins (bacterial breakdown product),
• Stain,
• Tartar,
• Food debris
All fluoresce under the wavelengths used in most caries detection devices, whether or not caries is present.
Lussi A , Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33(4),261–266.
Lussi A, Hibst R, Paulus R . DIAGNOdent: an optical method for caries detection. J Dent Res 2004;83C, C80–83.
Verdonschot E H, van der Veen M H. Lasers in dentistry 2. Diagnosis of dental caries with lasers. Ned Tijdschr Tandheelkd 2002;109(4), 122–126.
Konig K, Flemming G, Hibst R. Laser-induced autofluorescence spectroscopy of dental caries. Cell Mol Biol (Noisy-le-grand) 1998;44(8), 1293–1300.
Alwas-Danowska HM, Plasschaert AJ, Suliborski S, Verdonschot EH. Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis. J Dent 2002;30(4):129-34.
Rechmann P, Rechmann BM, Featherstone JD. Caries detection using light-based diagnostic tools. Compend Contin Educ Dent. 2012;33(8):582-4, 586, 588-93; quiz 594, 596.
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CariVu Fiber Optic Transillumination
CariVu: Transillumination
• Near Infrared light…no radiation
• Enamel appears transparent or light
• Porous lesions appear darker by trapping and absorbing the light: these include cracks and caries
• Video capture….live scans
• Stored in Dexis, excellent for communication to patient and yes…to insurance companies
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With proximal surfaces, one can identify
where the lesions are
buccally and lingually
Utilizing CariVu
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For identifying cracks, and to a certain
level, the severity of the cracks
Utilizing CariVu
Allows superior interproximal decision making
regarding Watching, Follow-up, Infiltrating, Drilling
Utilizing CariVu
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BITEWINGS VERSUS
CARIVU
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Crystal Structure DiagnosticsThe Canary System Detects Cracks & Cavities not
Visible on X-rays
+ Around & beneath intact margins of fillings & crowns
+ Under sealants (including opaque sealants)
+ On proximal surfaces
+ On smooth surfaces, pits & grooves
+ Around orthodontic brackets
Measures tooth structure breakdown, allows for early
treatment
+ Restore conservatively
+ Remineralize back to health
+ Seal with confidence
Research claims validated by 60+ papers
15+ case reports & 2 FDA CFR 21 clinical trials
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The Science Behind The Canary System
• Pulses (2 Hz) of laser light hit the tooth surface.
• Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).
• Defective tooth crystal structure affects the retained heat and luminescence signatures.
➢Energy Conversion Technology
Temperature
increase < 1oC
not harmful
• Detected signals reflect the tooth’s condition.
• Detects 50 micron lesion up to 5 mm below the surface.
Delegated Scanning & Whitening Assistant
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Sensitivity & Specificity Study: University of Texas October 2012
Study Design• 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
• Visual ranking by 2 dentists • Canary Scan• DIAGNODent• Polarized Light Microscopy used as
the gold standard to confirm presence of lesion & depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100% 18%
Specificity 100% 100%
Spearman Correlation with Lesion Depth
.84 .21
Canary is Superior to X-Rays for Proximal Caries DetectionJan J et al. Caries Res 2014;48:384–450 DOI: 10.1159/000360836
Objective:
To compare the accuracy of The Canary System, ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro.
Methods:
ICDAS-II (Direct Visual Examination): Blinded examiners ranked 100 proximal surfaces using ICDAS-II by
direct visual examination of the surfaces
Manikin mouth models: The teeth were then set in manikin mouth models, creating contacting proximal
surfaces that very closely resemble in vivo situation.
Histological validation: All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions.
Conclusion:• BW radiographs could only identify 26.7% of the lesions which questions its ability to be the
gold standard
• The Canary System is the only method examined with both high sensitivity and high specificity.
• The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
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Pain Mandibular Right Posterior Quadrant
No pathology on x-ray. Canary Scan
Revealed Pathology on Mesial & Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
Removal of Amalgam Confirms Caries
97
58 36Crack on mesial and distal
marginal ridges with caries.
Caries around the lingual
margin
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Interproximal Caries Detection
Bitewing radiograph did not detect caries.
Caries located on buccal aspect of the contact area
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Demineralized enamel
Caries Detection Method
The Canary System
DIAGNOdent
Sensitivity 83% 64%
Specificity 79% 46%
• Canary Numbers >20 when scanning sealants (3M™ ESPE™ Clinpro™ Sealant) placed over pit & fissure caries.
• The caries detection ability of the Canary System was not affected by sealant & was more accurate than DIAGNOdent.
Sensitivities and specificities for pit & fissure caries detection after sealant placement.
Canary Number 66
Canary Number 37Caries into dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
Detection of Caries Beneath Sealants
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After all the cleaning and diagnostic technology being used, what if you find something?
Topical Therapies• More caries resistant• Remineralization• Desensitization
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Minimally Invasive Treatment
• Apply MIPaste Plus for 3 minutes
• Patient applies at home 2x/day
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MI VARNISH™ WITH RECALDENT™ (CPP-ACP)Bioavailable calcium, phosphate & fluoridefor an enhanced varnish treatment
Xylitol Oral Health Products
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SALIVA-CHECK BUFFER, from GC America, tests for salivary flow and buffering capacity
• No tooth reduction.
• Adhesive and mechanical retention
• Radiolucent
Resin Infusion-ICON
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Resin Infusion-ICON
Other Materials• Clinpro 5000 with TCP (3M)• Enamelon with fluoride and ACP (Premier)• Remin Pro (Voco)• Sensodyne ProNamel• Arm & Hammer’s Enamel Care• Arm & Hammer Complete Care w/ Enamel Strengthening• Colgate Sensitive pro relief• Fluoride Varnishes• Glass Ionomers
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Huge Marketing Opportunity• Remineralizing teeth
• Non Ionizing Diagnostic Tools
• Minimally Invasive Dentistry
• Health Product Sales
• Community Educational Programs
• Internet and Local Media Advertising
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Paradigm Shift
• One can place a number of restorations or fillings and yet not treat the underlying disease
• The bacteria remain in the plaque on the teeth, capable of creating new areas of tooth decay
• Patients value a shift from a surgical approach to disease management and prevention
How will you diagnose?
How will you treat?
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Everyday Go To Minimally Invasive Burs
0512C1300F0710C 0116C
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FREE DISPOSABLE SINGLE USE DIAMONDS
Text DIAMOND3 To
770.212.2090 For
Free Pack Of
NeoDiamonds
SS WHITEConservative
Burs
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Access, viscosity, small areas
Deep, narrow, preparations
Lots of enamel
Flowables
• Voco (Grandio SO HF, Xtra Base)
• Ultradent (PermaFlo)
• Kerr (Revolution, Premise, Vertise)
• Ivoclar (Tetric Flow)
• Heraeus (Venus Diamond Flow, Bulk Fill)
• Shofu (Beautiful Flow Plus-Zero & Low Flow)
• G.C. America (G-aenial Universal Flo)
• Dentsply (SureFil SDR, EsthetX Flow)
• Kuraray (Clearfil Majesty ES Flow)
• Tokuyama (Estelite Flow Quick)
• 3M (Filtek Supreme Flow Plus)
Flowables
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Flowable
Medium Size Defects
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Small to Medium sized Lesions (<2MM)
• Mostly superficial
• Good restoration longevity
• ½ enamel with ½ extending into dentin
• Dentin is fairly dense
• Open &/or Closed defect
• Risks are low
• Minimal occlusal loading
Large Defects(occlusal)
Recurrent decay
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Think about material choices & their long term durability & susceptibility for failure in adhering to deep dentin.
pulpal proximity
Large sized Lesions (>2MM)
• Mostly dentin
• Dentin has more moisture and less substance
• Open and Closed defects
• Complications & Risks are higher
• Porous, Wet, Dentin Available
• Interproximal concerns
• Increased Occlusal Loading
• Remaining Tooth Structure
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Bond Strengths Related To Type of Dentition
0
5
10
15
20
25
30
35
40
45
50
DEJ Superficial(Sound) Dentin
Beveled Enamel Deep Dentin Affected CariousDentin
Infected CariousDentin
45 45
30 30 30
10
Irie m, suzuki k, watts dc, 2004, marginal gap formation of light activated restorative materials, affects of immediate setting shrinkage and bond strength. Dent Mat 18, 2002; 203-210
Caries Indicator Dyes• Roydent-To Dye For• Kuraray-Caries Detector*• Ultradent-Seek*/Sable Seek*• ProOptions-Caries Indicator• Danville-Caries Finder• Pulpdent-Snoop• Vista-Caries Indicator• Ronvig-See It• Patterson-• Henry Schein-• Pearson-
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Note Caries on Floor of 2nd Molar
Further Inspection Reveals More Caries
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Caries Removal Burs• SS White
– Single use
– Polymer
– Hardness
– 5000-10,000 rpms
• Komet
– Multi use
– Ceramic
– Hardness
– 1000-1500 rpms
Article on the Comparison of Caries Removal Burs
J Adhes Dent 2011 Feb;13(1):7-22. doi: 10.3290/j.jad.a18443.Current concepts & techniques for caries excavation & adhesion to residual dentin.de Almeida Neves A, Coutinho E, Cardoso MV, Lambrechts P, Van Meerbeek B.
Round Burs (#6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White)
1,000-1,500rpm 5-10,000rpm
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NSK Electric Handpieces
Handpiece Lubricants
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Long term failure occurs at gingival margins and adhesive interfaces.
Yiu CK, Hiraishi N, King NM, Tay FR. Effect of dentinal surface preparation on bond strength of self-etching adhesives. J Adhes Dent. 2008 Jun;10(3):173-82.
Higher bond strengths when using tungsten carbide burs with SE adhesives
Preparation• Limited to removal of pathology with the exception of access and bevels.
• Maintaining enamel and superficial dentin
• Preserving occlusal stops
– Marginal ridges
– Transverse ridges
– Oblique ridges
• Rounded line angles
• Purge hand piece oils
• Bur Choice
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Total etch Self etch
# of components
Etchant
Primer
Adhesive
Bonding Agents
Generation4th 5th 6th 7th
Total-Etching
Bonding to Enamel/Dentin
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Bonding to Enamel/Dentin
Self-Etching
Factors that compromise bond durability in restorative dentistry
“The major shortcoming of contemporaryadhesive restoratives is their limited durability in vivo.”
alarming
words …
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
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Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
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Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandora’s box, releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped withinthe mineralized dentin matrix.
In the presence of water (such as thatderived from water sorption or from
adhesives, MMPs (2,8 & 9) can breakdowncollagen fibrils that are not protected
by intrafibrillar minerals
Sukala et al. (2007)Mazzoni et al. (2007)
Bond Degredation
• Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin bonds. Compend Contin Educ Dent. 2011 Sep;32(7):60-4, 66.
Resin-dentin bonds are not as durable as was previously thought. Microtensile bond strengths often fall 30% to 40% in 6 to 12 months.
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Without
chlorhexidine
With
chlorhexidine
as a MMP
inhibitor
Chlorhexidine prevented degradation of hybrid layers created by
Prime&Bond NT after 12 months of intraoral function
Brackett et al. Chlorhexidine preserves hybrid layers
but not nanofillers in vivo. Oper Dent (2009)
MMP inhibition with chlorhexidine
Potential ways to extend bond longevity
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•Courtesy Pacific University (Dr Marc Guisberger)
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•Courtesy Pacific University (Dr Marc Guisberger)
InstroN• Ultra Tester (Ultradent)
• Ultra Jig (Ultadent)
Ultradent’s shear bond strength testing method has been adopted as an ISO Standard. The UltraTester machine uses this highly accurate method to determine bond strengths.
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Ultradent Internal Testing
Shear Bond Test Results - 2012Average Shear Bond Strength to Dentin: 24.2 MPa
•Courtesy Pacific University (Dr Marc Guisberger)
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Maximum/Minimum Shear Bond Strength per Bonding Material
Shear Bond Test Results - 2012•Courtesy Pacific University (Dr Marc Guisberger)
Why different pH?
3.2 2.7 2.54.6
MDP Penta-P MDP BPDM
Adhesive Functional
Monomers
MDP
2.3 1.6
GPDM
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Total etch Self etch# of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR
• Developed by Kuraray 1983
• Acidic Monomer Activates Silanes & Chemically Bonds to Metal Oxide Ceramics (Zirconia & Alumina).
• (Key Ingredient to make a Silane Universal)
• Hydrophilic & Hydrophobic
• Very Durable Dentin Bond
(Creates An Insoluble, calcium Salt with Dentin)
• Is The Most Copied Monomer In Dentistry
• The Most Researched Monomer In Dentistry
• 20 + Years Of Research On Metal Oxide Ceramics (Zirconia & Alumina)
• Strongest & Most Durable Bond to Metal Oxide (Zirconia & Alumina) Ceramics
MDP ADHESION MONOMER:
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When bonding to enamel, an etch & rinse approach is definitely preferred, indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel. When bonding to dentin, a mild self-etch approach is superior, as it {MDP} involves (like with glass-ionomers) additional ionic bonding with residual HAp. This additional primary chemical bonding definitely contributes to bond durability. Altogether, when bonding to both enamel and dentin, selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue
Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater (2009),doi:10.1016/j.dental.2009.11.148
MDP Penta-P MDP MDP
Adhesive Functional Monomers
MDP GPDM
MDP Modified
Phosphates
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NEW “UNIVERSAL” SYSTEMS
• Simple & easy to use
• Direct & indirect techniques
• Use as Total, Selective or Self Etch
• Low sensitivity
• Lots of MDP Based Products
DRAWBACKS OF ANY COMPOSITE RESIN
• Material placement techniques
• Variable substrate
• Polymerization stress & shrinkage
• Water absorption
• Hydrophobic bonding agents
• Decreased adhesive bond strength over time
• MMPs and Cathepsins
• Microleakage
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DECREASED BOND STRENGTHS DUE TO:
• Substrate
• Preparation technique
• Bur selection
• Hand piece oils
• Bonding agent
• Curing device and position
• Material selection
• Layering technique
Direct Composite Restorations
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What substrate are we treating?
Class I or II
:Composite Preparation
3x Tubule Density Equals Higher Fluid &
Increased Difficulty for Bonding
%30 Degrease in Bond Strengths with most
bonding systems.
“Adhesive dentistry could be expressed as a
simple relationship between bonds and
stress. If the bonds can withstand the
stress, the restorative technique will be
successful.”
Unterbrink and Liebenberg (1999)
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“C-FACTOR” DEFINITION
Configuration Factor:
“The ratio of bonded to un-bonded (free) surfaces”
Feilzer, DeGee, Davidson (1987), Universtiy of Amsterdam, ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
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What are you placingWhere in the tooth How are you utilizing it?
EnamelSuperficial DentinMiddle DentinDeep Dentin Sclerotic DentinInfected DentinAffected Dentin
“C-FACTOR” DEFINITION
MDP BASED BONDING AGENT AND…..X?
Excellent Flow & Handling Base/ Lining
“C-FACTOR”
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Tokyo Medical & Dental University, 2010 J. Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W/ 71%/WT FLOWABLE ON DENTIN ONLY)
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RESIN TO DENTIN HYBRID ZONE
Dentin Replacement with Composite Cap?
Dentin substitute
Flowable Resins
-3%-6% vol. shrinkage
-1.6-3mpa shrinkage stress
-thin on pulpal floor only
-or SureFil SDR +
-What bonding agent?
Glass Ionomers
Enamel Replacement
Modern Nanohybrid Composite
CR April 2014 NanoHybrid offers best results
ADA reports flowable resins are used by
82% of dentists as bases or liners.
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82% of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation. 1
Insight
1Council on Scientific Affairs of the American
Dental Association. Spring 2009;4(2).
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REDUCES INTERNAL STRESS BY 60% COMPARED TO TRADITIONAL RESINS.
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS1/3 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
LOW STRESS ADAPTATION• Marginal Integrity
• Adaptation at the
most vulnerable
interface
• Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The #1 reason for
composite failure is
recurrent decay – and
the floor of the proximal
box of a Class II is the
most vulnerable area
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NOT ALL FLOWABLES FLOW!
SureFil SDR flow Viscous, non self-
leveling flowable
Adaptation isn’t just at the floor of the proximal box
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
• EXCELLENT CAVITY ADAPTATION
• EXCELLENT RADIOPACITY
• LOW STRESS
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INCREASE CLASS II EFFICIENCY
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NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines(leaves room for the wedge)
Built in lip for increased stability in forceps
Anatomically shaped tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal V3 Ring to ensure ideal separation on smaller teeth.
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Selective Etch Enamel Only
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• More efficient than Halogens
• Halogen produces light from 370 to 800 nm then filters out all
but blue light in 400-500 nm range
• Longer lasting / Cordless / Batteries
• Faster curing (5 seconds)
• Nanometer range closely matched CQ range (450-470)
• Smaller in size/lighter
• Less heat
BENEFITS OF LED LIGHTS
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COMPARISONS - LIGHTS
Access to the curing site = Energy to the
resin
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Machined from Aerospace Aluminum
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$200 $205
$321
$73
$175 $175
$11
$0
$50
$100
$150
$200
$250
$300
$350
Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2, 16-20i VALO
Curing Light Replacement Battery Cost
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• Long term research?
LIGHT CURED BULK FILL COMPOSITES
• Dentin & Enamel Replacement• Requires one layer
• 1.6%-2.4% vol. shrinkage
• 2.3-2.8mpa shrinkage stress
• Bonding agent• (2 bottle highly filled system)
• Self Cured BulkFill• Danville Materials (Zest Dental Solutions)
• Coltene
• Pulpdent
• Parkell
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BULK FILL COMPOSITES
• Fastest growing dental material category in North America.
• Convenient, Time Savings
• Reduced polymerization shrinkage
• Depth of cure
• Flow or adaptability
• Physical properties
• Wear
• Esthetics
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BULK FILL COMPOSITES
• Bulk fill composites 4mm max typically
• 10 second cure
• More translucent
• Typical shrinkage is 1.6-2.4%
• SonicFill (Kerr)
• Venus Bulk Fil (Heraeus)
• Quixx (Dentsply)
• Tetric EvoCeram Bulk Fill (Ivoclar)
• X-tra Base, X-tra Fil (VOCO)
• Filtek Bulk Fill Flowable (3M/ESPE)
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
5
10
15
20
25
30
35
Bulk Fill Oblique Vertical Horizontal
11
17.615.7 16
19.8 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor & Layering Technique on Microtensile Bond Strengths to Dentin; S. Nikolaenko, R. Frankenberger et al, University of Erlangen, Nuremburg Germany, Dental Materials, 2004 Vol. 20: 579-585
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These CRA research results agree with
Dr. Tagami’s results on SonicFill.
Tagami stated SonicFill cures to only 70% on
bottom at 4 or 5mm depth of cure.
Test your light output and practice with your materials
Curing bulk fills remains a question
CRA questions the ability for most practitioners to place bulkfill materials
properly in addition to getting adequate curing.
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Internal (Polymerization) Stresses of Composites
“A Simple Pain-Free Adhesive Restorative System by Minimal
Reduction & Total-Etching (1993)
Takao Fusayma DDS,
Tokyo Medical & Dental University
SELF CURE BULKFILL….
• Danville-BulkEZ
• Coltene-Fill-Up!
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/
(RFA-DE-10-004) “Tooth-colored resin restorations have an
average replacement time of 5.7 years due to secondary caries precipitated by bond failure.”
Fig. 15 – Graph representing the mean annual failure rates
per adhesive class, determined according to a systematic
review of Class-V clinical trials of adhesives during theperiod 1998–2004 [2].
Van Meerbeek B, et al. Relationship between bond-strength tests and clinical
outcomes. Dent Mater (2009), doi:10.1016/j.dental.2009.11.148
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ORAL BACTERIA DEGRADATION OF RESIN RESTORATIONS
BULK FILL SELF CURE MATERIAL
Releases/recharges calcium, phosphate and fluorideChemically bonds and seals tooth
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• No Bonding agent necessary
• No layering bulkfill
• No polymerization stress
• Bioactive
• Bioavailable
• No sensitivity
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DO Restoration
Tooth #29
CLASS V AND CLASS II TOOTH #31
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Drawbacks of Any Composite Resin• Material placement techniques
• Variable substrate
• Polymerization stress & shrinkage
• Water absorption
• Hydrophobic bonding agents
• Decreased adhesive bond strength over time
• MMPs and Cathepsins
• Microleakage
• Light polymerization
Decreased Bond Strengths due to
• Substrate
• Preparation technique
• Bur selection
• Hand piece oils
• Bonding agent
• Curing device and position
• Material selection
• Layering technique
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What problems are believed to be associated with high-
polymerization stress?
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity, microleakage and/or
secondary caries
Lots of optionsWhat works best for your practice and skills?
How much time do you have?Bond Strengths?
Risks and Longevity?
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?How are you restoring
these different preparations
• Bioactive material
• affinity to tooth structure. when placing a glass ionomer a weak acid or conditioner is used to aid in releasing calcium and phosphate ions from the tooth structure. These calcium and phosphate ions combine into the surface layer of the glass ionomer and form an intermediate layer called the interdiffusion zone. This bond layer can be very strong and significantly reduce the microleakage that would occur at the margins of the restoration.
• Very good fluoride and ion release helps remineralize tooth structure in the remineralization–demineralization process that naturally occurs in the oral cavity.
• They bond to enamel, dentin, and metals.
Why Glass Ionomers?
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• They produce good marginal integrity.
• They shrink only one ninth the amount of composite material.
• They are fluoride-rechargeable.
• There are no free monomers in the material.
• The cavity preparation can be bulk-filled, making the materials easy to place.
• They exhibit excellent biocompatibility.
Why Glass Ionomers?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/
(RFA-DE-10-004) “Tooth-colored resin restorations have an
average replacement time of 5.7 years due to secondary caries precipitated by bond failure.”
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Fig. 15 – Graph representing the mean annual failure rates
per adhesive class, determined according to a systematic
review of Class-V clinical trials of adhesives during theperiod 1998–2004 [2].
Van Meerbeek B, et al. Relationship between bond-strength tests and clinical
outcomes. Dent Mater (2009), doi:10.1016/j.dental.2009.11.148
Deep Preparations Bonding Agent & Flowable composite
Conventional Glass Ionomer or GI then Composite Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation & C Factor
Coefficient thermal expansion similar to
dentin
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LARGE SIZED LESIONS (>2MM)• Mostly dentin
• Dentin has more moisture and less substance
• Open and Closed defects
• Complications & Risks are higher
• Porous, Wet, Dentin Available
• Interproximal concerns
• Increased Occlusal Loading
• Remaining Tooth StructurePulpal
Proximity
Seals & Protects the Pulp:• For Direct & Indirect Pulp Capping
• Light-curable, Radiopaque Liner
• Significant Calcium Release:
• Stimulates Hydroxy Apatite & Dentin Bridge Formation.
Resin-Modified Calcium Silicate Pulp Protectant/Liner
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THERACAL LC (BISCO)CONVENTIONAL GLASS IONOMER
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GLASS IONOMER SANDWICH
•Class I, II, III & V posterior
restorations
•Open & Closed Sandwich
techniques
•Composite replacement
•Amalgam replacement
•High caries risk patients
•Pediatric patients
•Geriatric patients
•Special needs patients
•Long term resistance to
microleakage
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GLASS IONOMER MATERIALS• Dentsply-ChemFil Rock Restorative
• SDI-Riva LC, light cure HV, Riva SC, self cure HV
• G.C. America-Fuji II LC, Equia Fil (Fuji IX)
• VOCO-Ionolux, Ionofil Molar AC
• 3M/ESPE-Ketac Nano, Photac Fil Quick, Vitremer, Ketac Molar Quick, Ketac Fil Plus
• Shofu- FX II
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• GC EquiaFil Compressive Strength 255mpa
• Equia Forte 280mpa
• Riva SC compressive strength 271mpa
• Chemfil Rock Compressive 200mpa
• Voco Ionolux had higher compressive strength than Equia Fil or ChemfilRock
• Surefil SDR compressive strength 220mpa
• Dentin 280mpa-297mpa
• Enamel 384mpa
• Grandio SO HF has compressive 417mpa
• Fuji II LC 170mpa (RMGI) Compressive strength
COMPRESSIVE STRENGTHS
GC AMERICA
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MINIMALLY INVASIVE PREPARATIONS
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Komet & Kavo
Komet SF1LM
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GLASS IONOMER INTERFACEIn
terfa
ce
An
aly
sis (TEM
)
CARDOSO et al. J Dent 2010
RESIN TO DENTIN HYBRID ZONE
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A3.5 A3 A2
Glass Ionomer Bulk Fill
EQUIA FORTEEQUIA™ FORTE is a complete system that is an ideal solution for posterior restorations:
•Class I, II, III and V posterior restorations •Composite replacement •Amalgam replacement •High caries risk patients •Pediatric patients •Geriatric patients •Special needs patients •Buildups•Long term provisionals
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EQUIA FORTECaries control/quadrant dentistry
(Class II, III, V & core buildup)
245
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WHAT DOES EQUIA COAT DO?Fill porosities to increase physical properties of the restoration and offers a much smoother surface…
(SEM
im
ag
es
x1000)
100um 100um
Some voids are observed A smooth surface is obtained
EQUIA FilPolished by using silicon
carbide paper (#600)
EQUIA FilAfter coating
SDI
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VOCO
ENDODONTIC SANDWICH TECHNIQUE
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ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
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ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
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ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
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ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
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Open Sandwich with glass ionomer & nanohybrid composite
Glass Ionomer vs. Open Sandwich
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• 7 years later.
Glass Ionomer vs. Open Sandwich
• 7 years later.
Glass Ionomer vs. Open Sandwich
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How do we create them?
Interproximal Contacts
Interproximal concerns & Issues• Voids
• Sensitivity
• Condensing
• Shape
• Flash
• Contact
– Position
– Tightness
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Problem & SolutionTofflemire vs. Sectional Matrices
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Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS & SILICONE RUBBER ADAPTERSMICROTHIN MATRICES 0.025MM (0.001 IN)WOODEN WEDGES
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NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines(leaves room for the wedge)
Built in lip for increased stability in forceps
Anatomically shaped tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal V3 Ring to ensure ideal separation on smaller teeth.
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Note how the anatomical shape of the V3 Ring matches the lingual contour of the molar while engaging the gingival undercut
Wave Wedge
Hole to fit with positive grip Pin-Tweezers Inter-proximal contour for
a better gingival seal and V-shaped concavity to protect the papillae
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Pin-Tweezers
4.5mm
5.5mm
6.5mm
Tab can be bent 90˚ for contra-angle placement
Holes designed to fit with positive grip Pin-Tweezers
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by TrioDent
by TrioDent
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by TrioDent
by TrioDent
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3.5mm 4.5mm 5.5mm 6.5mm 7.5mm
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SuperCurveSuper snug, non-stick
•Micro-thin – 35-38µ (0.0014”)
•Color-coded for easy recognition
and re-ordering
•Matrix very stable after placement
•Less risk of catching matrix wings
during ring placement, especially
with a back-to-back MO/DO
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Palodent Plus-DentsplyIdentical except for color
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PRIME N BOND ELECT (DENTSPLY/SIRONA)
• LONG STANDING RESEARCH OVER 13 YEARS
• PENTA RESIN TECHNOLOGY (CHEMICAL ADHESION)
• TOTAL ETCH
• SELECTIVE ETCH
• SELF ETCH
• DIRECT RESTORATIONS
• INDIRECT RESTORATIONS
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TPH SPECTRA ST LV & HV (DENTSPLY/SIRONA)
• MICROSCALED SPHERICAL
SUPERSTRUCTURES FROM SUBMICRON
GLASS
• SPHERETEC™ FILLERS’ MORPHOLOGY,
PARTICLE SIZE ALLOW FOR IMPROVED
HANDLING, ESTHETICS, & WEAR
• COVERS ALL 16 VITA SHADES IN JUST 5
SHADES
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QUICKLY POLISHES THE TPH SPECTRA ST COMPOSITE
• ENHANCE FINISHING
• POGO POLISHING SYSTEM
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Dual Force(Clinician’s
Choice)
Garrison Dental 3D Ring System
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Garrison Dental
XR = Extra Retention
Fender Wedges & Slick Bands
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Implementing various technology and software tools
-Enhance dental care-Lower overhead-Improve performance-Increase Efficiency-Create A Higher Income
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What happened to your piece of pie?
• More people working in the front than those producing the dentistry
• Layers of supervisors and managers, many of which have little or no patient contact
• A dental budget has: • rent at 5%
• equipment at 5%
• marketing needs at 3% to 10%
• lab expenses at or more than 10%
• dental supplies at 5%
• total team expenses at 20%.
• This item is one that you can control. It is the largest item in your budget. Most offices are staffed at closer to 30%.
Working Harder or Smarter?
• Look at your team• Is everyone trained to offer the same care
and service repeatedly
• Protocol Software• Repetition and consistency• Scripts• Daily Procedures
• Accountability Software• Tracking & Monitoring Tasks• Business Phones
• Technology to improve services• Software• Leverage mobile devices• Practice management software additives
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SLYDIAL-END OF DAY PATIENT PHONE CALLS
• Free voice messaging product
• Call all of your patients at one time and leave them a message
• Saves time if you have lots of patients to call
• Instantly leaves them your custom message
•
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Remember The Old Appointment Book?
How LONG Did It Take To Answer A Question About Balances, Forgotten
Appointments?
Practice Management Software
• Easy, Intuitive Management
• Faster
• Efficiency
• Consistency
• Key Performance Indicators
• Cloud Based?
• Integrations!!
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TIP
• VOIP Phone System Integrates with your existing dental practice management software (DPMS)
• Dentrix
• Dentrix Ascend Cloud Based coming soon…
• Eagle Soft
• Easy Dental• SoftDent
• Practice Works
• Mac Practice
• Open Dental
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TEAMWORK• Auto confirms appointments and adds to the Practice Management
Software
• Auto Birthday Messages
• Auto propagation of messages
• Easy to implement with minimal time to use.
• Improve business opportunities dramatically
• Cuts down on current employee time by streamlining many tasks
• Saves money on traditional procedures
• Less postage
• Less paper goods
• Less employee time
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• 2011 33% reported they did not trust online reviews.
• A recent study reported 88% of people trust online reviews
• 92% or internet users read product reviews
• 89% said it influences their purchases
• 74% of internet users said they would most likely not do business if there was a negative review
• Currently having one bad review is considered normal, but lots of bad reviews is not good.
ONLINE REVIEWS
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Reviews text message
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Reviews text message
Reviews text message
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Weave Reviews Via Cell phone message • Select Ratings to be sent to:
• Google• Yelp• Facebook
• Customize Order of Review Sites
• FYI-A dental/medical office can have more than one listing on Google, Yelp etc.. Because they typically employee more than one doctor as well as the business name (ie. Aesthetic Dental Designs and also Todd Snyder, DDS and my Associate can have a site too, just use different phone numbers and emails)
Weave Mobile App
-Same functionality
-From anywhere you have a wifi or cell connection.
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WEAVE IS THE BEST SOFTWARE TOOL I OWN
• It lets me do more in less time than what it would take three people to do in an hour.
• It replaces your existing phone with a Voice Over Internet Phone that attaches to your practice management software.
• It gives you the ability to cut your phone bill and be replaced with a modern phone platform that allows you to.
• Text your patients
• Record all phone calls
• Automated appointment reminders, followups, post op notices, birthday greetings, and more
• Collect balances instantly via text
• See unscheduled patients and have the ability to instantly send automated text messages to fill gaps in the schedule
• So much more….. YOU HAVE TO GET A DEMO IT IS AMAZING!!
• THE COST IS TYPICALLY THE SAME AS YOUR EXISITING PHONE BILL BUT YOU GET RID OF YOUR PHONE AND FOR THE SAME COST YOU REPLACE IT WITH SOMETHING BETTER THAT MAKES YOU MONEY!
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Online Real Data
THE POWEROF
ACTIONABLE METRICS
.
TIP
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TWO WAYS TO INCREASE PRODUCTION
PATIENT Visits PRODUCTION on Visits
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NEW PATIENTS
HOW MUCH DO WE REALLY LOVE THEM?
RECAPTURED
PATIENTS
47 $65,114
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356
Before AfterHygiene Re-Appointment
$167,400 increase through Actionable Metrics
Hygiene Re-Appointment
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Hygiene Re-Appointment
REAPPOINTMENT METRICS
How well is your staff reappointing patients?
How many people are past due?
You run a report?
How do you follow up on the report?
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Slipping Through The Cracks
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Delivering Best Dentistry
ACTIONABLE MONITORING DRIVES GROWTH
37% Increase in Production
In One Year!
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Accuracy, Consistency, Data
• Get an analysis of your company and see where you can make more money and be more efficient!
• You have no idea what you are missing!
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Text “action” to: 77453
Text RaceData to 77453
TIP
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Google Website Speed, Responsive Design and Build Issues/Code are very IMPORTANT
WEBSITE PAGE SPEED IS VERY IMPORANT (and so is relevant content too, read why)
https://www.wordstream.com/blog/ws/2018/01/22/google-speed-update
Jan. 22 2018
https://webmasters.googleblog.com/2018/01/using-page-speed-in-mobile-search.html
Jan. 27 2018
https://www.forbes.com/sites/jaysondemers/2018/01/29/will-googles-new-page-speed-criteria-affect-your-site/#6c3dbe8f6a8f
Jan. 29 2018
July 2018
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CHECK YOUR PAGE SPEED
https://developers.google.com/speed/pagespeed/insights/
CHECK YOUR PAGE CODE
MOBILE FRIENDLY?
https://search.google.com/test/mobile-friendly?id=De1nibkdCgXmmSqhS04nzw
https://validator.w3.org/nu/?doc=https%3A%2F%2Fwww.blux.com%2F
My NGenys Built Websites
http://www.aestheticdentaldesigns.com/
http://www.drtoddsnyder.com/ just got started on
Only a couple weeks to build if you provide the photos and content.
OR they can do photography and content for you..
-
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NGenys
Pronounced Ingenious
Websites, Photography, Brand, Social Media and More
www.NGenys.com
Proof of Work / Transparency, NO ONE ELSE OFFERS
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MOST WEBSITE
COMPANIES
Do Not Service Your Account
MonthlyPROVE it, have them show you
what they did last month
TECHNOLOGY
ONLINE
Efficiency 24/7 STAFF TRAINING
Accountability/Trackability
TIP
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Unit 1 Introduction Rapport
Unit 2 Foundation of Rapport
Unit 3Fundamental Techniques in Handling People
Unit 4 Six Ways to Make People Like You
Unit 5 Mirroring & Matching
Unit 6 Outcome of Calls
Unit 7 How to Build Rapport
Module 5 Rapport 2: Personality types
Unit 1 The Know-it-All
Unit 2 The Storyteller
Unit 3 The Easy Peasy
Unit 4 The Rusher
Unit 5 The Informationalist
Unit 6 The Nervous Nelly
Unit 7 The Indecisive
Unit 8 The Price Shopper
Module 6 Rapport 3: Advanced rapport
Unit 1 Empathy
Unit 2 How Long to Build Rapport
Unit 3 VIP Process
Unit 4 Positive Language
Unit 5 Elements of the Rapport Process
Unit 6 Phone Success Quiz #02
Module 7 Engage: Foundation
Unit 1 Introduction to the Engage
Unit 2 What is Engage
Unit 3 Proactive v. Reactive Scheduling
Unit 4 GREAT vs. EAGER Calls
Module 8 Engage: Elements of engaging the patient
• 14 Modules
• Quizes
• Exam
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• 13 Modules
• Quizes
• Final Exam
Module 5 Working with Emergencies
Unit 1 Emergencies
Unit 2Scheduling Quiz #01
Module 6 Broken & Changed Appointments
Unit 1 Introduction
Unit 2Broken Appointment Policy
Unit 3Handling Broken Appointments
Unit 4Broken Appointments COSTS
Unit 5What patients must know
Unit 6Important Points
Module 7 Confirmations
Unit 1 Confirmations
Module 8 Early and Late Patients
Unit 1Early and Late Patients
Unit 2Scheduling Quiz #02
Module 9 Next Appointment Updates
Unit 1Next Appointment Updates
Module 10 Patient Reactivations
Developing
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1. Telephone Skills
2. Customer Care Protocols/Scheduling
3. Team’s Role/Training
4. Resource Library
5. 24/7
97% of offices don’t train.
(954) 323-2220
Inquire with “Heather” for a $200 Discount
Remember The Old Appointment Book?
How LONG Did It Take To Answer A Question About Balances, Forgotten
Appointments?
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www.Chip-In.orgGuaranteed lowest credit card processing fees & a charitable
give back
COST?
• Cant afford? Technology makes you money!
• All Star is the least expensive & best training I have seen
• Replace existing phone bill with Weave
• Creates income
• Social Media & Internet is FREE• Unless you hire out
• Dental Intel- Priceless..
• Olark/SlyDial Free widgets
• Chip-IN.org see how much money you could save…
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REVIEW• Modern diagnostic tools
• Good technique is critical, selective etch technique
• Thin layer of flowable as first incremental layer
• OR SureFil SDR + over 5 years proven research
• Good handling, adaptable nanohybrid composite
• Conventional Glass Ionomers as a restorative option
• Tight contacts with Palodent Plus sectional rings
• Software that is free or inexpensive to create huge income opportunities and lower overhead
• Latest in website technology to survive on the internet
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TODD SNYDER(949) 643-6733
doc@tcsdental.com
www.aestheticdentaldesigns.comwww.drtoddsnyder.com
www.toddsnyderracing.com