Sollisch suggests that medical professionals are not very good at marketing, euphemisms, or even simple politeness. Older people are told that their joints and discs are “degenerative.” If you are over 50 and have X-rays taken of your spine, you should be prepared to hear that you have “degenerative disc disease.” Yet, according to the Cleveland Clinic, this is often simply a condition in which the cushioning of the spine gradually wears away, a natural part of aging, not truly a disease. Can’t we do better?

Sollisch also recounts that when his wife experienced a complicated pregnancy, her obstetrician declared that she had an “incompetent cervix” and placed her on bed rest. She was deeply offended, and the sting of those words remained with her more than 30 years later.

Euphemisms are often used in other settings: used cars become “pre-owned” vehicles, and companies avoid saying employees are being fired by calling it “right-sizing.” What we call things matters, especially in medicine, where the goal is to improve and preserve an individual’s health. Sollisch is especially troubled by the word “geriatric,” which derives from the Greek word for old age, so why is it used in reference to a pregnant woman in her 30s?

My wife and I recently had a similar experience. She fell in our kitchen and broke her hip — or, as she jokingly prefers to say, “fractured her femur.” Within 24 hours of the accident, she underwent surgery in which a rod and two pins were placed in the bone. To say the least, the initial recovery period was brutal. After 2 months, she was only barely able to get around using a walker.

At her 60-day post-operative follow-up appointment, we were greeted by a physician assistant (PA) who, apparently without having reviewed my wife’s medical history, declared that she must have osteoporosis. We knew that was not the case. The PA then insisted that the likelihood of my wife ever walking again without major assistance was extremely poor. For only the third or fourth time in our 54-year marriage, my wife cried after the PA left the room. She was devastated.

The point is that someone with very limited knowledge of my wife’s history delivered words that, for many people, could have caused profound despair or even depression. To my wife’s credit, however, she became so determined to prove that prediction wrong that she doubled down on her rehabilitation exercises. Today, she is steadily recovering and can once again walk independently for short distances.

The lesson is simple: words matter, and how we use them matters even more.

Reference

1. Sollisch J. Why aren’t doctors better with words? Wall Street Journal. April 12, 2026.

From Decisions in Dentistry. September/October 2026;12(2):9-12.

Collectively, these pressures highlight the unmet need for educational strategies that are needs‑driven, person‑centered, and adaptable to match our evolving field. How can we inspire and engage the next generation? The rise in structured innovation frameworks, notably the Biodesign Innovation Process, helps align education programs with student needs.^2,3

What Is the Biodesign Innovation Process?

Established biodesign and healthtech innovation programs offer a model for rigorous training of healthcare innovators in dental and medical education.

The curriculum centered around the Biodesign Innovation Process occurs in three phases:

1. Identify
2. Invent
3. Implement

Each is designed to provide a scaffold for moving from observation to impact.

In the identify phase, trainees conduct immersive and structured observations across clinical settings to catalog unmet needs affecting patients, clinicians, and systems. These observations are converted into concise need statements that prioritize clinical impact, feasibility, and value.

The invent phase focuses on generation and prototyping of multiple solution concepts in an iterative approach while considering regulatory and economic constraints.

In the implement phase, promising concepts are advanced through piloting and stakeholder engagement, with attention to sustainability, value creation, and real‑world adoption.

For dental education, the key insight of this framework is not the specific technological outputs but the reproducible, needs‑first mindset to build education innovators and thinkers.

Practical Applications for Innovators in Dental Education

Biodesign and design-thinking frameworks offer complementary lenses through which, as a community, we can evaluate entrenched structures and re-imagine strategies to inspire and engage the next generation.⁴ These initiatives do not require a comprehensive curricular redesign.⁴ They represent steps to building a culture of innovation grounded in practical needs to enhance student engagement and inspire action.

Next Steps to Develop a Culture of Innovation

Practical starting points include:

• Needs‑finding in authentic settings. Develop structured observation and needs-assessment exercises into dental schools and real-world practice settings to identifying patient, learner, and system‑level challenges.
• Biodesign Innovation workshops. Introduce short, faculty‑facilitated sessions in which students empathize with specific user groups (eg, dental students, residents, support staff) with goals to define focused needs and conceptualize potential solutions.
• Innovation electives or societies. Create electives or extracurricular programs in which student teams engage with innovators and leaders to explore state-of-art technologies and processes.
• Implementation‑focused capstone projects. Invite senior students or residents to pair proposed innovations with basic implementation plans, including stakeholder mapping, simple outcome measures, and feasibility considerations.

Re-Imagining the Future

Integrating the Biodesign Innovation Process into dental education offers a unique opportunity to evolve curricula and inspire the next generation. By training students and residents to systematically identify unmet needs, codesign solutions with patients and colleagues, and thoughtfully implement change, our profession can better align educational outcomes with the realities of contemporary practice and future expectations.

References

1. Guo R, Zhang Y, Li W, Liu D, Hu W. Digital intelligence in dental education: a bibliometric analysis. Int Dent J. 2026;76:109495.
2. Chuenjitwongsa S, Amir LR, Jessani A, Samaranayake LP, Osathanon T. Integrating design thinking into dental education. Front Oral Health. 2025;6:1547335.
3. Yock PG, Zenios S, Makower J, et al. Biodesign: The Process of Innovating Medical Technologies. Cambridge, Massachusetts: Cambridge University Press; 2015.
4. Nath S, Chung D, Yang J, Wu DT. Piloting an innovation society as a tool to supplement dental curricula. J Dent Educ. 2023;87 Suppl 1:911-913.

From Decisions in Dentistry. September/October 2026;12(2):6-9.

One of the most common reasons for endodontic retreatment is the discovery of a previously missed MB2 canal. Although clinicians have more diagnostic and treatment technologies than ever before, untreated canals continue to significantly contribute to endodontic failure in maxillary molars.

Research consistently demonstrates a strong relationship between missed canals and unsuccessful root canal therapy.¹ The objective of both primary treatment and retreatment is complete elimination of infection within the root canal system while preserving the natural tooth. Failure to identify all canals, whether due to anatomical complexity, limited visibility, inadequate knowledge of internal anatomy, or underutilization of available technology, can greatly reduce the long-term prognosis.²

Endodontic retreatment is often performed to manage failed primary root canal therapy, but its success rate of 75% to 85% falls well below the 94% success rate reported for primary root canal treatment (RCT).³ Incomplete RCT due to the lack of canal localization and therapy, difficulty in internal anatomy management, bacterial leakage in the marginal gap during the final restorations, delayed restoration, and new decay on the tooth structure are some of the main reasons for treatment failure.⁴

Research shows the overall prevalence of missed canals among endodontically treated teeth is approximately 13% to 23.4%.^5-7 The prevalence of missed canals is higher in maxillary first molars (40.6%). The overall prevalence of apical periodontitis among teeth with missed canals is approximately 90%. The second mesiobuccal canal in the maxillary first molars and the mesiobuccal and distobuccal canals in mandibular teeth are the most commonly missed.² Failure to locate and treat all root canals results in inadequate mechanical debridement and persistent bacterial infection, increasing the risk of apical periodontitis and its associated clinical signs, including inflammation, pain, sinus tract formation, and periapical radiolucency.⁴

Adequate microbiology and internal anatomy control are key factors in RCT. Technologies, such as cone-beam computed tomography (CBCT), dental microscope, and ultrasonic scaler, are fundamental for successful RCT and retreatment. The three-dimensional images provided by CBCT offer multiple views to detect the rarefaction’s size, position, and extension. They also help detect failures, such as incomplete treatment, internal or external resorptions, and missed canals.^8,9

Importance of Visualization

High-quality endodontic care depends on enhanced visualization of the complex root canal system. The use of the dental microscope is the standard of care in multidisciplinary dentistry. In endodontics, it is absolutely necessary to perform precision tasks in deep, narrow, and dark spaces such as the pulp chamber and root canals.¹⁰

A clinician’s hands become more skilled as visual capacity increases. Compared with unaided vision or low-power (2×) loupes, an operating microscope provides substantially greater magnification and dramatically improved resolution, allowing clinicians to distinguish fine anatomical details with far greater accuracy.¹¹ Research shows the importance of magnification in the management of canals’ internal anatomy, especially when locating the MB2 canal of the first and second molars, which is one of the most challenging procedures in complex endodontics.¹²

One of the greatest advantages of the dental microscope in endodontics is its ability to improve the detection of complex root canal anatomy, including the MB2 canal. Compared with unaided vision, the combination of variable magnification and coaxial LED illumination provides exceptional visualization of the operating field, enabling clinicians to identify anatomical details that might otherwise be missed. Enhanced visualization not only improves treatment precision but also promotes better ergonomics by allowing clinicians to maintain a more upright, neutral working posture.¹³ The dental microscope and ultrasonic scaler are critical parts of the endodontist’s armamentarium. The combination of enhanced magnification and coaxial illumination provided by the dental microscope, together with the slim diameter, angulation, and extended working length of ultrasonic tips, allows clinicians to conservatively remove dentin and canal obstructions while maintaining clear visualization of the deepest portions of the root canal system.¹⁴

Locating the MB2 canal in maxillary molars begins with careful visual examination of the pulp chamber floor under the dental microscope. Developmental map lines, combined with tactile exploration using an endodontic explorer between the mesiobuccal and palatal canal orifices, often guide the clinician to the MB2 canal, which is typically located 2 to 3 mm palatal and slightly mesial to the MB1 canal.¹⁵ Additional visual clues, including the white line test, red line test, presence of moisture at the canal orifice, and the bubble test, can further aid in identifying this elusive canal.¹⁶

Selective RCT is an option in endodontic retreatment cases when periapical pathosis is present in a specific root canal in a multirooted tooth while the other periapical tissue remains healthy.¹⁷ A valuable resource, selective RCT needs to be explained to the patient to ensure full understanding and informed acceptance. The recommendation should be based on key diagnostic and prognostic factors, including the extent of any required crown or restoration adjustments, the quality and integrity of the root canal filling following RCT, and the presence or absence of periapical pathology identified on radiographic examination. The final decision should be made after the dentist has accessed the tooth and analyzed internal factors in the pulp chamber, such as the degree of contamination or filling quality in the other root canals. A selective RCT may reduce time and costs for the patient and should be considered in appropriate cases.

Case Report

A 50-year-old woman was referred to the office for a consultation. The patient manifested mild spontaneous pain and sensitivity when biting and touching tooth number three, with a history of a root canal treatment done 1 year ago. Clinically, the tooth presented a well-adjusted ceramic crown without mobility and inflammation in the soft tissues around the mesial root.

We took three different angulation X-rays. The mesial root was the only one with a periapical rarefaction; the two other root canals presented normal radiographical aspects in the periapical area. By analyzing the periapical X-ray, we considered that the mesial root canal filling was poor, manifesting a possible missed MB2 (Figure 1).

We suggested CBCT to gather all possible information to complete the diagnosis. By analyzing the CBCT scan in the axial plane, the missed MB2 was detected and the palatal and distal roots were shown to be healthy (Figure 2).

A selective mesial RCT was recommended due to the well-adjusted crown, healthy periapical tissues, and correct root canal filling on the palatal and distal roots. The endodontic access was performed under a dental microscope using low-to-medium magnification levels (4×, 6×, and 10×). A number two carbide bur was utilized to create the access, allowing for conservative removal of tooth structure with minimal alteration or wear of the existing crown and restoration (Figure 3A). When getting deeper into the pulp chamber floor, we switched to an ultrasonic scaler diamond bur tip to enable clear, deep vision into the internal area of the pulp chamber. The guttapercha was discovered when removing all the composite.

An E5 ultrasonic tip was used to conservatively trough dentin distally and palatally from the MB1 canal while adhering to the pulpal floor map and white line guidelines for MB2 canal identification. Ethylenediaminetetraacetic acid (EDTA) was periodically applied to maintain a hydrated pulpal floor, enhancing the visualization of anatomical color variations, texture changes, and developmental grooves. Under medium and high magnification with the dental microscope, progressive refinement of the access was performed until the MB2 canal orifice was identified by the characteristic humid bubbling pattern (Figure 3B and C).

Once the MB2 canal was located, we gauged and scouted the canal with #8, #10, and #15 K files on the cervical root third, recapitulating and constantly flooding the pulp chamber with sodium hypoclorite 5.25% between the K files. Then, we used an orifice shaper instrument to smooth the cervical dentin triangle for better access into the apical third of the root canal and a #10 K file in oscillatory motion with an oscillatory contra angle in 60° motion activated with the low handpiece (Figure 3D and E).

Once reaching the apical third, an apex locator with a teflon #15 file and periapical X-ray were used to confirm the working length. The step-back shaping technique was implemented. First, K file instrumentation and recapitulation were used to maintain the glide path with a #10 file until reaching a #35 K file to working length. Rotary files were used to shape the canal until reaching file 25.06, always using EDTA with every instrument from the sequence.

When recapitulating, passive ultrasonic irrigation was used by activating a K file #10 to the working length with the E5 ultrasonic tip for 10 seconds. Once reaching the apical third canal shape, we removed the MB1 guttapercha, using first an E5 ultrasonic tip to heat the guttapercha, followed by a endodontic rotary orifice opener; Hedstrom file #30, #35; and rotary files until reaching the approximate working length (WL). A #15 K file was then used to confirm the WL with an apex locator and periapical X-ray (Figure 3F).

The working length was confirmed, and the canal was shaped with rotary files, irrigated with sodium hydroxide and EDTA 17%, and finalized with a #35 K file. The sodium hypochlorite irrigation was activated with a #10 file by ultrasound, the final rinse was done with isopropyl alcohol, and paper points were used to dry (Figure 3G). After finishing the MB1 canal retreatment, the Tagger hybrid obturation technique was performed using the McSpadden Guttacondensor #35 in each canal, and then a composite filling was placed on top (Figure 3H and I).

The patient was scheduled for radiographic follow-up at 3 months to evaluate the healing response, monitor the repair process, and assess clinical progression.

Conclusion

Treating a first or second upper molar brings anatomical management challenges. Finding the MB2 canal is an absolute must. CBCT provides the clinician with a comprehensive understanding of the tooth’s internal anatomy, allowing evaluation of previous treatments, identification of potential causes of RCT failure, and development of a more predictable treatment strategy. This 3D assessment enhances diagnostic accuracy and provides greater confidence when approaching complex endodontic procedures.

Successful management of the MB2 canal requires a thorough understanding of root canal anatomy, including its typical location, anatomical variations, and clinical guidelines for identification, negotiation, cleaning, and shaping. The clinician must recognize the anatomical landscape and apply contemporary techniques to improve the probability of successful outcomes.

The identification and management of the MB2 canal is a highly demanding procedure that requires exceptional visual control and precision. Accurate dentin removal, avoidance of perforation risks, and recognition of subtle differences in color and texture require the use of multiple magnification levels under a dental microscope. Coaxial illumination provided by the microscope enhances visualization of anatomical details, allowing the clinician to distinguish critical structural variations and perform conservative dentin removal with improved control. Ultrasonic tips further contribute to the precision and safety of this delicate step.

A well-established technique for MB2 canal scouting and shaping is essential to achieve proper glide path development. The presence of a pronounced cervical dentin triangle may obstruct access to the remaining canal anatomy and compromise cleaning and shaping procedures. Careful removal of restrictive dentin, combined with the controlled use of rotary and/or reciprocating instruments and advanced irrigation protocols, facilitates safe and effective MB2 canal management.

This case report demonstrates the decision-making process involved in determining whether all root canals should be addressed during endodontic retreatment. It also highlights how technological advancements, appropriate diagnostic assessment, and a simplified, evidence-based retreatment protocol can help overcome the technical challenges associated with previously treated root canal systems.

References

1. Gulabivala K, Ng YL. Factors that affect the outcomes of root canal treatment and retreatment — a reframing of the principles. Int Endod J. 2023;56(Suppl 2):82-115.
2. Mashyakhy M, Hadi FA, Alhazmi HA, et al. Prevalence of missed canals and their association with apical periodontitis in posterior endodontically treated teeth: a CBCT study. Int J Dent. 2021;2021:9962429.
3. Sabeti M, Chung YJ, Aghamohammadi N, Khansari A, Pakzad R, Azarpazhooh A. Outcome of contemporary nonsurgical endodontic retreatment: a systematic review of randomized controlled trials and cohort studies. J Endod. 2024;50:414-433.
4. Tabassum S, Khan FR. Failure of endodontic treatment: the usual suspects. Eur J Dent. 2016;10:144–147.
5. Rouhani A, Aboutorabzadeh SM, Reyhani M, Kheirabadi N, Mortazavi S, Navabi S. Prevalence of missed canals in endodontically treated teeth: A cone-beam computed tomography study. J Clin Exp Dent. 2023;15:e605–e611.
6. Costa F, Pacheco-Yanes J, Siqueira Jr J, Oliveira A, Gazzaneo I, Amorim C. Association between missed canals and apical periodontitis. J Endod. 2019;52:400-406.
7. Karabucak B, Bunes A, Chehoud C, Kohli MR, Setzer F. Prevalence of apical periodontitis in endodontically treated premolars and molars with untreated canal: a cone-beam computed tomography study. J Endod. 2016;42:538-541.
8. Venkatesh E, Elluru SV. Cone beam computed tomography: basics and applications in dentistry. J Istanb Univ Fac Dent. 2017;51(3 Suppl 1):S102–S121.
9. Scarfe WC, Levin MD, Gane D, Farman AG.Use of cone beam computed tomography in endodontics. Int J Dent. 2010;2009:634567.
10. Carr GB, Murgel CAF. The use of the operating microscope in endodontics. Dent Clin North Am. 2010;54:191-214.
11. van As GA. Magnification alternatives: seeing is believing, Part I. Dentistry Today. 2013;32(6):82-87.
12. Alaçam T, Tinaz AC, Genç O, Kayaoglu G. Second mesiobuccal canal detection in maxillary first molars using microscopy and ultrasonics. Aust Endod J. 2008;34:106-109.
13. Buhrley LJ, Barrows MJ, BeGole EA, Wenckusl CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod. 2002;28:324-327.
14. Sujith R, Dhananjaya K, Chaurasia VR, Kasigari D, Veerabhadrappa AC, Naik S. Microscope magnification and ultrasonic precision guidance for location and negotiation of second mesiobuccal canal: An in vivo study. J Int Soc Prev Community Dent. 2014;4(Suppl 3):S209–S212.
15. Coelho MS, Lacerda MFLS, Silva MHC, Rios MA. Locating the second mesiobuccal canal in maxillary molars: challenges and solutions. Clin Cosmet Investig Dent. 2018;10:195–202.
16. Mulay S, Kadam G, Jain H. Accuracy of various diagnostic aids in detection of mb2 canal in maxillary first molar: in vivo study. World Journal of Dentistry. 2016;7(2):78-82.
17. Nudera WJ. Selective root retreatment: a novel approach. J Endod. 2015;41:1382-1388.

From Decisions in Dentistry. September/October 2026;12(2):10-14.

Computer-aided design and computer-aided manufacturing (CAD/CAM) technology has emerged as one of the most influential innovations in restorative dentistry. With its use expanding dramatically, CAD/CAM is now routinely used for the fabrication of inlays, onlays, veneers, full-coverage crowns, fixed dental prostheses, implant-supported restorations, removable prostheses, and orthodontic appliances. CAD/CAM is no longer a niche technology but an integral component of modern practice, with applications extending across routine and complex restorative care.

Digital Workflow

CAD/CAM describes a process in which clinical information is captured, digitized, manipulated using specialized software, and ultimately converted into a physical restoration.¹ This digital workflow replaces several traditional steps, including elastomeric impressions, stone models, articulation, and many laboratory-dependent fabrication stages.

The CAD/CAM process is broadly divided into three key stages. First, data acquisition i s performed through intra- or extraoral scanning. Modern intraoral scanners capture the geometry of prepared teeth and surrounding structures using noncontact optical systems, typically based on light-emitting diode technology.² Light is projected onto the tooth surface and reflected back to sensors, generating a three-dimensional (3D) digital representation of the clinical situation. Currently, nearly half of practitioners use intraoral scanning, which facilitates the process of digital crown fabrication.³

Second, digital data are processed using CAD software. This software allows the clinician or trained auxiliary to define margins, design restoration contours, adjust occlusion, and evaluate proximal contacts in a virtual environment. Many platforms incorporate automated design proposals based on tooth libraries and occlusal schemes, which can then be refined based on clinical judgment and patient-specific considerations.⁴ This stage offers significant control over restorative outcomes while reducing dependence on external laboratory communication.

The final stage involves manufacturing the restoration through subtractive milling or additive manufacturing (3D printing). Although milling has dominated the field for many years,⁵ 3D printing is now becoming the method of choice for chairside restorations, offering high accuracy, predictable material properties, and reliable marginal adaptation. 3D printing decreases material waste, provides unlimited geometric reproducibility, reduces the presence of microcracks in the restoration, lowers costs, decreases treatment delays, and offers personalized treatment. The clinical use of 3D printing has created versatile applications that streamline digital workflow. Technological advancements have also paved the way for the integration of new dental materials into dentistry.⁶ With both methods, a streamlined workflow enables same-day restorative care across many clinical situations, reducing treatment time and improving patient acceptance.

Material Utilization

The rapid adoption of CAD/CAM technology has been closely linked to advances in restorative materials. Current systems support metals, ceramics, zirconia, and resin-based materials.⁷ However, ceramic and zirconia restorations account for the majority of CAD/CAM-fabricated prostheses in general practice.

Glass-ceramic materials, such as lithium disilicate and lithium silicate ceramics, possess a biphasic structure, with crystalline particles dispersed within a glass matrix. This microstructure provides a favorable combination of flexural strength, fracture resistance, optical properties, and adhesive bonding capability.⁸ These characteristics make glass ceramics particularly well suited for single-unit restorations in both anterior and posterior regions, where esthetics and strength are equally important. Their compatibility with adhesive cementation further enhances retention and marginal seal.

Zirconia, in contrast, is a polycrystalline ceramic with exceptional mechanical strength and fracture toughness. While traditional zirconia has been associated with limited translucency and weaker adhesive bonding, its strength makes it an excellent choice for frameworks, copings, and long-span fixed dental prostheses.⁹ Recent developments in translucent and multilayer zirconia have expanded its use into more esthetically demanding indications, although material selection should continue to be guided by occlusal load, span length, and esthetic requirements.¹⁰ It is interesting to note that because the term ceramic is defined as a material that is predominantly composed of ceramic, the roughly +70% ceramic filler in resin-based blocks has allowed them to be classified as permanent ceramic restorative materials.³

Resin-based materials, including resin composites, polymethyl methacrylate, and nano-ceramics, are also compatible with CAD/CAM workflows, especially with 3D printing, however, initially long-term wear resistance and color stability were inferior to ceramic alternatives.¹¹ Over time, the materials have been perfected and 3D printing has evolved to become a well-accepted modality and appears to becoming the preferred method of fabrication in the dental office.

Metal frameworks fabricated via CAD/CAM, such as cobalt-chromium alloys and titanium, demonstrate mechanical properties that are often superior to those produced through conventional casting techniques.¹² Digital fabrication improves consistency, fit, and reproducibility, reducing the variability associated with manual laboratory processes.

Regardless of material selection, surface quality is a critical consideration. Machined restorations may exhibit surface roughness that can contribute to plaque accumulation and microbial adhesion if not properly finished.¹³ Polishing or glazing protocols should therefore be incorporated into clinical workflows to optimize surface smoothness and promote long-term periodontal and peri-implant health.

Artificial Intelligence

As CAD/CAM systems continue to evolve, artificial intelligence (AI) is increasingly integrated into digital dentistry. AI-driven algorithms are now capable of assisting with margin detection, tooth shade selection, occlusal design, and esthetic customization based on large datasets of prior restorations.¹⁴ These tools have the potential to reduce operator variability, improve efficiency, and enhance consistency across restorations.

In restorative dentistry and dental materials research, AI has also shown promise in predicting restoration performance, including debonding risk and the influence of material composition on mechanical properties.¹⁵ These advancements may translate into more predictable outcomes and simplified workflows, particularly as same-day dentistry becomes more prevalent (Figure 1).

Advantages

Chairside digital workflows eliminate the need for conventional impressions, provisional restorations, and multiple appointments. This reduction in clinical steps not only improves efficiency but also minimizes opportunities for error, such as impression distortion or provisional crown failure.¹⁶

From a patient perspective, same-day dentistry offers convenience; reduced time away from home, work, or travel; and immediate resolution of functional and esthetic concerns. From a practice management standpoint, in-office fabrication can become economically viable with relatively modest restoration volumes, offsetting the initial capital investment over time.¹⁷

Successful integration of CAD/CAM technology requires training, team involvement, and thoughtful scheduling. While highly complex esthetic cases may still benefit from laboratory collaboration, most single-unit restorations can be predictably managed in-house with excellent results.¹⁸

Conclusion

CAD/CAM technology has transformed restorative dentistry by combining precision, efficiency, and patient-centered care. Digital workflows provide a practical means of delivering high-quality restorations while streamlining clinical processes. As materials, software, and artificial intelligence continue to advance, the role of CAD/CAM in everyday practice is expected to expand further. Embracing this technology allows clinicians to meet today’s patient expectations while maintaining clinical excellence and practice sustainability.

References

1. Ahmed KE. We’re going digital: the current state of CAD/CAM dentistry in prosthodontics. Prim Dent J. 2018;7:30-35.
2. Vecsei B, Czigola A, Roth I, Hermann P, Borbely J. Digital impression systems, CAD/CAM, and STL file. In: Kinariwala N, Samaranayake L, eds. Guided Endodontics. Cham, Switzerland: Springer; 2021:27-63.
3. Thakkar P, Surathu N, Surathu N, Lawson N. Contempory indirect restorations: a review of subtractive and additive materials and techniques. Compendium. 2025;46:10.
4. Lambert H, Durand JC, Jacquot B, Fages M. Dental biomaterials for chairside CAD/CAM: state of the art. J Adv Prosthodont. 2017;9:486-495.
5. Takaichi A, Fueki K, Murakami N, et al. A systematic review of digital removable partial dentures. Part II: CAD/CAM framework, artificial teeth, and denture base. J Prosthodont Res. 2022;66:53-67.
6. Jeong M, Radomski K, Lopez D, Liu JT, Lee JD, Lee SJ. Materials and applications of 3d printing technology in dentistry: an overview. Dent J (Basel). 2023;12:1.
7. Raja SR, Mahaprasad A, Satapathy S, et al. In vitro evaluation of surface roughness and bacterial adhesion on different CAD/CAM restorative materials. J Pharm Bioallied Sci. 2025;17(suppl 1):S552-S559.
8. Yeslam H, von Maltzahn N, Nassar H. Revolutionizing CAD/CAM-based restorative dental processes and materials with artificial intelligence: a concise narrative review. PeerJ. 2024;12:e17845.
9. Najeeb M, Islam S. Artificial intelligence in restorative dentistry: current trends and future prospects. BMC Oral Health. 2025;25:592-599.
10. Solís-Pinargote NW, Yanushevich O, Krikheli N, et al. Materials and methods for all-ceramic dental restorations using CAD/CAM technologies: a narrative review. Dent J (Basel). 2024;12(2):47.
11. Hajaj T, Marian D, Zaharia C, et al. Influence of marginal preparation design on fracture resistance of CAD/CAM ceramic crowns. J Funct Biomater. 2025;16:205.
12. Abu Alhuda S, Arossi GA, Anagnostopoulos-King F, et al. Current evidence and advances in CAD/CAM resin composite blocks for chairside dental restorations. Appl Sci. 2024;14:10423.
13. Ling X, Ma Y, Malyala R, et al. Survival rates of CAD/CAM ceramic dental restorations: a systematic review and meta-analysis. Med (Basel). 2026;12(1):Epub ahead of print.
14. Mihali SG, Pradelli G, Manfredi M, et al. State-of-the-art zirconia and glass-ceramic materials in restorative dentistry. Appl Sci. 2025;15:12841.
15. Darwood A, Sauret-Jackson V, Marti B, Dawood A. Clinical accuracy and precision of intraoral scanning in dentistry: a systematic review. J Prosthodont Res. 2022;66:53-67.
16. Refaey HS, Abdelrahman T, El-Damanhoury HM, et al. Effect of preparation design on marginal fit and fracture resistance of zirconia-reinforced lithium disilicate CAD/CAM overlays. BMC Oral Health. 2025;25:Epub ahead of print.
17. Rekow ED. Digital dentistry: the new state of the art—is it disruptive or destructive? Dent Mater. 2020;36:9-24.
18. Schwendicke F, Samek W, Krois J. Artificial intelligence in dentistry: chances and challenges. J Dent Res. 2020;99:769-774.

From Decisions in Dentistry. September/October 2026;12(2):16-19.

Introduction

Composite dentistry has evolved significantly, from early macrofill systems to today’s sophisticated nanohybrid and universal materials designed to deliver strength, esthetics, and clinical efficiency within a single restorative solution. Yet despite these advances, many clinicians still encounter daily challenges with handling consistency, shade predictability, and polish retention that affect both workflow and long-term outcomes.

Achieving reliable results requires more than material selection alone. It demands a working understanding of composite science, how resin matrix design, filler architecture, and polymerization stress interact, and how that science translates into a complete restorative workflow: from shade mapping and layering strategy to surface texture and finishing protocol. Equally important is the ability to recognize and correct common composite failures before they affect the patient, and to integrate direct composite confidently into comprehensive treatment planning.

This continuing education article explores those principles in the context of modern universal composite design. Materials, such as BISCO’s Quantium Universal Composite, which incorporates an advanced blend of nano, micro, and pre-polymerized filler technologies, represent a new generation of restorative materials developed to support the demands of a complete, contemporary clinical workflow, from routine posterior restorations to esthetically driven anterior cases.

Mastering Modern Composite Dentistry

The term “universal composite” describes contemporary materials that may be used clinically in both anterior and posterior indications. Although there is no defined compositional or microstructural requirement of a universal composite, this term implies the composite will have sufficient mechanical properties for posterior applications and optical properties for anterior applications.

Before the introduction of resin-based composites, esthetic restorations were limited to brittle silicate cements and unfilled acrylic resins with high polymerization shrinkage.^1,2 The modern dental composite was introduced in the early 1960s when Bowen synthesized BisGMA and reinforced it with silanated 150 µm glass filler.³ This material was significantly stronger and exhibited lower polymerization shrinkage than the materials it replaced.⁴

Early composites incorporated mechanically ground glass particles ranging from approximately 10 to 100 microns in diameter, referred to as macrofilled composites.⁵ The large filler particles in these macrofilled composites produced rough surfaces, poor polishability, and abrasive wear of opposing dentition.

In the late 1970s, manufacturers began incorporating colloidal silica particles produced through pyrogenic (fumed) processes, with an average diameter of approximately 40 nanometers. These fumed silica particles were initially added to fill the spaces between larger ground glass fillers, where they protected the exposed resin matrix from abrasive wear.⁶ The esthetic advantages of fumed silica were recognized later. Because their size is smaller than the wavelengths of visible light, voids left by fumed silica particles lost from the composite surface are visually undetectable, unlike the larger defects created by dislodged ground glass fillers.

Composites containing only fumed silica could therefore achieve an exceptionally high level of surface polish. However, incorporating fumed silica alone at high filler volumes led to particle agglomeration and poor handling. To circumvent this limitation, manufacturers introduced pre-polymerized resin filler (PPRF) particles, also referred to as pre-polymerized fillers (PPF), composite material polymerized in bulk, milled into 1- to 200-micron particles, and incorporated as a filler in a fresh resin matrix.⁵

These materials were termed microfilled composites, and remain one of the most highly polishable categories of composites. A weakness of PPRF particles, however, is that they fail at the interface between the PPRF and the surrounding resin matrix, preventing their success in load-bearing restorations.⁷

Throughout the 1980s and 1990s, manufacturers progressively reduced the size of ground glass fillers, while continuing to incorporate fumed silica particles.⁸ These so-called hybrid composites, which combined ground glass particles with colloidal silica, became the dominant category for posterior restorations because they balanced mechanical strength with polishability. As filler particle sizes continued to decrease, the term microhybrid emerged to describe composites combining ground glass particles smaller than approximately 1 micron with discrete colloidal silica.⁴

In the 2000s, nanotechnology was applied to composite design.^9,10 Nanofilled composites use discrete nanoscale particles, including spherical silica and zirconia-silica particles in the 5 to 20 nanometer range, together with nanocluster agglomerates approximately 0.6 microns in average diameter that behave as larger functional fillers while retaining the polishability and gloss retention characteristic of nanoscale components.¹⁰

A more recent approach to filler architecture has been the development of uniform spherical silica fillers produced through controlled chemical synthesis with average diameters in the range of approximately 150 to 500 nanometers. These suprananofilled composites differ from conventional nanohybrid and nanofilled in that the particles are larger and highly uniform in size and spherical in shape, which allows efficient packing and high filler loading without the handling problems associated with broad particle size distributions.^11,12

Components of Contemporary Composite Resins

Filler particles are produced from a variety of inorganic sources, including mined quartz, melt-derived glasses, colloidal silica, and crystalline ceramics.⁹ Heavy metal glasses containing barium, strontium, ytterbium, or zirconium are commonly used because they provide radiopacity in addition to mechanical reinforcement.⁸

Fabrication occurs through two principal methods:

1. Mechanical grinding of larger glass particles, which produces irregularly shaped particles that cannot practically be made smaller than approximately 0.1 microns in diameter⁹
2. Chemical precipitation, which produces spherical, colloidal silica particles ranging in size from 40 nm nanofillers to 500 nm fillers in suprananofilled composites.

Clusters of nanoscale colloidal silica in agglomerates and PPRF particles can also be derived. These fillers comprise the majority of filler types in contemporary universal composites.

Although particulate fillers dominate contemporary composite formulations, an alternative reinforcement strategy uses short glass fibers rather than discrete particles. Short fiber-reinforced composites incorporate E-glass fibers approximately 1 to 2 millimeters in length within an otherwise conventional methacrylate matrix.¹³ The clinical rationale for fiber reinforcement is improved fracture toughness: fibers oriented within the composite arrest crack propagation through crack-bridging, crack-deflection, and fiber-pullout mechanisms that are not available to particulate composites.¹⁴ Fiber-reinforced composites are typically used as a base layer in restorations for their toughening properties and are generally recommended to be covered with a layer of particulate composite to achieve desirable esthetic properties. Some new research, however, has reported favorable esthetic properties of a fiber-reinforced composite.¹⁵

The organic resin matrix is composed of one or more monomers, a diluent, a polymerization inhibitor, and a photoinitiator system. The primary monomer in most contemporary composites is either BisGMA or urethane dimethacrylate (UDMA), often in combination. BisGMA produces a polymer with high modulus and dimensional stability but is highly viscous and prone to water absorption.¹⁶

UDMA replaces the rigid aromatic center of BisGMA with a more flexible urethane linkage, resulting in lower viscosity and improved toughness and wear resistance.^17,18 Because BisGMA has a viscosity approaching 1,000,000 mPa·s, a low-viscosity diluent monomer, such as triethylene glycol dimethacrylate (TEGDMA), is typically added to improve handling and allow adequate filler incorporation. TEGDMA also increases the degree of conversion of the composite during polymerization, but its lower molecular weight contributes to greater polymerization shrinkage.^16,19 Manufacturers balance the BisGMA-to-TEGDMA ratio carefully to optimize handling, conversion, shrinkage, and final mechanical properties.

Photoinitiator systems. For more than four decades, the dominant photoinitiator in dental composites has been camphorquinone (CQ), an alpha-diketone that absorbs visible light with a peak near 468 nanometers, well within the output range of standard dental LED curing units. CQ is a Norrish Type II photoinitiator, meaning it requires a co-initiator. It is also an intense yellow powder, and although this color partially bleaches during polymerization, residual yellowing can affect the shade of bleached and high-value composites.²⁵

To address these limitations, alternative photoinitiator systems have been introduced. Norrish Type I photoinitiators, such as 2,4,6-trimethylbenzoyl-diphenylphosphine oxide and bisacylphosphine oxide, do not require co-initiators and produce comparable or higher degrees of conversion than CQ. However, because they absorb at shorter wavelengths (maxima near 400 nanometers), composites containing them require polywave or broad-spectrum LED units that emit violet light in addition to blue.

More recently, germanium-based photoinitiators, such as dibenzoyl germanium, have been introduced. These absorb in the near-violet to blue range with a maximum near 418 nanometers that overlaps the output of standard LED units, do not require co-initiators, and offer excellent color stability.²⁵ Their higher photoreactivity also enables a greater depth of cure than comparable CQ-based formulations.²⁶ The clinical relevance of incorporating this newer photoinitiator is to allow accelerated cure for rapid curing composites and deeper depth of cure for bulk fill composites.

Properties of Contemporary Composites

Flexural strength, elastic modulus, and wear are among the mechanical properties most commonly used to characterize composite restoratives. Filler content is a major determinant of these properties, but its influence on individual properties differs in magnitude. A recent analysis of 16 commercially available composites demonstrated a strong positive correlation between filler weight percentage and elastic modulus, but only a moderate positive correlation with flexural strength.²⁶ The weaker relationship between filler content and strength reflects the role of the filler-matrix interface in fracture initiation: strength depends not only on the volume of reinforcing filler but also on the size, shape, and silane integrity of the filler particles and on the homogeneity of their distribution within the matrix. Modulus, by contrast, is governed primarily by stress transfer between filler and matrix and is less sensitive to particle morphology.

Wear behavior is influenced by filler particle size, filler loading, silane coupling integrity, and the degree of conversion of the resin matrix. Smaller filler particles reduce the depth of resin matrix exposed between fillers, reducing the magnitude of the so-called “protection hypothesis” in which composite is selectively worn away at the resin exposed between filler particles.²⁷ Nanofilled and supra-nanofilled composites have demonstrated wear resistance comparable to or better than microhybrid materials, in part because their uniform or nanocluster architectures allow individual particles to wear away in proportion with the surrounding matrix, preserving surface integrity.^28,29

The clinical success of an esthetic restoration depends not only on its mechanical performance but also on its ability to match the optical properties of the surrounding tooth structure. Increasing filler content generally reduces translucency, as filler particles scatter transmitted light.²⁶ The depth of cure of the composites can also be improved by increasing composite translucency, however, depth of cure can also be improved by using a more photoactive germanium-based initiator system that absorbs more efficiently and generates more free radicals per unit of light energy delivered.²⁶

Uniform spherical silica fillers in the 150 to 300 nanometer range in suprananofilled composites have introduced a further optical refinement: they scatter visible light selectively, producing a wavelength-dependent reflection that reflects light in the yellow and red spectrum.³⁰ This phenomenon, sometimes referred to as structural color, underlies the development of single-shade universal composites that match a range of tooth shades without requiring multiple opacities and pigmentations.

Gloss retention, the ability of a composite to maintain a polished surface over time, depends on the uniform wear of filler and matrix at the composite surface. In composites containing larger ground glass particles, the resin matrix between and around the particles is preferentially worn by abrasion, leaving the harder filler particles to protrude from the surface. As these particles continue to lose support from the surrounding matrix, they are eventually plucked from the surface, creating concavities that scatter light and dull the restoration.³¹

Composites containing only nanoscale fillers, uniform spherical fillers, or nanocluster architectures avoid this mechanism: their constituent particles are smaller than the wavelengths of visible light, so the small voids created by individual particle loss do not produce optically detectable defects. Systematic review evidence confirms that suprananofilled, nanofilled, and microfilled composites consistently maintain smoother and glossier surfaces than microhybrid, nanohybrid, and conventional hybrid composites following polishing and simulated toothbrush abrasion, with composites containing small, spherical particles demonstrating the best long-term gloss retention.³¹

Polymerization Shrinkage and Shrinkage Stress

Polymerization shrinkage arises from the conversion of inter-monomer van der Waals distances to shorter covalent bond lengths during network formation.¹⁶ Of greater clinical concern than shrinkage itself, however, is the resulting shrinkage stress at the adhesive interface, which can compromise marginal adaptation, contribute to post-operative sensitivity, and predispose restorations to marginal staining or recurrent caries.²¹

The relationship between filler content and shrinkage stress is more complex than the relationship between filler content and volumetric shrinkage. Although increasing filler content reduces the volume fraction of polymerizing resin and therefore the magnitude of shrinkage, the same increase in filler content raises the elastic modulus of the composite, which amplifies the stress generated by any given amount of shrinkage.²⁶ A recent analysis of 16 commercially available composites found no significant correlation between filler weight percentage and shrinkage stress, suggesting that resin formulation, monomer composition, and the kinetics of polymerization play a larger role than filler content in determining the final stress generated at the bonded interface.²⁶ Interestingly, that analysis also found that the bulk-fill version of a flowable composite produced lower shrinkage stress than the conventional flowable from the same manufacturer in some product families but not in others.

Several strategies have been used to reduce polymerization shrinkage and shrinkage stress through monomer modification. Because shrinkage occurs as monomers move from their initial separation distance to the shorter length of a covalent bond, reducing the number of reactive double bonds per unit volume of resin proportionally reduces the total shrinkage produced during polymerization. This can be achieved by increasing monomer molecular weight, which spaces reactive sites further apart along each molecule, or by incorporating hybrid organic-inorganic polymers that contribute an inorganic backbone with relatively few reactive sites.²¹

Addition-fragmentation monomers take a different approach: rather than reducing the total shrinkage, they reduce shrinkage stress by undergoing reversible bond exchange during polymerization, which allows the developing polymer network to rearrange and relax internal stresses before they can be transferred to the cavity walls.²⁰ Modulated polymerization kinetics, which slow the rate of network development and extend the gel phase during which the composite can flow and adapt, similarly allow shrinkage to occur without generating stress at the bonded interface and have been used in flowable bulk-fill materials.²⁴

Conclusion

The evolution of resin-based composites, from Bowen’s original BisGMA-silica formulation to today’s nanohybrid and suprananofilled materials, reflects more than 60 years of incremental refinement in filler technology and resin chemistry. Contemporary microhybrid, nanofilled, and suprananofilled composites achieve a filler architecture fine enough for anterior polishability while retaining the mechanical properties needed for posterior load-bearing restorations, which is what qualifies them as universal composites.

Within these categories, the clinical performance of any individual product is shaped largely by two variables: its photoinitiator system and its resin matrix. The photoinitiator governs depth of cure and curing time, while the resin system is the significant determinant of polymerization shrinkage and the resulting stress at the bonded interface. Understanding how these components interact allows clinicians to select composites more deliberately, rather than relying on marketing claims of universality alone.

References

1. Paffenbarger GC, Nelsen RJ, Sweeny WT. Direct and indirect filling resins: A review of some physical and chemical properties. J Am Dent Assoc. 1953;47:516-524.
2. Skinner EW. A comparison of the properties and uses of silicate cement and acrylic resin in operative dentistry. J Am Dent Assoc. 1959;58:27-36.
3. Bowen RL. Properties of a silica-reinforced polymer for dental restorations. J Am Dent Assoc. 1963;66:57-64.
4. Ferracane JL. Current trends in dental composites. Crit Rev Oral Biol Med. 1995;6:302-318.
5. Lutz F, Phillips RW. A classification and evaluation of composite resin systems. J Prosthet Dent. 1983;50:480-488.
6. Lang BR, Jaarda M, Wang RF. Filler particle size and composite resin classification systems. J Oral Rehabil. 1992;19:569-584.
7. Lambrechts P, Vanherle G. Structural evidences of the microfilled composites. J Biomed Mater Res. 1983;17:249-260.
8. Bayne SC, Heymann HO, Swift EJ, Jr. Update on dental composite restorations. J Am Dent Assoc. 1994;125:687-701.
9. Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134:1382-1390.
10. Ferracane JL. Resin composite — state of the art. Dent Mater. 2011;27:29-38.
11. Wang R, Bao S, Liu F, et al. Monodisperse silica-filled composite restoratives: Mechanical and light transmission properties. Dent Mater. 2017;33:280-287.
12. Wang R, Habib E, Zhu XX. Evaluation of the filler packing structures in dental resin composites: From theory to practice. Dent Mater. 2018;34:1014-1023.
13. Garoushi S, Gargoum A, Vallittu PK, Lassila L. Short fiber-reinforced composite restorations: A review of the current literature. J Investig Clin Dent. 2018;9:e12330.
14. Jakab A, Palkovics D, Szabó V, et al. Mechanical performance of extensive restorations made with short fiber-reinforced composites without coverage: A systematic review of in vitro studies. Polymers (Basel). 2024;16:590.
15. Babaier R, Garoushi S, Vallittu P, Säilynoja E, Lassila L, Watts DC. Effects of different polishing systems on gloss and roughness of cad/cam reinforced resin composites: An in vitro study. Clin Oral Investig. 2026;30:246.
16. Peutzfeldt A. Resin composites in dentistry: The monomer systems. Eur J Oral Sci. 1997;105:97-116.
17. Asmussen E, Peutzfeldt A. Influence of uedma, bisgma and tegdma on selected mechanical properties of experimental resin composites. Dent Mater. 1998;14:51-56.
18. Musanje L, Ferracane JL, Ferracane LL. Effects of resin formulation and nanofiller surface treatment on in vitro wear of experimental hybrid resin composite. J Biomed Mater Res B Appl Biomater. 2006;77:120-125.
19. Gonçalves F, Azevedo CLN, Ferracane JL, Braga RR. Bisgma/tegdma ratio and filler content effects on shrinkage stress. Dent Mater. 2011;27:520-526.
20. Ghayeghchi MM, Atai M, Nodehi A. Addition-fragmentation chain transfer monomer in dental resins: Synthesis, characterization, and properties. Dent Mater. 2025;41:1442-1453.
21. Braga RR, Ballester RY, Ferracane JL. Factors involved in the development of polymerization shrinkage stress in resin-composites: A systematic review. Dent Mater. 2005;21:962-970.
22. Ilie N, Hickel R. Resin composite restorative materials. Aust Dent J. 2011;56:59-66.
23. Weinmann W, Thalacker C, Guggenberger R. Siloranes in dental composites. Dent Mater. 2005;21:68-74.
24. Ilie N, Hickel R. Investigations on a methacrylate-based flowable composite based on the sdr technology. Dent Mater. 2011;27:348-355.
25. Kowalska A, Sokolowski J, Bociong K. The photoinitiators used in resin based dental composite—a review and future perspectives. Polymers (Basel). 2021;13:470.
26. Lopez C, Nizami B, Robles A, Gummadi S, Lawson NC. Correlation between dental composite filler percentage and strength, modulus, shrinkage stress, translucency, depth of cure and radiopacity. Materials (Basel). 2024;17:3901.
27. Bayne SC, Taylor DF, Heymann HO. Protection hypothesis for composite wear. Dent Mater. 1992;8:305-309.
28. Ahmed N, Abbasi MS, Haider S, et al. Smart monochromatic composite: A literature review. Int J Dent. 2022;2022:2445394.
29. Ferracane JL. Is the wear of dental composites still a clinical concern? Is there still a need for in vitro wear simulating devices? Dent Mater. 2006;22:689-692.
30. Yamaguchi S, Karaer O, Lee C, Sakai T, Imazato S. Color matching ability of resin composites incorporating supra-nano spherical filler producing structural color. Dent Mater. 2021;37:e269-e275.
31. Amaya-Pajares SP, Koi K, Watanabe H, da Costa JB, Ferracane JL. Development and maintenance of surface gloss of dental composites after polishing and brushing: Review of the literature. J Esthet Restor Dent. 2022;34:15-41.

From Decisions in Dentistry. September/October 2026;12(2):28-31.

Alveolar ridge bone volume deficiency is a common barrier to restoratively driven dental implant placement. Conventional bone augmentation techniques, such as guided bone regeneration (GBR), stabilize bone grafts with resorbable or nonresorbable membranes or metallic meshes. However, shaping and fixation are performed intraoperatively and can be time-consuming and less predictable in large vertical or combined defects, particularly for less experienced surgeons.

With the adoption of digital technologies, such as cone-beam computed tomography (CBCT), intraoral scans, and three-dimensional (3D) printing, new solutions emerge that enable clinicians to customize scaffolds to individual patients. Patient-specific 3D-printed scaffolds are designed from CBCT scan data to match defect anatomy and provide a rigid, precontoured framework that maintains space while supporting bone formation.^1–5

Restorative-driven dental implant rehabilitation of the full or partial edentulous alveolar ridge requires adequate 3D bone volume to position the implants with stable peri-implant tissues. Following extraction, the alveolar ridge undergoes resorptive remodeling, often greatest on the buccal aspect, with clinically relevant loss of width and height during early healing.⁶ For many patients, ridge preservation or augmentation becomes the first stage of implant therapy.

While effective, GBR’s predictability in severe defects depends on variables that are difficult to standardize, including intraoperative barrier adaptation, fixation, contouring, and flap management.^1,2 In severe vertical or combined defects, small inaccuracies can translate into dead space; graft micromotion, which can lead to complications such as soft-tissue dehiscence; infection; and loss of regenerated bone volume.

With advances in digital dentistry and additive manufacturing, the field of bone regeneration now offers a different approach: define the prosthetic target digitally and fabricate a patient-specific scaffold that delivers the planned contour with planned fixation.

Digital Workflow and Material Selection

For implant site development, a scaffold is a 3D construct placed at a deficient ridge to maintain space, stabilize the graft material, and guide vascular and cellular ingrowth until sufficient native bone forms to support implants.^4,7 Patient-specific scaffolds differ from conventional meshes, or bone blocks, because the external geometry and fixation features are designed from the patient’s CBCT dataset rather than adapted chairside.³

CBCT data are exported in DICOM format and segmented to delineate the defect and adjacent roots and neurovascular structures. Prosthetically driven planning (diagnostic wax-up or digital setup) defines the target tooth position and ridge contour, after which the scaffold is modeled to reproduce the planned form while maintaining safety offsets and incorporating preplanned fixation channels. The finalized STL file is fabricated with a material-appropriate additive manufacturing workflow (eg, laser sintering/melting for titanium, fused deposition modeling for thermoplastics, or printing and sintering for calcium-phosphate ceramics).^2,4

Material selection determines whether the device behaves primarily as a space-maintaining barrier that is removed (eg, titanium mesh) or as an osteoconductive graft substitute that is remodeled into bone (eg, calcium phosphate or hydroxyapatite blocks).

Customized Nonresorbable Titanium Meshes

Patient-specific titanium meshes are among the most widely used customized devices for ridge augmentation. Titanium provides high strength and stiffness and can be printed to achieve a precise fit and planned contour. As titanium is nonresorbable, the mesh is typically removed at re-entry during implant placement.

Clinical studies report clinically meaningful ridge gains prior to implant placement when customized titanium meshes are combined with particulate grafting and meticulous soft-tissue management.^8,9 Design considerations include rounding mesh edges and avoiding over-contouring at anticipated incision lines to reduce exposure risk, incorporating fixation holes to permit rigid stabilization and minimize micromotion, and planning soft-tissue management to achieve tension-free closure. Staged soft-tissue augmentation may be appropriate in patients with thin biotypes.

Customized Nonresorbable Polymer Meshes

Polyether ether ketone (PEEK) is a high-performance polymer that can be fabricated as a patient-specific barrier. It is radiolucent and avoids metallic imaging artifacts, but it is bioinert, nonresorbable, and generally requires removal.^9,10 Clinical studies have reported predictable dimensional gains before implant placement with patient-specific PEEK barriers, and a randomized clinical trial comparing customized PEEK vs titanium mesh reported comparable augmentation outcomes when protocols were standardized.^10,11

Customized Resorbable Polymer Scaffolds

Resorbable thermoplastics, such as polycaprolactone (PCL), can be printed into patient-specific frameworks. PCL has a slow degradation profile, which can help maintain space during prolonged bone formation, but also extends scaffold presence in the wound.¹² In a pilot randomized controlled trial, insertion of a 3D bioresorbable PCL scaffold into extraction sockets improved maintenance of ridge height at 6 months compared with natural healing, with mineralized bone observed within scaffold porosities.¹²

Patient-specific resorbable scaffolds have also been reported as frameworks for staged augmentation before implant placement, demonstrating regenerated volume adequate for implant insertion and histologic evidence of new bone formation.¹³ For larger ridge defects, custom PCL mesh frameworks combined with particulate grafting have shown vertical and horizontal gains sufficient to support implant therapy in case reports.¹⁴

Customized Resorbable Bioceramic Blocks

Three-dimensionally printed calcium-phosphate ceramics (eg, hydroxyapatite, β-tricalcium phosphate, biphasic calcium phosphate) can be fabricated as patient-specific blocks that function as osteoconductive graft substitutes. These constructs are fixed to native bone as a block and guide bone ingrowth through a porous architecture, with gradual remodeling depending on composition and resorption kinetics.^4,15

In a case series of horizontal ridge defects, customized 3D-printed nanohydroxyapatite blocks were designed from CBCT data, fixed to the ridge, and combined with autologous blood-derived concentrates; re-entry at 6 months demonstrated ridge gain, biopsy-based evidence of new bone formation, and successful implant placement.¹⁶ Long-term human histology supports that printed calcium-phosphate ceramics can remain integrated and remodeled in the alveolar ridge years after placement.¹⁵

In particular, for bioceramic bone blocks, interconnected porosity supports early vascular invasion and diffusion of nutrients, which are prerequisites for robust osteogenesis.⁵ However, higher porosity reduces mechanical stability.⁵ Clinically, implant-site scaffolds must balance biologic permeability with stiffness sufficient to resist collapse under soft-tissue pressure, particularly in vertical augmentation.

Clinical Indications and Possible Complications

Customized scaffolds can reduce intraoperative variability by delivering a precontoured framework matched to the planned ridge form. Indications for customized scaffolds include severe horizontal and/or vertical ridge deficiencies requiring precise contour control; defects in which intraoperative mesh bending is difficult (eg, anterior maxilla or combined defects); proximity to anatomical structures, such as mental nerve; and clinical scenarios in which reduced operative time and standardized barrier fit may mitigate technique sensitivity.³

Scaffold exposure remains the predominant complication for space-maintaining barriers and slow-resorbing scaffolds. Risk increases with thin, soft-tissue biotype, limited keratinized tissue, flap tension, over-contouring, smoking, and suboptimal plaque control.^2,3 Soft-tissue dehiscence and scaffold exposure can increase contamination and compromise regenerated volume.

Risk mitigation begins at scaffold design with features such as rounded edges, reduced prominence, and continues through surgery with considerations such as rigid fixation, periosteal release for tension-free closure, and meticulous flap handling. In selected cases, autologous blood products (ABP) such as platelet-rich fibrin (PRF) may be used as an adjunct.

Surgical Considerations for Successful Outcomes

Although materials selection and scaffold designs are important for clinical success, clinical considerations at the pre-operative, intra-operative, and post-operative stages determine both the short-term and long-term success of bone augmentation and implant rehabilitation.

Pre-operative planning includes control of systemic inflammation, and local active disease (eg, periodontitis, endodontic infection), along with optimization of plaque control and patient oral hygiene self-care. In addition, prosthetic design to guide implant position and the required ridge dimensions are critical to success. Scaffold should be designed to reproduce the target bone volume and contour with planned fixation and smooth scaffold margins at anticipated flap margins to reduce risks of soft tissue dehiscence. Finally, selection of an appropriate staged timeline based on defect morphology and expected maturation is key.

A full-thickness flap with adequate tension-free release is elevated. The recipient bed is thoroughly degranulated, and cortical perforations (decortication or microperforations) may be performed to enhance bleeding and angiogenesis. The scaffold is secured with fixation screws to minimize micromotion. For barrier-type devices (eg, titanium or PEEK), the contained space is densely filled with particulate graft to balance volume stability and remodeling. For 3D printed ceramic blocks, intimate contact with native bone is critical and particulate graft is limited to fill the residual gaps. Adjunctive soft-tissue protection (eg, collagen membranes, connective tissue grafting, and/or ABP) may be considered.¹⁷ Primary, tension-free closure is achieved with periosteal release and layered suturing.

Post-Operative Care and Re-Entry

Post-operative management emphasizes plaque control, antiseptic rinses, and close follow-up during the first 2 to 4 weeks. At re-entry, nonresorbable barriers are removed, regenerated bone is assessed, and implants are placed in a restoration-driven position. Minor contour discrepancies may be corrected with secondary contour bone augmentation. If scaffold exposure occurs, management is determined by timing and severity. Early, extensive exposure with infection often necessitates early removal of the scaffold, whereas late, small exposures without suppuration may be managed with local hygiene measures and careful monitoring until re-entry.

Case Study 1

A patient presents with an advanced alveolar ridge defect of the mandible (Figure 1). The patient was treated with GBR utilizing a customized 3D-printed titanium mesh framework in combination with a mixture of allograft and xenograft (Figure 2). The bone graft materials were hydrated with recombinant human platelet-derived growth factor-BB. In addition, the Ti-mesh was covered with a collagen barrier membrane (Figure 3). Backward design was performed to guide and facilitate future implant placement in one of the clinical cases. The CBCT scan at 6 months post-op and clinical assessment upon uncovering of the graft site revealed ridge augmentation and bone formation (Figure 4).

Case Study 2

A patient presented with a severe anterior mandibular ridge defect secondary to gunshot trauma, with > 22 mm vertical deficiency that precluded restoration-driven implant placement. CBCT imaging was used for defect segmentation. A patient-specific porous bioceramic block was digitally designed to restore ridge height and contour and included two screw channels for rigid fixation (Figure 5).

A full-thickness flap was elevated, and the recipient bed was prepared. The customized block demonstrated intimate adaptation to the defect margins and was stabilized with two titanium fixation screws (Figure 6). L-PRF was combined with the construct to support early healing and soft-tissue management. Primary closure was achieved without tension.

At 8 months, CBCT evaluation demonstrated substantial ridge regeneration with maintenance of the planned contour (Figure 7). Digital implant planning was performed, and three implants (3.5 × 13 mm) were placed in the reconstructed ridge. A biopsy harvested during implant site preparation demonstrated osteogenesis adjacent to the bioceramic scaffold, consistent with graft incorporation.

The site was restored with an implant-supported ceramic prosthesis. Follow-up radiographs demonstrated stable peri-implant bone levels and durable maintenance of the augmented ridge dimensions at 18 months and up to 4 years after functional loading (Figures 8 and 9), supporting the feasibility of patient-specific printed bioceramic blocks for severe ridge defects prior to implant rehabilitation.

Discussion

Digital, restoration-driven planning remains fundamental; scaffold design should deliver the target ridge form and incorporate fixation trajectories that respect anatomic constraints. Rigid stabilization is essential to limit micromotion, and soft-tissue management frequently dictates outcomes in vertical or combined defects.

Material selection should be matched to the clinical objective: removable titanium or PEEK meshes optimize space maintenance, whereas patient-specific bioceramic blocks function as osteoconductive graft substitutes in selected defects and may reduce the need for autogenous block harvesting. Current clinical evidence is dominated by case reports and small series; controlled comparative studies are needed to clarify indications, complication profiles, and long-term remodeling across materials.

Conclusion

Patient-specific 3D-printed scaffolds extend GBR by standardizing space maintenance and contour control for implant site development. Customized titanium and PEEK meshes provide strong, predictable frameworks but require removal, while customized bioceramic blocks act as osteoconductive graft substitutes that can integrate and remodel. When paired with prosthetic-driven planning, rigid fixation, and meticulous soft-tissue management, customized scaffolds can support predictable ridge development for restorative-driven implant placement.

References

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2. Rider P, Kačarević ŽP, Alkildani S, et al. Additive manufacturing for guided bone regeneration: a perspective for alveolar ridge augmentation. Int J Mol Sci. 2018;19:3308.
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10. El Morsy OA, Barakat A, Mekhemer S, Mounir M. Assessment of 3-dimensional bone augmentation of severely atrophied maxillary alveolar ridges using patient-specific poly ether-ether ketone (PEEK) sheets. Clin Implant Dent Relat Res. 2020;22:148-155.
11. Mounir M, Shalash M, Mounir S, et al. Assessment of three-dimensional bone augmentation of severely atrophied maxillary alveolar ridges using prebent titanium mesh vs customized polyetheretherketone mesh: a randomized clinical trial. Clin Implant Dent Relat Res. 2019;21:960-967.
12. Goh BT, Teh LY, Tan DBP, Zhang Z, Teoh SH. Novel 3D polycaprolactone scaffold for ridge preservation—a pilot randomised controlled clinical trial. Clin Oral Implants Res. 2015;26:271-277.
13. Ivanovski S, Staples R, Arora H, et al. Alveolar bone regeneration using a 3D-printed patient-specific resorbable scaffold for dental implant placement: a case report. Clin Oral Implants Res. 2024;35:1655-1668.
14. Park JY, Jeon SH, Lee JY, Park JM, Cha JK. Vertical and horizontal ridge augmentation using customized three-dimensionally printed polycaprolactone mesh in atrophic posterior maxillae: a case report. J Oral Implantol. 2025;51:326-336.
15. Mangano C, Giuliani A, De Tullio I, et al. Histological and histomorphometrical results of a 3-D printed biphasic calcium phosphate ceramic 7 years after insertion in a human maxillary alveolar ridge. Front Bioeng Biotechnol. 2021;9:614325.
16. Mekcha P, Wongpairojpanich J, Thammarakcharoen F, Suwanprateeb J, Buranawat B. Customized 3D printed nanohydroxyapatite bone block grafts for implant sites: a case series. J Prosthodont Res. 2023;67:311-320.

From Decisions in Dentistry. September/October 2026;12(2):32-35.

Total hip and knee arthroplasties (TJA) are among the most frequently performed surgical procedures in North America, with more than 1 million performed annually in the United States.¹ By 2060, the total number of hip replacements is projected to increase by 659% while the number of total knee replacements is estimated to increase by 469%.¹ This tremendous growth in the number of these surgeries will also raise the risk of periprosthetic joint infection (PJI).

Although the incidence of PJI is relatively low, affecting approximately 1% to 2% of primary arthroplasties, the consequences are significant.² PJI is associated with significant patient morbidity, often requiring complex and prolonged treatment involving surgical debridement, long-term intravenous antibiotic therapy, or complete implant removal followed by staged reimplantation.² In severe cases, especially when infection becomes chronic or systemic, patients may require permanent resection arthroplasty or even amputation.³

Furthermore, the mortality rate following PJI is up to 2.5 times higher than that of noninfected arthroplasty patients, particularly among older adults or those with comorbidities.^4,5 PJI also significantly compromises implant survival and functional outcomes. Infected implants demonstrate lower long-term success rates due to poor osseointegration, soft tissue damage, and biomechanical instability.^4,5 The impact of PJI on the healthcare system is equally profound. The management of periprosthetic joint infections can increase treatment costs by up to fivefold compared to uncomplicated primary arthroplasty.⁶

History of Antibiotic Prophylaxis

The use of antibiotic prophylaxis before dental procedures was historically recommended in the dental and orthopedic communities as a precautionary measure to prevent PJI. This recommendation was based on the theoretical concern that transient bacteremia resulting from invasive dental procedures (IDP), particularly those involving manipulation of the gingiva, periapical tissues, or perforation of the oral mucosa, could lead to hematogenous seeding of prosthetic joints. Dental extractions, scaling and root planing, and probing are associated with the highest frequency of bacteremia.⁷ Viridans group streptococci, a major component of the oral flora, were considered the primary organisms of concern due to their capacity to enter the bloodstream and potentially colonize distant sites, including joint prostheses. This precautionary antibiotic prophylaxis approach was widely adopted in dentistry, despite limited direct evidence linking dental procedures to subsequent PJI events.³

Early guidelines, such as the 2003 joint statement by the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) recommended administering 2 grams of amoxicillin, or 600 mg of clindamycin in penicillin-allergic individuals, 1 hour prior to invasive dental procedures.³ These recommendations were recommended following joint replacement surgery, regardless of the type of dental procedure performed or the presence of individual patient risk factors. However, over the subsequent decade, multiple studies demonstrated that transient bacteremia is not unique to dental treatment but occurs more frequently during routine daily activities such as tooth brushing, flossing, and mastication.^4,5

In response to the evolving evidence base, the ADA and the AAOS updated their joint guidance in 2012, acknowledging that the available data were inconclusive. They stated that no direct evidence existed to either support or refute a definitive association between dental procedures and PJI and therefore determined that routine antibiotic prophylaxis could not be universally recommended for all patients with prosthetic joints.

Unlike the earlier 2003 guidelines, the 2012 statement did not endorse a specific antibiotic regimen. Instead, it emphasized individualized decision-making and encouraged oral health professionals to exercise professional judgment in collaboration with orthopedic surgeons and patients. A case-by-case risk assessment was recommended, considering the patient’s medical history; presence of comorbid conditions such as immunosuppression or poorly controlled diabetes; type and timing of the joint replacement; and the nature of the planned dental procedure. This represented a significant departure from the prior precautionary approach, signaling a shift toward more personalized, evidence-informed care.⁸ This shift occurred in parallel with growing awareness of the risks associated with antibiotic use, including gastrointestinal disturbances, hypersensitivity reactions, adverse drug reactions, antimicrobial resistance, and Clostridioides difficile infection, which outweigh any theoretical benefit in most patients.⁹

By 2015, the ADA issued a strong recommendation against routine antibiotic prophylaxis for dental procedures in patients with prosthetic joints.¹⁰ This recommendation was based on a systematic review of the literature, which found no compelling evidence linking invasive dental procedures to the development of PJI. The guideline issued a strong recommendation that, in general, antibiotic prophylaxis is not recommended prior to dental procedures for patients with prosthetic joint implants.¹⁰ It emphasized that maintaining good oral hygiene and regular dental care are more critical in reducing the overall risk of systemic infections. Furthermore, it advised clinicians to reserve prophylactic antibiotics only for specific high-risk individuals (such as those with immunosuppression, poorly controlled diabetes, or prior history of PJI), in consultation with their orthopedic surgeon or medical specialist.

The AAOS reinforced this position with its 2016 Appropriate Use Criteria, emphasizing interdisciplinary coordination and clinical judgment.¹¹ These updates reinforced the conclusions of the 2015 guideline, emphasizing no established causal link exists between invasive dental procedures and PJI. Moreover, the ADA highlighted that the risks associated with antibiotic use. Subsequent updates by the ADA reaffirmed that routine antibiotic prophylaxis prior to dental procedures is not indicated for patients with prosthetic joint implants.^12,13

Finally, in an interesting 2024 study, Brenner et al¹⁴ concluded that there was an increased infection rate in patients with teeth at 6 months and greater since the primary TJA. Their conclusion was that just having teeth is a potential risk factor for late PJI.¹⁴

Even with the overwhelming body of evidence that exists today, Thornhill et al¹⁵ reported in the Journal of the American Dental Association that US dentists are under pressure from orthopedic surgeons and their patients with prosthetic joints to provide antibiotic for IDPs. Some orthopedic surgeons continue to recommend an antibiotics regimen before both routine (dental prophylaxis) and advanced dental treatment (extractions).

Current Evidence and Recommendations

Current literature does not support routine systemic antibiotic prophylaxis prior to dental procedures for most patients with TJA. Four major studies conducted that there were no significant difference in PJI rates between patients who received prophylaxis and those who did not, regardless of procedure type or timing.^6,15-17 Furthermore, they demonstrated that the absolute risk of developing a PJI following dental treatment is exceedingly low.

In addition, in 2024 Simon et al¹⁸ reviewed the records of 10,894 patients who didn’t receive antibiotic prophylaxis and found only four dental-associated PJIs, concluding that routine antibiotic prophylaxis prior to dental procedures were not shown to affect the risk of late-presenting PJI. Masuda et al¹⁹ found similar results and questioned the recommendation of antibiotic resistance. Springer et al,²⁰ in a study of an English population in which antibiotic prophylaxis is not routinely recommended, concluded that because they did not find a significant positive association between IDPs and PJI, there is no justification for administering antibiotic prophylaxis prior to dental procedures in patients with prosthetic joints. They emphasized that routine antibiotic prophylaxis would add cost and inconvenience, expose patients to potential adverse drug reactions, and contribute to unnecessary antibiotic use, which can promote antimicrobial resistance.

In contrast, the risks associated with unnecessary antibiotic use are well documented. These include allergic reactions, gastrointestinal disturbances, and C. difficile infection, as well as broader public health concerns such as the emergence of antibiotic-resistant organisms and increased healthcare costs.¹⁰ Given the absence of demonstrated clinical benefit and the presence of well-established risks, routine antibiotic prophylaxis is not justified for most patients with stable joint prostheses and no significant systemic health concerns.

In support of minimizing the use of antibiotic prophylaxis, in November 2024, the combined AAOS and the American Association of Hip and Knee Surgeons published a detailed paper supporting the recommendation that the routine use of antibiotics is not supported by the literature.²¹ They concluded that routine systemic antibiotic prophylaxis before dental procedures in patients with hip or knee replacements is unlikely to reduce the risk of subsequent prosthetic joint infection. They indicated that the available evidence does not support the practice as an effective preventive strategy. Ideally, this will help the dental community reduce unnecessary antibiotic prophylaxis and curb the current estimated $59 million annual cost, which is likely to rise as arthroplasty rates continue to increase.¹⁵

When Antibiotic Prophylaxis Is Not Indicated

Antibiotic prophylaxis is not recommended for routine dental procedures, such as dental prophylaxis or noninvasive restorations, especially in patients without systemic comorbidities.¹¹ Patients who are more than 3 to 6 months post-arthroplasty with well-functioning prostheses and no history of PJI do not require antibiotic coverage. Similarly, daily oral hygiene activities, including brushing, flossing, and chewing, are not indications for antibiotic prophylaxis.^5,6

Indications for Antibiotic Prophylaxis

Although routine antibiotic prophylaxis is not recommended for most patients with TJA, it may be indicated in select clinical scenarios.

Antibiotic prophylaxis may be considered within the 3 three months following joint replacement surgery. During this period, increased local vascularity and ongoing soft tissue healing may theoretically elevate the risk of hematogenous seeding of the site.¹¹ Although this association has not been definitively established, many expert panels support the use of antibiotic prophylaxis for invasive dental procedures performed during the early post-operative phase.

Patients with certain systemic conditions are considered at elevated risk for PJI and may benefit from antibiotic prophylaxis. These include individuals with a prior history of PJI, immunocompromised states (eg, human immunodeficiency virus/acquired immunodeficiency syndrome, chemotherapy, prolonged corticosteroid use), poorly controlled diabetes (HbA1c >8%), and inflammatory arthropathies such as rheumatoid arthritis or systemic lupus erythematosus. Additional risk factors include end-stage organ disease, severe malnutrition, and systemic frailty.^12,23,24

Dental interventions that induce significant bacteremia may warrant antibiotic prophylaxis in medically compromised individuals. These include tooth extractions, periodontal surgery, scaling and root planing, dental implant placement, and apical endodontic surgery.^4,22

The presence of acute oral infections, such as odontogenic abscesses, cellulitis, or advanced periodontitis, represents another clinical indication for antibiotic prophylaxis before dental intervention, particularly in high-risk patients.

When antibiotic prophylaxis is indicated, the standard regimen consists of amoxicillin 2 grams orally 30 to 60 minutes before the procedure.³ For patients with a penicillin allergy, clindamycin 600 mg, azithromycin 500 mg, or clarithromycin 500 mg may be used; however, clindamycin should be prescribed cautiously due to its association with C. difficile colitis.⁹

Total Joint Arthroplasty

Two clinical timing questions frequently arise in perioperative management:

1. When to perform dental procedures following TJA?
2. When to proceed with TJA after recent dental treatment.?

If a dental surgical procedure precedes the TJA, timing should allow for complete mucosal healing to minimize the risk of bacteremia and systemic microbial dissemination

Oral wound healing progresses through distinct phases: inflammation (3 to 5 days), proliferation (up to 14 days), and remodeling (up to 6 weeks), with delayed healing observed in patients with diabetes or other systemic conditions. Rodriguez²⁵ emphasized that full epithelialization, typically achieved within 21 days, is key to minimizing the risk of bacteremia. Consequently, elective TJA should generally be scheduled no earlier than 3 weeks after invasive dental procedures, provided soft tissue healing is complete and there are no signs of residual infection.

The consensus generally recommends deferring elective invasive dental procedures for approximately 3 months post-operatively. This precaution is based on the biological rationale that the early post-operative phase is marked by active tissue remodeling, neovascularization, and heightened local perfusion near the prosthetic site, potentially increasing susceptibility to hematogenous bacterial seeding.¹¹ Although Thornhill et al¹⁵ found no increased PJI risk from dental procedures, their studies did not specifically examine the early post-operative period. Supporting this precautionary delay, Martins et al,²² in a systematic review of 89 studies, confirmed that extractions and periodontal procedures are associated with the highest incidence of bacteremia (62% to 66% and 36% to 44%, respectively), further supporting temporary delay.²²

Conclusion

PJI is a rare but serious complication of TJA and its prevention requires thoughtful coordination between dental and orthopedic providers. Current evidence does not support the routine use of antibiotic prophylaxis for dental procedures in patients with prosthetic joints. Instead, a risk-stratified approach is recommended, reserving prophylaxis for high-risk individuals, those in the early post-operative period, or those presenting with active oral infections.

Elective IDPs should be deferred for approximately 3 months following TJA, while elective arthroplasty should be scheduled at least 3 weeks after invasive dental treatment to ensure adequate mucosal healing. These evidence-based guidelines aim to reduce unnecessary antibiotic use, promote antimicrobial stewardship, and ensure patient safety through individualized, interdisciplinary care.

References

1. Shichman I, Askew N, Habibi A, et al. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2040–2060. Arthroplast Today. 2023;21:101152.
2. Villa JM, Rajschmir K, Lin S, Higuera-Rueda CA. What is the true impact of periprosthetic joint infection diagnosis on mortality? J Arthroplasty. 2024;39:S410–S414.
3. American Dental Association; American Academy of Orthopaedic Surgeons. Advisory statement: antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc. 2003;134:895–899.
4. Tomas I, Diz P, Tobias A, Scully C, Donos N. Periodontal health status and bacteraemia from daily oral activities: systematic review/meta-analysis. J Clin Periodontol. 2012;39:213–228.
5. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc. 2009;140:1238–1244.
6. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis. 2010;50:8–16.
7. Martins CC, Lockhart PB, Firmino RT, et al. Bacteremia following different oral procedures: Systematic review and meta-analysis. Oral Dis. 2024;30:846-854.
8. Watters W, Rethman MP, Hanson NB, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013;21:180-189.
9. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc. 2019;150:906–921.
10. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline. J Am Dent Assoc. 2015;146:11–16.
11. Quinn RH, Murray JN, Pezold R, Sevarino KS, Members of the Writing and Voting Panels of the AUC for the Management of Patients with Orthopaedic Implants Undergoing Dental ProceduresThe American Academy of Orthopaedic Surgeons appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures. J Bone Joint Surg Am. 2017;99:161-163.
12. American Dental Association. Antibiotic Prophylaxis for Prevention of Prosthetic Joint Infection Clinical Practice Guideline (2014). Available at ada.org/resources/research/science/evidence-based-dental-research/antibiotics-to-prevent-prosthetic-joint-infection. Accessed May 14, 2026.
13. American Dental Association-Appointed Members of the Expert Writing and Voting Panels Contributing to the Development of American Academy of Orthopedic Surgeons Appropriate Use Criteria. American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures. J Am Dent Assoc. 2017;148:57-59.
14. Brenner, JD, Atallah, M., Yatsonsky, D. et al. Higher onset of periprosthetic joint infections in patients with teeth compared to those without teeth. Cureus. 2024;16:e63696.
15. Thornhill MH, Gibson TB, Pack C, et al. Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis. J Am Dent Assoc. 2023;154:43–52.
16. Kao FC, Hsu YC, Chen WH, Lin JN, Lo YY, Tu YK. Prosthetic joint infection following invasive dental procedures and antibiotic prophylaxis. Infect Control Hosp Epidemiol. 2017;38:154–161.
17. Sax, OC, Baine, SS, Chen, Z, et al. Antibiotic prophylaxis is not necessary for invasive dental procedures in existing total knee arthroplasty implants. Orthopedics. 2023;46:76-81.
18. Simon, SJ, Aziz, AA, Coden, GS. et al. Antibiotic prophylaxis prior to dental procedures after total hip and knee arthroplasty dies not decrease the risk of periprosthetic joint infection. J Arthoplasty. 2024 Sep;39:S420-S424.
19. Masuda S, Fukasawa T, Takeuchi M, et al. Association between dental procedures and periprosthetic joint infection: A case-crossover study. J Orthop Sci. 2024;29:1145-1148.
20. Springer BD, Baddour LM. Lockhart PB, et al. Antibiotic prophylaxis for prosthetic joint patients undergoing invasive dental procedures: time for a rethink? J Arthroplasty. 2022;37:1223-1226.
21. Hannon CP, Grosso MJ, Fillingham YA, et al. AAOS clinical practice guideline summary prevention of total hip and knee arthroplasty periprosthetic joint infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2025;33:e1260-e1267.
22. Martins M, Ruiz K, Shaughnessy M, et al. Dental procedure–induced bacteremia and the risk of prosthetic joint infection: a systematic review. Clin Oral Investig. 2023;27:1509–1518.
23. Haj Yahya B, Chaushu G, Hamzani Y. Evaluation of wound healing following surgical extractions using the IPR Scale. Int Dent J. 2020;71:133-139
24. Ruggiero SL. Mucosal healing and antibiotic considerations in dental management of medically compromised patients. Oral Maxillofac Surg Clin North Am. 2024;36:115–126.
25. Rodriguez T. Timing of dental surgery and joint arthroplasty: how soon is safe? J Dent Res. 2024;103:220–227.

From Decisions in Dentistry. September/October 2026;12(2):36-39.

New medications, including those for common medical conditions, such as hypertension, diabetes, and cardiac and autoimmune disorders, can significantly impact oral health. In the past decade, many pharmaceutical companies have focused on developing new psychiatric and mental health medications with a particular focus on substance use disorders that frequently accompany mental health issues.

Ever-growing opiate addiction and the need for its treatment elevated the use of substance use treatment medications to entirely new levels. Medications, including buprenorphine and naloxone (brand name Suboxone^®), while used to treat opioid dependence and manage pain, may significantly impact oral health. These effects include adverse changes in the oral cavity, significant interactions with dental procedures, and impacts on post-operative dental pain management. Understanding how newly introduced medications affect oral health is crucial for ensuring patient safety and optimal treatment outcomes.

Suboxone is a crucial tool in fighting the opioid epidemic, helping people regain control over their lives by reducing dependency on opioids while lowering the risk of overdose and misuse. One of the most widely used medications to treat opioid use disorder (OUD), Suboxone is effective in managing opioid dependence while also reducing the risk of misuse compared to other treatments such as methadone.

Suboxone contains two active ingredients: buprenorphine and naloxone. Available in sublingual/buccal film or sublingual tablet formulations, Suboxone films or tablets are placed sublingually or inside the buccal vestibule, allowing the medication to dissolve and be absorbed directly through the mucous membranes.

In sublingual preparations, Suboxone comes in 2.0/0.5 mg, 4.0/1.0/0.5 mg, 8.0/2.0 mg, or 12.0/3.0 mg formulations containing 2.0, 4.0, or 8.0 mg of buprenorphine and 0.5, 1.0, or 3.0 mg of naloxone. The maintenance dose of Suboxone (which usually starts on the third day of treatment and beyond) is available in 4.0/1.0 mg or 8.0/2.0 mg formulations.¹

Other forms of buprenorphine-based medications, such as Subutex (which contains only buprenorphine without naloxone), Zubsolv, and Bunavail, each offer different delivery mechanisms or dosing.² Suboxone remains the most recognized brand today in the treatment of OUDs. The introduction of generic versions has further increased its popularity, driven by lower costs and wider availability.

Indivor Inc, the drug manufacturer, advises patients to take a sip of water, swish it gently around the teeth and gums, and spit out the residue from the Suboxone strip after it has been absorbed by the oral mucosa. Patients are advised to wait at least 1 hour after taking Suboxone before brushing their teeth.¹

Mechanism of Action

Buprenorphine’s mechanism of action is similar to other opioids. A partial agonist at opioid receptors, buprenorphine activates opioid receptors in the brain but to a much lesser extent than full agonists such as heroin, oxycodone, or hydrocodone. Such action helps reduce cravings and withdrawal symptoms without providing the intense high that is associated with full opioid agonists. Additionally, buprenorphine allows patients to gradually reduce their dependence.

Naloxone is an opioid antagonist that blocks opioid receptors and is included in Suboxone to prevent misuse, as Suboxone is an opioid itself.³ The addition of naloxone reduces the potential for abuse, as naloxone discourages attempts to misuse the drug. An alternative version of the medication, Subutex, does not contain any naloxone. Although the most important benefits of Suboxone administration include multiple medical and social factors, the practice shows that the most common beneficial elements include the lower overdose risk and decrease in the intensity of withdrawal symptoms.⁴

Dental-Related Adverse Reactions

Adverse events related to the sublingual/buccal administration of Suboxone sublingual film are oral hypoesthesia, glossodynia, oral mucosal erythema, headache, nausea, vomiting, hyperhidrosis, constipation, signs and symptoms of withdrawal, insomnia, pain, and peripheral edema.⁴

Glossodynia and oral hypoesthesia are the most significant complications. Glossodynia, also known as burning mouth syndrome, causes a burning, tingling, or scalding sensation in the mouth that lasts for at least 4 to 6 months.⁵

Suboxone, like all medications, may cause side effects. While it is generally well-tolerated when used as prescribed, it can still lead to a variety of side effects, especially when misused or taken improperly. Some side effects are serious and may require urgent medical attention, such as respiratory depression, hypotension, liver problems, and adrenal insufficiency.⁶ Although rare, respiratory depression can occur, especially if combined with other central nervous system depressants such as alcohol, benzodiazepines, or other opioids. Therefore, sedation administration in a dental setting needs to be carefully planned.

Liver problems can cause bleeding because the liver can’t produce enough clotting factors, causing coagulopathy. This may make the patient not only prone to hemorrhage but also susceptible to thrombosis due to a parallel reduction in procoagulants and anticoagulant factors.⁷ These possible complications must be considered when planning a surgical dental treatment. Signs of liver failure may include yellowing of the skin or eyes (jaundice), dark urine, severe fatigue, nausea, and upper right abdominal pain.

Adrenal insufficiency is a long-term side effect of opioid use. Buprenorphine can affect the adrenal glands, potentially causing adrenal insufficiency. Symptoms may include fatigue, weakness, dizziness, low blood pressure, and potential shock.

From a dental perspective, chronic long-term side effects of Suboxone use include xerostomia, enamel demineralization, tooth decay, gingivitis, and periodontal diseases. Poor salivary flow caused by opioid effects increases the acidity in the mouth and can significantly contribute to dental erosion.⁸

Suboxone can have serious interactions with other medications or substances used during dental treatment, such as benzodiazepines and other opioids. Combining Suboxone with drugs such as alprazolam (Xanax), diazepam (Valium), or lorazepam (Ativan) increases the risk of respiratory depression. Combining Suboxone with sedatives can dangerously depress the central nervous system, leading to severe drowsiness, respiratory depression, and even death.⁹ Concurrent use of other opioids for post-operative pain management is not only dangerous but counteracts Suboxone’s effects, potentially leading to withdrawal symptoms or overdose.

Suboxone has tremendous effects on dental enamel because of its method of delivery: thin transmucosal strip placed sublingually or intrabuccally.¹⁰ The strip takes approximately 10 minutes to fully dissolve. During this waiting period, the highly acidic ingredients in Suboxone can drastically reduce oral pH, resulting in an acid attack on enamel. Additionally, the medication can diminish salivary flow and increase the oral virulence of Streptococcus mutans, raising the risk for dental caries.¹¹

With repeated use of Suboxone, these effects may dissolve the tooth enamel and disturb the normal chemical balance of the oral cavity. In the absence of appropriate precautions, patients may be at increased risk of oral diseases and pathologies. Oral health professional should be prepared to closely monitor patients taking Suboxone to help protect their oral health.

Interactions With Dental Anesthesia

Though chronic opioid use can change the way individuals perceive pain, often leading to a higher pain threshold, the alteration of administered doses is often needed. While some medications can interact with local anesthetics used in dentistry, Suboxone has no evidence-based interactive properties.¹²

As many dentists have seen, administering local anesthetics and achieving profound local anesthesia may present challenges with opioid users. This can be explained by many factors, including altered pain perception caused by long-term opioid use, psychological factors associated with anxiety and depression, and anxiety-driven expectations of pain.¹³ Due to these factors, dentists may need to use alternative or additional methods for anesthesia and pain management for patients with a history of opioid use. Oral health professionals need to be aware of a patients’ Suboxone use to tailor their pain management strategies accordingly.

Need for Altered Pain Management

Patients taking Suboxone or other opioid-dependence medications, such as methadone, may need particular pain management strategies. As opioids may not be practical, or their use may increase the risk of relapse, dentists must coordinate with the primary prescriber to avoid misunderstandings and possible overdose.¹⁴

Suboxone can affect pain management before, during, and after dental treatments. Patients already taking Suboxone or other opioid medications for ongoing pain management therapies may have a reduced response to standard pain management protocols in dentistry. This can complicate post-operative pain control, requiring alternative strategies, such as nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs or acetaminophen).

Patients taking Suboxone and psychotropic medications, such as antidepressants, antipsychotics, or benzodiazepines, may have altered responses to sedation during dental procedures. It is crucial to understand what adjustments in the dosages of sedatives or anesthetics may be required.¹⁵

Communication Is Key

Dental providers must review medical history and medications for each new and recare patient. Frequently, dental patients (particularly emergency dental patients) do not see opioid treatment medications like Suboxone or methadone as relevant to dental treatment. Additionally, many patients in recovery do not feel their history of past drug use and current medication treatment should be reported to dental providers, especially in cases of noninvasive dental treatment.

Dentists must review all medications the patient is taking to anticipate any potential interactions or complications. Additionally, opioid or stimulant-focused questionnaires should be utilized to identify or assess these areas of potential problems. In many cases, dentists may need to collaborate with a patient’s physician or other prescriber to adjust medications before or after a procedure, especially if it involves surgery or significant pain management. Such efforts provide additional safety for the patient and treating providers.

A Medical Miracle or Dental Pariah?

Since its introduction, Suboxone has become a game-changing medication for OUD, allowing people to control opioid withdrawal symptoms, manage urges, and regain normal function. Subsequently, patients with OUD are able to focus on rehabilitation, employment, and relationships while managing their opioid dependence. As a result, many medical practitioners view Suboxone not just as a short-term panacea but as a substantial pathway to long-term recovery.¹⁶

A practical, accessible, and relatively safe compared to other treatment options, Suboxone offers both medical and societal benefits. Suboxone has earned a strong reputation for its harm reduction, helping millions of people transition away from full opioid agonists like heroin, oxycodone, and fentanyl, reducing the risk of overdose deaths. It delivers the so-called “ceiling effect,” suppressing withdrawal symptoms and cravings without the intense high of full opioids, subsequently lowering the risk of misuse and overdose.³

By combining buprenorphine (a partial opioid agonist) with naloxone (an opioid antagonist), Suboxone controls misuse of opioid drugs and greatly reduces withdrawal symptoms when prescribed and taken correctly. Additionally, Suboxone is more accessible and less problematic than older opioid treatment medications, such as methadone, because it can be prescribed by medical practitioners in traditional office settings and does not require daily visits to treatment centers.

Despite its accomplishments in addiction treatment, Suboxone can present some significant challenges in dentistry. Common dental-related side effects include xerostomia, oral mucosa irritation, and ulcerations. Suboxone reduces saliva flow, thereby decreasing acid neutralization, which may lead to increased oral acidity. This can create a fertile environment for enamel demineralization, caries development, gingival edema, and subsequent oral infections.⁸

When taken as a sublingual tablet or film, Suboxone can cause mucosal irritation or even intraoral ulcerations. Prolonged exposure to the medication may damage the soft tissues of the buccal mucosa and sublingual areas of the oral cavity.

Perhaps one of the primary challenges Suboxone poses for dentistry is pain management due to the development of opioid resistance. Because buprenorphine has a strong affinity for opioid receptors, it makes it difficult for other opioids used in post-operative pain management to be effective. This makes post-operative pain management challenging, particularly after invasive dental procedures such as extractions or implant surgeries. Further complicating post-operative pain management, adjustment of Suboxone’s dosage may be needed, requiring additional efforts to coordinate care with the prescribing physician.

Balancing the Two Sides

When seen holistically, Suboxone is a life-saving drug that significantly enhances the general well-being and standard of living of those battling opioid addiction. Without it, the negative effects of OUD (overdose, social disintegration, and other health issues) perhaps exceed potential dental complications.

Dentists can manage oral side effects by increasing preventive care, educating patients, and carefully managing dry mouth and pain. Regular dental check-ups, increased hydration, and saliva substitutes or stimulants can also help mitigate dental risks. As new medications are introduced, they can significantly affect oral health, dental procedures, post-operative dental pain management, and the overall healing process. Dentists must remain vigilant about patients’ medication histories to prevent complications, ensure effective treatment, and collaborate with healthcare providers when necessary. Patient communication and comprehensive health assessments are key to managing the impact of new medications on dentistry.

Conclusion

Crucial to the opioid crisis response, Suboxone is essential in assisting individuals to overcome their addictions. With the opioid crisis taking tens of thousands of lives a year in the United States and other countries, Suboxone is a critical tool to help people manage their addiction and prevent overdose deaths. For those battling opioid addiction, Suboxone is unquestionably a medical miracle as it provides a route to recovery that drastically lowers the chance of overdose and enhances long-term results.

Conversely, Suboxone is associated with dental complications that must be addressed appropriately. Its benefits to general and public health and recovery far exceed the risks of oral health complications that can be managed successfully by applying evidence-based dental medicine practices.

References

1. Indivor Inc. Suboxone Prescribing Information. Available at suboxone.com/pdfs/prescribing-information.pdf. Accessed May 7, 2025.
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3. Kumar R, Viswanath O, Saadabadi A. Buprenorphine. In: Treasure Island, Florida: StatPearls Publishing; 2024.
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9. Park TW, Larochelle MR, Saitz R, Wang N, Bernson D, Walley AY. Associations between prescribed benzodiazepines, overdose death and buprenorphine discontinuation among people receiving buprenorphine. Addiction. 2020;115:924-932.
10. Suzuki J, Mittal L, Woo SB. Sublingual buprenorphine and dental problems: a case series. Prim Care Companion CNS Disord. 2013;15:13l01533.
11. Togioka BM, Patel P. Buprenorphine and Naloxone. Treasure Island, Florida: StatPearls Publishing; 2024.
12. Manza P. Does suboxone interfere with novocain? Available at bicyclehealth.com/suboxone-faq/does-suboxone-interfere-with-novocain. Accessed May 7 2026.
13. Hashemian AM, Omraninava A, Kakhki AD, et al. Effectiveness of local anesthesia with lidocaine in chronic opium abusers. J Emerg Trauma Shock. 2014;7:301-304.
14. Veazie S, Mackey K, Bourne D, et al. Evidence brief: managing acute pain in patients with opioid use disorder on medication-assisted treatment. Available at ncbi.nlm.nih.gov/books/NBK549201. Accessed May 7, 2026.
15. Sritapan Y, Clifford S, Bautista A. Perioperative management of patients on buprenorphine and methadone: a narrative review. Balkan Med J. 2020;37:247-252.
16. Scanlan S. Suboxone: concerns behind the miracle. Available at hmpgloballearningnetwork.com/site/addiction/article/suboxone-concerns-behind-miracle. Accessed May 7 2026.

From Decisions in Dentistry. September/October 2026;12(2):40-45.

A patient presented with a screw-retained implant crown in the posterior mandibular region (Figure 1). After verifying proper seating and confirming adequate torque of the prosthetic screw, the access channel required restoration (Figure 2). Before placing the restorative material, the screw channel was sealed using a single piece of polytetrafluoroethylene (PTFE) tape (Figure 3), leaving 2 to 4 mm of restorative space for the composite.

Once the screw head was protected, the restorative phase begins. A 1 to 2 mm 45° bevel is placed along the margin of the access opening to improve adhesion and enhance shade blending. The crown surface was then conditioned according to the restorative material. The composite was placed in incremental layers of approximately 2 mm within the access opening.

The first layer consisted of OMNICHROMA BLOCKER to mask the dark color of the underlying implant components. A second and final layer of OMNICHROMA composite was then placed and carefully adapted to the surrounding crown structure. Incremental placement allows better control during shaping and helps minimize polymerization stress.

One of the advantages of using a universal shade composite for implant access restorations is its ability to visually blend with surrounding restorative materials. The structural color technology of OMNICHROMA allows the composite to harmonize with the existing restoration, producing a natural appearance once polished. When masking darker implant components is necessary, a flowable opaquing material, such as OMNICHROMA BLOCKER Flow, should be used as the initial layer to improve the final esthetic outcome.

After final curing, the occlusion was carefully checked and adjusted to ensure the restoration did not interfere with the patient’s bite. Finishing and polishing were then performed. The final result restored the crown’s occlusal form while effectively sealing the screw access channel (Figure 4). The restoration blended well with the surrounding zirconia crown, maintaining both function and esthetics (Figure 5).

Using a universal shade composite combined with an opaque blocker layer can simplify the restorative process while delivering predictable and esthetic results.

Tokuyama
tokuyama-us.com
877-378-3548

From Decisions in Dentistry. September/October 2026;12(2):20.

This year’s OMAM theme, “Let’s Bloom,” celebrates personal and professional growth. It’s especially timely as practices continue navigating staffing challenges, changing patient expectations, and the demands of busy benefit seasons. In that environment, recognition isn’t just a nice gesture, it’s an investment in practice culture.

Office managers are often the heartbeat of the practice. They wear countless hats every day, balancing patient care, team leadership, operations, financing, scheduling, compliance and problem solving. While patients may spend most of their appointment with the clinical team, office managers often shape the first impression, financial conversations, scheduling, follow-up, and overall patient experience.

Recognition also strengthens engagement. When people feel valued, they stay engaged. A supported office manager is better equipped to support their team, create a positive work environment, and help deliver exceptional patient experiences.

The “Let’s Bloom” theme reflects the growth office managers inspire every day. When you think about growth, you picture a seedling breaking through the soil. But the beautiful time is when fruits and flowers bloom. We want to recognize the beauty of personal and professional growth for the dental office team.

Office managers spend so much time helping other people grow. OMAM is an opportunity to focus on their own growth and development. When we invest in ourselves through learning, networking and professional development, we become stronger leaders, better communicators and more confident professionals.

September is the perfect month to celebrate as it arrives just before the busy end-of-year benefits season, making it a natural time to pause and recognize the people who keep practices organized and on track. September feels like a season of fresh starts. A month-long celebration gives dentists, teams, and even patients time to intentionally recognize the office managers who coordinate schedules, solve problems, support staff, and help practices succeed behind the scenes.

OMAM makes recognition easy. The OMAM website, available at omam.carecreditvirtual.com, offers celebration ideas, social media resources, virtual flowers, and downloadable certificates of appreciation to help practices celebrate in ways that fit their culture.

Recognition can be as simple as coffee and breakfast, a team lunch, or a handwritten note. Any type of recognition that is meaningful, personal, genuine, and specific will let managers know that they’re not just appreciated, but why they’re appreciated.

The goal of OMAM is simple: ensure the people who help hold the practice together know their contributions are valued. At the end of the day, when office managers thrive, the practice thrives. This September, OMAM gives dental teams a dedicated reason to appreciate, celebrate, and help their office managers bloom.

Office Management Appreciation Month
omam.dentalmanagers.com
American Association of Dental Office Management
DENTALMANAGERS.COM
CareCredit
CARECREDIT.COM

From Decisions in Dentistry. September/October 2026;12(2):22.

Quantium is available in six body shades and six enamel shades, including A1, A2, A3, A3.5, B1, and B2, as well as a bleach and translucent incisal shade. The incisal shade is ideal for building a palatal shell layer that allows light to be transmitted through to recreate nature along the incisal edge. With impressive compressive and flexural strengths, Quantium (unit-dose only) is designed to be used at room temperature or warmed. Clinicians will appreciate the easy handling and durability, whether heated or not.

When restoring anterior teeth, the clinician must decide whether to use a single shade or layered approach. The size of the restoration and appearance of adjacent teeth play a big role in determining how many layers are necessary to create a seamless restoration. Quantium is forgiving and flexible and allows room for error with its simplified shade palette. This flexibility allows for quick clinical decisions regarding shade and yields a blended restoration at the transition zone between the tooth and resin, even when the clinician is short of time.

Clinical Case Report

In the following case, the patient presented for a scan for final retainers after completing orthodontic treatment with clear aligners. The patient was happy with the alignment of her teeth but was concerned about the appearance of her worn maxillary lateral incisors. She opted to have #7 (Figure 1) and 10 (Figure 2) restored with composite resin rather than porcelain prior to fabricating her retainers. The restoration of #7 and 10 was not planned ahead of time, so quick decisions had to be made to stay on schedule. Quantium A2 body and A2 enamel shades were chosen to restore the worn and fractured incisal edges. A scalloped bevel was placed at the transition zone. The preps were microabraded prior to being selectively etched to increase the bond strength. The adhesive Allbond Universal by Bisco was used. Quantium A2 Body was placed via a freehand technique without stents, and up to midway into the scalloped bevel. Once cured, a layer of Quantium A2 enamel was placed over the first layer and extended apically beyond the bevel.

After curing, a series of finishing and polishing steps was completed. A polishing paste was not used as a final step in this case. Though the occlusion was addressed in the clear aligner treatment plan, a resin material with high strength was the most appropriate choice. If the adjacent teeth had displayed a moderate to high level of incisal translucency, a palatal layer using Quantium incisal could have been used in addition to the body and enamel shades.

Photos were taken immediately post-op and the transition line between enamel and resin was difficult to detect (Figures 3 and 4). The patient was very happy with the results. She did not need to be anesthetized and realized an instant cosmetic improvement with no restrictions to follow after the appointment. Both restorations were completed in less than 15 minutes.

Quantium Universal offers excellent value and is an essential material for predictable anterior resin restorations. It can be used as a standalone, single shade option, or a multilayered restoration to create beautiful results that are likely to last.

BISCO
bisco.com
800-247-3368

From Decisions in Dentistry. September/October 2026;12(2):23.

As research continues to advance and patients become more aware of the connection between periodontal disease and systemic health, dental care is shifting toward a more personalized, predictive, preventive, and participatory (P4) approach.² While patients contribute through recommended self-care practices, dental hygienists drive the predictive and preventive aspects of a P4 approach by using assessments to identify risk factors, intervene early, and implement disease-prevention therapies. Combining identified risk factors with each patient’s periodontal status allows clinicians to tailor treatment plans for personalized periodontal care.

Within a personalized treatment plan, ultrasonic instrumentation choices, including technology optimization, insert selection, and technique, play a critical role in delivering patient-centered periodontal care.

Moving Beyond ‘One-Size-Fits-All’ Insert Selection

Patient-centered periodontal care begins with the recognition that no two patients and no two mouths are the same. Variations in disease state, anatomy, tissue condition, and deposit type directly influence ultrasonic insert selection and clinical technique. From periodontal health and gingivitis to the treatment of periodontitis, thoughtful consideration of ultrasonic insert characteristics is essential to delivering effective, individualized care. The Cavitron^® family of inserts supports personalized periodontal care across a wide range of patient needs.

Evaluating key ultrasonic insert characteristics, such as diameter, cross section, shape, and length, supports tailored treatment plans and maximizes ultrasonic technology.

Diameter selection — ultrathin, slim, or standard — should be guided by deposit type and amount to optimize efficiency, effectiveness, and patient comfort. Cross-section options, such as round, diamond/square, or rectangular, influence how energy is distributed at the tip and how deposits are disrupted, directly impacting clinical efficiency.³ Insert shape, whether straight or curved, affects adaptation to flat or contoured anatomy, while shank length plays a key role in accessing periodontal pockets and posterior regions. The Cavitron ultrasonic insert portfolio enables clinicians to select inserts based on these characteristics to align ultrasonic performance with individual patient needs.

Optimizing Ultrasonic Technique for Patient-Centered Periodontal Care

Maximizing the benefits of ultrasonic instrumentation involves implementing proper techniques. The three A’s of ultrasonic instrumentation are:

1. Adaptation
2. Angulation
3. Activation

When executed correctly, they enhance both effectiveness and efficiency.

The last 4 mm of a Cavitron ultrasonic insert tip is referred to as the active area. The active area is responsible for the disruption and removal of biofilm, calculus, and stain. Proper adaptation involves maintaining contact between the last 2 to 3 mm of the active tip area and the tooth surface. This is achieved by maintaining an angulation of 0 to 15° between the insert tip and the tooth surface.

Improper angulation may compromise root surface preservation, patient comfort, and effective deposit removal. Activation refers to the working stroke created and controlled by the clinician. Stroke movement is determined by deposit type and quantity and involves controlled tapping or sweeping motions that promote efficient deposit removal while maintaining patient comfort. Together, these techniques guide efficient biofilm and calculus disruption and removal during ultrasonic debridement procedures. When effective techniques are paired with appropriate insert selection, dental hygienists are better equipped to deliver efficient, patient-centered periodontal care.

Maintaining Equipment Performance

Routine maintenance of ultrasonic scaling systems, including handpieces and inserts, is often overlooked. Proper maintenance begins with following instructions for use for reprocessing and sterilization, as well as routinely evaluating ultrasonic inserts for wear, which can impact the efficiency of ultrasonic procedures.

Advancing Patient-Centered Periodontal Care

Modern periodontal care extends beyond routine scaling to embrace the principles of P4 medicine: predictive, preventive, personalized, and participatory care. Supported by the Cavitron family of inserts, clinicians can reimagine ultrasonic instrumentation through a patient-centered lens, focusing on biofilm disruption, appropriate insert selection, optimal technique, and proactive monitoring, to elevate clinical outcomes and redefine the standard of patient-centered periodontal care.

Dentsply Sirona
www.dentsplysirona.com/en-us/explore/preventive.html
844-848-0137

References

1. World Health Organization. Global Oral Health Status Report. Available at who.int/team/noncommunicable-diseases/global-status-report-on-oral-health-2022. Accessed August 3, 2026.
2. Bartold PM, Ivanovski S. P4 Medicine as a model for precision periodontal care. Clin Oral Investig. 2022;26:5517-5533.
3. George MD, Botbyl D, Donley TG, Preshaw PM. Ultrasonic Periodontal Debridement Theory and Technique. 2nd ed. Hoboken, New Jersey: Wiley Blackwell; 2024.

From Decisions in Dentistry. September/October 2026;12(2):24-25.

The way patients find dentists has changed forever. Referrals once drove nearly all growth. In other words, a happy patient told a friend, who told a neighbor, and so on. But in 2026, that chain has gone digital. Patients don’t ask friends for recommendations first anymore, they ask Google, ChatGPT, or Siri.

Artificial intelligence (AI) has become the new referral source, and it’s reshaping every stage of the patient journey, from discovery to decision. AI is the invisible assistant helping people figure out who to trust and where to go.

According to Salesforce, 71% of consumers now expect AI to help them make smarter decisions, including healthcare choices. For dental practices, that means visibility no longer depends on traditional search engine optimization alone. It relies on whether AI systems understand, trust, and recommend your practice.

The modern patient journey starts with a question, not a search term: “Who’s the best cosmetic dentist near me who takes Delta Dental?” That question might go to Google’s Search Generative Experience, ChatGPT, Bing Copilot, or Apple’s new search assistant. These tools don’t return 10 blue links. They return summaries that blend reviews, website content, and verified data into a short, confident answer.

AI doesn’t “crawl” websites like a search engine. It reads structured data, reviews, and content contextually. It’s designed to act like a human assistant, interpreting tone, expertise, and reliability before recommending a provider.

This is why many dentists are seeing a drop in web traffic, even when they still rank high on Google. AI is answering patients’ questions before they reach your website.

Here’s how AI-driven discovery works in 2026:

1. A question is asked: typed, spoken, or through a chatbot.
2. AI interprets the intent. It determines whether the user needs education, comparison, or a provider.
3. AI gathers trusted data. These include your reviews, listings, service pages, and structured website info.
4. AI delivers an answer. It summarizes the top providers that match the query.

If your data are incomplete, inconsistent, or unverified, you’re invisible at step 4.

AI doesn’t evaluate your practice by design alone, it looks for signals that indicate trustworthiness and authority, including:

Structured data (schema markup) that clearly defines your name, address, services, and reviews.
Review volume and recency. AI prefers active, current feedback from real patients.
Content clarity. Educational blogs, FAQs, and treatment guides that answer questions conversationally.
Listing accuracy across Google, Apple Maps, Yelp, and directories.
Local relevance. Proximity, city mentions, and consistent geographic keywords.

Each of these data points feeds into how AI determines whether to recommend your practice. The more complete your digital profile, the higher your chance of inclusion in AI-generated recommendations.

AI discovery is still new and that’s good news. Most dental practices haven’t caught up yet. By getting your digital presence in order now, you’ll gain visibility before the rest of the market adapts.

Practices that focus on structured data, reputation management, and multiplatform consistency will dominate patient discovery in the next 12 to 24 months. AI isn’t here to replace your marketing, it’s here to reward the ones who keep their house in order.

At DDS MediaPro, we help dental practices structure their data, improve their visibility, and adapt to the AI-driven patient journey, so when AI recommends a dentist, it recommends you. Reach out today: ddsmediapro.com; 866-239-1576.

From Decisions in Dentistry. September/October 2026;12(2):46.