Patient Centered, Minimally Invasive Dentistry -- A Caring Paradigm By Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

Ultradent founder and CEO, Dr. Dan E. Fischer, stands before a crowd of almost 150 dentists at Ultradent’s Esthetic Elite Congress, which are hosted a few times a year to provide practical continuing education and practice enhancement.

Dr. Fischer looks out into the crowd with a familiar smile. He starts off his lecture with a few simple words about patients. In a very impassioned way, he says, “They light up our lives.”

Almost at once, the crowd members nod their head in recognition. They understand the passion behind these words. For those who’ve met Dr. Fischer and been on the receiving end of an unexpected hug or pat on the back, they already understand that his passion extends beyond the dental chair. This passion exemplifies Dr. Fischer’s life, his quarter century in dental practice and the business he’s worked hard to build.

DT: Ultradent Products, Inc. has evolved into a global products manufacturer. Can you share the Ultradent story?

Dr. Fischer: In school, I discovered that the greatest challenge for quality impressions was to adequately control bleeding and retract issues. The materials we had at the time were simply not adequate. As a result, I set up a lab in the basement of my home. After working on patients during the day, I would go to my lab at night and test different chemistries to stop bleeding – usually drawing blood on myself! My first endeavor was a hemostatic solution called Astringedent®. I soon learned that the delivery was critical to this technology, so the development of the syringe delivery system, the Dento-Infusor, soon followed. My initial plan wasn’t to start a dental company. However, I soon learned that the only logical way to get this technology to dentists was through a quality dental company. In order to do this, I needed the support of my family to make the process possible. Most people don’t know that Ultradent started as a family company. The first manufacturing lot was processed on our kitchen table. It wasn’t long before we became FDA compliant with the appropriate facility, good manufacturing practices, etc.

Ultradent grew rapidly in the 1980s, and now manufactures and packages more than 500 materials, devices and instruments. We are driven by the need to enrich the quality of life and improve human oral care. To meet that goal, Ultradent has become a global company, with distribution in more than 100 countries and subsidiaries in Germany, Italy and Brazil. This global perspective is an integral component of Ultradent’s vision.

We also sponsor continuing education seminars and training, often inviting dentist, lecturer and student groups from all over to our facility for training on Ultradent’s latest products and techniques. In order to stay engaged with such professionals, I still maintain a part-time dental practice. In fact, I don’t think I would be as effective without the opportunity to continue connecting with my patients.

DT: What does “minimally invasive” dentistry mean to you?

Dr. Fischer: Over the years, I’ve learned the value of preserving and/or enhancing the natural dentition. We know that trauma to a tooth is additive. The more we cut a tooth, the more we weaken the tooth. If we continue to cut the tooth in the same manner over multiple years, we increase the probability that the vitality of the tooth will be lost. I define “minimally invasive” dentistry as; first, maximizing preventive dentistry; and second, relative to operative dentistry, facilitating treatment in ways that preserves as much of the patient’s original dentin and enamel as reasonably possible. With respect to the latter, it is important to be cognizant about alternatives in conventional dentistry such as maximizing the value of high-strength adhesives and quality composite materials.

We must place a great emphasis on technologies that prevent and/or cure the infectious disease of caries. However, if we managed to find a cure for caries today, we’d still need more dentists! Changes in technology and lifestyles have enabled humans to live longer lives. The majority of our aging population, including baby boomers, will not be content with solutions such as dentures. I always say that teeth are like tires; they’re only good for so many miles before the treads wear out and the sidewalls fail. With the drive for esthetics and quality-of-life, particularly with regard to “smiles,” we have real challenges ahead of us to keep up with the pace. This requires us to rethink how we treat our patients. Our solutions must keep conservation of hard and soft tissues in mind. The new “minimally invasive, patient-centered” paradigm will require us to use new technologies to reach more people in varying socio-economic groups, providing affordable dentistry. We must invent and develop ways to deliver these exciting technologies to humans around the globe.

Dentistry that incorporates a global vision should not only be affordable to patients, it also should provide dentists with a healthy income. Indirect procedures may require expensive laboratory fees or equipment such as a CEREC-type machines. For example, the owner of a CEREC may be required to generate a specific amount of restorations to pay for his or her equipment. In the specific case where the indirect is constructed by the laboratory, there is always a need to arrange a second appointment complete with a second injection, provisional removal, etc. We must consider other alternatives to be fair to ourselves and our patients! Adhesive systems and composite resins have continued to improve over the years. Studies have shown that these resins can wear as well as or close to natural enamel. These improvements can save us a great deal of time, but we must learn to appropriately prepare the substrate (dentin and enamel). This requires paying attention to all the potential contaminants, the use of quality, non-compromising adhesives (which seldom take longer to apply than compromising “quick” adhesives) and using care to place a quality, esthetic composite. Adhesive composite reconstructions often rival and in some cases exceed indirect restorations. The larger restorations are different than what we would typically call a “filling.” I feel the term “adhesive composite reconstruction” (ACR) is a much more accurate description. The clinician is providing much more of a service than just “filling a hole.”

One may argue that a large, ACR can take a substantial amount of time when done correctly. I would say that an emphasis on keeping it practical can enable us to facilitate quality and esthetic care that is affordable and can be achieved in less time. I also would suggest taking a closer look at the economic logic behind practicality. With a little practice, a dentist can reconstruct one to two proximal surfaces and one to two cusps in about 30-45 minutes. This estimate includes time for placement of one to two dentin shades and an enamel shade. If using only one shade, we need to reconstruct in layers. Using two to three different shades doesn’t take any longer. This type of restoration may cost the patient $200 to $350 dollars compared to an indirect restoration which could range between $600 to $850 dollars. In making a comparison, there are other costs that need to be considered such as the time required to make an impression, fabricate a provisional, cement the provisional, clean up the excess cement, etc. In the case of the laboratory procedure, the patient will need to be rescheduled for another appointment adding to the patient’s inconvenience. The second appointment will add to the overall cost by requiring a second injection, removal of the provisional, scouring the preparation, cleaning and fitting the prosthesis complete with adjustments, polishing the restoration where it’s been adjusted externally, isolating the tissues and again controlling the bleeding, etc. Occasionally, the lab will have to add to the restoration or repair it prior to cementation. Next, the prosthesis will be cemented and the excess cement will be removed. What is the cost of another operatory setup complete with cleanup, disinfection, etc.? What is the laboratory cost or equivalent CEREC cost? This is why it’s important to calculate net income. At the end of the day, profitability must account for time, materials, overhead, taxes, etc. And, at the end of the day, it is the “net” not “gross” income that is important.

ACRs facilitate another modern requirement in gorgeous ways, namely repairability. Repairability brings a rich new ethical meaning to dentistry. It should be our first choice in terms of options. Why? Repairability is a very important contributor to the “minimally invasive” need. We’ve lived and practiced “total replacement dentistry” for too long. Our tendency has been to replace an entire restoration every time we encounter a problem. This contributes to the cumulative trauma of a tooth. With resins, we have the ability to preserve the entire “old” composite that is still bonded to old dentin and/or enamel. New technologies and repairability together provide economic and caring “patient-centered” directions for operative dentistry. For a small repair, it is rare that anesthesia will be required. The procedure will typically only last a few minutes. As a result, repairability often enables us to provide treatments at a lower cost to more patients, providing us with the ability to reach lower income groups and maintain profitability. The gorgeous part is that this type of dentistry is often what we’d prefer for ourselves, our families and our friends even if they could afford the high ticket solutions! As dentists, we are driven to protect our own enamel and dentin. We understand that the more we cut a tooth, the more we weaken the tooth and cause its eventual loss in vitality. What could possibly be better than being able to provide a consistent message to all patients, regardless of economical status with the same level of esthetics? For the long-lasting success in a capitalist society, there are two critical foundations. First, we must be darn honest with a single clear and consistent message; and second, we must listen to the needs of those we serve. These two requirements set the stage for a third very important foundation: establishing quality caring relationships with our patient/customers.

It is important to realize that “permanent” is a falsehood in dentistry! We’ve called “definitive” restorations “permanent” for years, but in reality everything is temporary. In dentistry as in life, we’re simply buying time. With every age group, particularly with our aging population, adhesive repairability enables us to “keep the tread on the tires” in caring ways to “restore the sidewalls” with minimal invasive care. It also enables our patients to remain dentate when the alternative would be the complete loss of dentition and replacement with dentures. Repairability is a virtual mandate for our aging patients who are fragile in their overall health. More invasive procedures have the potential to cause more harm in the systemic sense.

DT: How has technology influenced your practice?

Dr. Fischer: The type of dentistry I practice today is substantially different than the type of dentistry I practiced as a young dentist in the 1970s. For example, when placing gold foils, I would spend multiple hours on every restoration meticulously working through each step using anywhere from 20 to 30 different instruments per restoration. In my early days, my goal was to practice as much full-mouth reconstruction as possible. The ability to prepare 28 teeth in a day and cement 28 crowns in one to two weeks was the pinnacle of dentistry for me! Moving back to Salt Lake City, Utah caused quite a stir because my patient base changed to include large families, which presented special requirements. I also discovered that there weren’t a lot of people who could afford full-mouth reconstruction. It wasn’t uncommon to place multiple quadrants of amalgam on a daily basis with a virtual “copalite amalgam, copalite amalgam”-type production line. I often felt like an assembly line worker!

Technology allowed me to find innovative ways to make old practices more efficient. More specifically, I found that I could treat multiple quadrants at the same time with direct-syringe delivery. While it was still important to address quadrants at the same time, the opportunity to practice tooth preservation and esthetic development caused me to finish my day with a sense of pride. This discovery changed the way I practiced dentistry by leaps and bounds. It definitely prompted my effort in researching and developing new ways to provide convenient delivery systems.

In the early ‘90s, tooth bleaching became an integral part of my practice and obviously and important product family for Ultradent. The invention of comfortable bleaching trays held in place by a sticky, viscous, long-lasting bleaching gel (Opalescence®) made bleaching comfortable and affordable to the masses. This invention has become the “golden standard” today. In addition to raising esthetic awareness, the invention enabled dentists alike to change people’s lives with an affordable treatment. The desire to have whiter teeth brought patients into the office who otherwise wouldn’t have scheduled an appointment. Having them in the dental chair enabled us to reach out, educate and treat patients for other oral health issues. It was definitely a win-win situation.

DT: Ultradent pioneered another segment in the industry being one of the first companies to manufacture syringe-packaged materials. Can you tell us more about this?

Dr. Fischer: The first area of significant research for me was related to the subject of controlling bleeding and tissue displacement, or what is called “tissue management.” This research was driven by my love for full-mouth reconstruction. For every type of restoration, the most critical issue is the gingival margin. Poor tissue management, especially when making impressions, is the major reason for inadequate impressions. This has a direct translation to other issues, such as poor fitting crowns.

Discovering the ability of ferric ion, first in Astringedent and now in ViscoStat®, used with the Dento-Infusor® to predictably obtain profound hemostasis dramatically changed the way I practice dentistry. Using these tools, I was able to save a significant amount of time with each procedure and the quality of my impressions was virtually without fault. At the same time, I embraced adhesive dentistry and discovered that having quality control of not only bleeding but also sulcular fluid was paramount. Because sulcular fluid is clear, we often ignore it because it isn’t as readily seen as blood. No adhesive procedure performed near the gingiva or subgingival should be performed without controlling sulcular fluid. Ultradent’s hemostatic agents combined with cord and/or the Dento-Infusor became part of my routine for controlling sulcular fluid. Ultradent is often referred to as the “syringe company.” It’s really hard to beat the convenience of a syringe with specialty applicator tips for quickly and dependably placing the right material in just the right spot and in just the right quantity. We also benefit from “syringe hydraulics,” which enables us to deliver against pressure when needed. With the speed at which we’re required to work today, it’s great that we don’t have to open containers on our trays and counters that are prone to spilling. Instead of going back and forth between the dappen dish and the preparation, we can stay in the oral cavity with a syringe-tip delivery. I found that using syringe delivery saved me a great deal of time.

As the demand for syringe-delivered products grew, Ultradent developed an in-house injection molding facility. Over the years, this has allowed us to produce a variety of plastic materials and devices. These materials range from syringe tips to all-purpose stacking containers and medical kit covers. We even produce materials and devices for other companies.

DT: We’ve heard a great deal about the non-profit organization sponsored by Ultradent called Smiles for Diversity. Can you tell us more about this program?

Dr. Fischer: At Ultradent, we strive to improve the quality of life and health of individuals in our community. We contribute financially through charitable programs and by donating dental products to humanitarian efforts on an international level. Smiles for Diversity is a progressive outreach program committed to countering challenging problems such as intolerance and hate crimes. The program promotes diversity and fosters multi-cultural awareness. Most recently, we’ve been actively involved in helping young men and women who’ve been expelled from a cult-like polygamous community along the Arizona/Utah border.

Conclusion

More than just a syringe company, Ultradent is guided by a leader with a vision for minimally invasive dentistry and patient centered treatment. The company continues to innovate with new products, and if you should ever be in Utah, call ahead for a visit. “At Ultradent, we’re excited about the future of our company and our ability to make a difference,” says Dr. Fischer, “Thank you for taking the time to get to know us better. If you’re ever near our facility, please stop by. If you come around lunchtime, lunch is on us!”