AGD Impact July 2024

Chronicling the Paths of Internationally Educated Dentists

By Carrie Pallardy

Dentists from around the world have come to practice in the United States. That journey, different for each person, is a long and complicated one. While the logistics alone are daunting, these dentists must also contend with leaving their home countries and establishing new lives. Five internationally trained dentists shared their stories with AGD Impact

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Doing It Right the First Time: A Look at Implant Surgical Guides

By Michal Christine Escobar

The use of implant surgical guides in dentistry is a crucial topic that impacts the precision and efficiency of implant procedures. When made and used correctly, these guides can offer remarkable accuracy in determining optimal positions and angles for implant placement.

Self-Instruction article, 1 CE credit

Spotlight on 2024 FAGD, MAGD and LLSR Recipients

Each year during AGD’s scientific session, the organization hosts the prestigious Convocation Ceremony for the year’s Fellowship, Mastership, and Lifelong Learning and Service Recognition recipients. These awards highlight the dedication to the craft of general dentistry that recipients demonstrate. AGD Impact spoke to several of this year’s recipients.

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Beat the Burnout Blues

Isolation in our profession may not be as commonplace as it once was. Group practices and partnerships allow us an opportunity to communicate and discuss daily tribulations. However, it is still possible to feel secluded when not constantly embracing change and advancement. I think that is why I enjoyed teaching early in my career. Sharing experiences seems important, and it elevated my persona.

However, it’s still possible to feel isolated in private practice. If that happens, it is easy to stagnate, not advancing in treatment knowledge or embracing new technology. Time may seem to pass us by, and we may give in to all the daily pressures we face — running a business, dealing with difficult patients, facing a cavalcade of increased costs due to inflationary trends beyond our control — and we may rest on our laurels. Dentistry is going through some exponential growth and change, and staying on the edge is both academically and financially taxing. Eventually, this may lead to reduced revenue, unachievable patient expectations and staffing challenges. It may sometimes seem easier to walk away from our chosen profession.

time, especially if feeling overwhelmed by advancements in dentistry led to burnout in the first place. Being able to offer something novel to patients not only shakes up the routine and gets us excited about something new, it is also a new potential revenue stream. Ideally, there should be a desire to rise above the burnout and elevate oneself to new heights. You also shouldn’t be afraid to reach out to others for support — both in the form of connecting with peers and seeking professional help.

Becoming involved in our AGD is a great way to help resolve burnout. AGD can not only help you learn a new skill through the various courses it offers, but it can connect you with dentists in your area. We are all general dentists who have similar goals and tribulations, and being able to speak to each other honestly will help each of us rise up.

Editor

Timothy F. Kosinski, DDS, MAGD

Associate Editor

Bruce L. Cassis, DDS, MAGD

Director, Communications

Kristin S. Gover, CAE

Executive Editor

Tiffany Nicole Slade, MFA

Managing Editor Leland Humbertson, MA

Associate Editor Caitlin Davis

Manager, Production/Design Tim Henney

Graphic Designers

Robert Ajami Eric Grawe

Burnout is described as emotional, mental and sometimes physical exhaustion brought on by longstanding stressful situations. Whether it is stress caused by the business side of dentistry, difficult patients or staff issues, the root cause of all burnout is stress. And, at a basic level, overcoming burnout happens by reducing stress.

We can reduce stress in many ways. Taking a vacation or indulging in a hobby are a couple of ideas that come to mind. Eating right and exercising regularly also go a long way. As dentists, we also have the unique ability to add something new to our armamentaria. I’ve talked to several dentists who’ve said that learning a new skill or treatment has revitalized their passion for dentistry. Focus on one thing at a

Never forget that advancement is hard but worth the effort. Moving on — or, better yet, upward — is achieved by leaning on others. Friends, family, professional mentors and educators are sources for overcoming burnout. Take the knowledge being shared, and appreciate what the profession provides and what others can give to help build a personal legacy. Most importantly, manage your health and emotional well-being. Job burnout can impair judgment, so focus on enriching aspects of life and release worries about things you can’t control. By doing so, you’ll improve your overall well-being and decisionmaking abilities. Be well.

Timothy F. Kosinski, DDS, MAGD Editor

Academy of General Dentistry 560 W. Lake St., Sixth Floor Chicago, IL 60661-6600 agd.org impact@agd.org 888.243.3368 312.335.3427 (fax)

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Inside General Dentistry

Look for the following article in the July/August 2024 issue of AGD’s peer-reviewed journal, General Dentistry. Giving the pulp another chance: a case report of vital pulp therapy retreatment

This article in the July/August issue of General Dentistry offers an important reminder that the regenerative potential of the dental pulp should be harnessed whenever possible to preserve tooth vitality. Preservation of the pulp may be still feasible after failed vital pulp therapy if the tooth is given a second chance to survive via the further removal of infection and inflammation, placement of a bioactive pulp dressing material on the remaining healthy pulp, and establishment of an effective coronal seal to foster successful healing. A 10-year-old boy underwent partial pulpotomy in a mandibular first molar with a diagnosis of reversible pulpitis. When the restoration dislodged after 19 months and there were no radiographically detectable lesions, a stainless steel crown was placed on the tooth. However, 15 months after crown placement, the molar developed sensitivity and was diagnosed with irreversible pulpitis and asymptomatic apical periodontitis. Nevertheless, the tooth responded positively to cold testing, and the pulp appeared clinically vital upon direct inspection. The tooth was re-treated with coronal pulpotomy, including the use of mineral trioxide aggregate as a dressing material, and examination 21 months posttreatment revealed successful resolution of the periapical lesion.

Advocacy

Interstate Compact on Dentists and Dental Hygienists Becomes Active

The Interstate Compact on Dentists and Dental Hygienists recently reached the threshold to become active. This compact is an agreement among multiple states to support the mobility of licensed dentists and dental hygienists by recognizing the licenses of other compact states. Partners in the compact include the Council of State Governments, the Department of Defense, the American Dental Association and the American Dental Hygienists’ Association. The dental compact will allow dentists and hygienists licensed in a compact state to easily obtain a privilege to practice in another compact state by paying a fee, getting a background check and taking any required tests of the state’s dental code. As of the end of May, the compact has passed in Iowa, Washington, Tennessee, Wisconsin, Virginia, Kansas, Maine, Minnesota and Colorado. As other states

join, the options to practice in multiple states will increase. It is expected that the first compact privileges will be awarded by the end of summer 2025 after the compact commission is organized and enacts the rules that will govern the compact.

Advocacy

Alabama General Dentist Testifies Before U.S. Senate Committee

AGD member and Alabama general dentist Gordon R. Isbell III, DMD, MAGD, testified before the U.S. Senate Committee on Health, Education, Labor and Pensions on May 16 and discussed access to and issues facing the delivery of oral healthcare in the United States. Isbell’s testimony came before AGD hosted members from across the country on Capitol Hill during its annual Hill Day, May 20–21.

During his testimony, Isbell addressed the need to ensure access to dental healthcare and strengthen the private practice of dentistry. His testimony highlighted the connection between oral and systemic health. He explained that AGD is prepared to collaborate on ways to bring awareness to the many challenges facing dentistry, dental patients and oral health overall.

Students

2024 AGD Senior Student Dental Award Recipients

AGD is proud to present the 2024 Senior Student Dental Award (SSDA) winners. These senior students throughout the United States, Canada and Puerto Rico have been recognized by their faculties for maintaining an academic scholastic balance between clinical and didactic courses of study and exhibit the potential to become outstanding general dentists. Recipients are awarded a complimentary one-year AGD membership and a certificate presented by their dental school’s dean. View the full list of this year’s SSDA winners at agd.org/SSDA

Dental Implant Marketing Is Different, and Here’s How to Do It Right

By Jackie Ulasewich Cullen

The market for dental implants keeps growing as more patients learn about them. Dental practices, wanting to meet the increasing need, are recognizing the need to market implants more aggressively. So why are so many dental practices struggling to book dental implant cases on a regular basis? The short answer is: It’s their approach.

Dental Implant Cases Are Unique — Treat Them Differently

Committing to dental implants is a life-changing decision in many ways, including financially, and the types of patients most dentists are looking to attract are not making the choice on a whim. Before investing tens of thousands of dollars in their oral health, they do their research and shop around. They carefully consider which dentist will be the right fit for them and may take months, a year or longer to finally commit to treatment. This is certainly not the case with other popular treatments like Invisalign®, teeth whitening or crowns.

You must approach marketing differently to attract qualified dental implant patients. The fatal mistake dental practices make is using the same tactics they do for everything else. This will not work because, as we have already established, dental implant patients are not like patients seeking other treatments. Their buying process is longer, so they must be cultivated.

What Does It Mean to Cultivate a Lead?

Cultivating means staying with a lead from beginning to end, doing everything you can not to let them fall through the cracks or go elsewhere. But it is a little deeper than that. Successful dental implant marketing is not about simply finding people with missing teeth. It’s about attracting people who are good candidates and who also have the means to finance the procedure, then converting them into paying patients. This means a dental practice must have a specific process in place to correctly handle the leads that come in.

The Mechanics of Sales

Having a new patient experience process or, as most businesses call it, a sales process, may seem obvious, but, in my experience as a marketing professional, most practices do not have even the minimum sales process established for any of their services, let alone one sophisticated enough to convert implant leads. When a practice does have an established sales process, usually the people involved incorrectly believe that the process begins when the patient calls the office and ends when they hang up the phone. This approach may be sufficient for scheduling a cleaning and exam, but it will not work for dental implants.

A sales process that aims to cultivate begins long before the potential patient makes contact and doesn’t end until they have

“Following up will always lead to more accepted treatment plans than hoping patients will call back.”

committed to a treatment plan. It involves digital marketing strategies using multiple channels to attract the right type of person who is looking for and needs dental implants or maybe does not realize dental implants are an option for their particular situation. Part of cultivating is ensuring that everything a potential patient sees with the practice’s name or logo sends a consistent message. This should include the practice’s main website and any ads, landing pages, social media or blog posts, emails and online reviews.

Don’t Leave Them Hanging

Once the patient decides to make contact, whether online or by phone, anyone responsible for handling leads needs to be well trained in the proper process. That means, first and foremost, responding promptly. Voicemails and online inquiries cannot be left to languish. Every person who has taken the time to make contact deserves a quick response if they cannot reach a live person on the first attempt. Having an automated system in place to respond to inquiries is the best possible solution. If that is not feasible, the practice must designate daily time to respond to leads.

Everyone Should Be in on It

The next step in cultivating a lead is understanding how to respond. This is where training comes in. Any team member who has contact with patients should be trained on how to build rapport with an implant patient and answer their questions in a way that will encourage them to schedule an appointment. All patient-facing team members are vital to this process, especially if they answer the phone or follow up with online appointment request forms. Without the proper training, perfectly qualified dental implant candidates will be lost to other practices.

It Never Ends

The sales process does not stop after the initial conversation, even if the patient books a consultation. If a patient fails to schedule right away, it doesn’t mean they’re a lost cause. They may just be in the information-gathering phase of their process. What you do next is crucial. You can either trust that they will call back at some point and schedule, or you can follow up with them until there is a definitive answer. Choosing the latter is the better strategy, not just because people get busy and tend to put non-urgent matters off, but also because making the effort to stay in touch shows that you value their business. If the patient does schedule right away and follows through with the consultation, but does not commit to treatment at that time, the same holds true. You can either hope they’ll return, or you can stay in front of them by following up.

Following up will always lead to more accepted treatment plans than hoping patients will call back.

Benefits, Benefits, Benefits

Implant patients may do a lot of research, but they are not always well informed about the benefits of dental implants. Any marketing intended to attract dental implant cases will be far more successful if it focuses on how implants improve quality of life and not the technicalities. Dentists love to expound on all the advanced technology, and it’s all very cool, but what does that do for the patient? Most of the time, it will scare them off. In a lot of cases, people needing implants are suffering in some way and seeking relief from their pain. They want to know that investing in their oral health will give them a better life. They want to feel validated in wanting that better life. Dental implant marketing that touches on those aspects will resonate with patients in pain and prompt them to act. As more patients learn about dental implants and more dentists start to market them, the competition will intensify. The dental practices that take the time and effort to differentiate their marketing, implement a solid sales process, and cultivate the leads that come in will have a leg up on the rest. ♦

Jackie Ulasewich Cullen is co-founder of My Dental Agency, a marketing company specializing in dental practice. To comment on this article, email impact@agd.org

Strategies to Help Introverted Dentists Find Success

By Gerard Scannell, DDS

Many aspects of dentistry may come easily, such as attention to detail and manual dexterity. However, the social aspects of the job can present unique challenges for many of us who are introverts. While dentistry requires interpersonal interactions and communication skills, introverted dentists can often find themselves struggling with the constant necessity of social engagement. Being introverted doesn’t inhibit success in this field, though. Rather, it demands finding a balance that allows us to thrive professionally while honoring our natural inclinations.

What typically differentiates introverts and extroverts is when and how they get their mental and emotional energy. Extroverts tend to gain energy from being around others and engaging in social interactions. They often feel recharged and invigorated after spending time with people. A common misconception about introverts is that they are antisocial, which is not the case. Introverts can enjoy and thrive in social situations, but they can also find that it drains their emotional batteries. Unlike extroverts, they gain energy from solitude and introspection. It’s important to note that these are general tendencies, and individuals may exhibit a mix of extroverted and introverted traits. Additionally, personality traits can vary in different situations and contexts.

I consider myself an introvert and have taken personality tests to confirm it. I have wanted to be a dentist since I was in middle school and shadowed in offices for countless hours prior to starting dental school. However, I never realized how draining some days practicing can be for an introvert due to the constant interaction with patients and staff. I can be animated and energetic in all my interactions, but I often need some quiet time to reset.

One advantage introverted dentists may have is the opportunity for focused, solitary work. Much of dentistry involves tasks that can be completed independently, such as conducting examinations, analyzing radiographs and performing procedures. For introverts who recharge through solitude, these moments of concentration can be a source of fulfillment and satisfaction.

While introverts may not thrive in large social gatherings, they often excel in one-on-one interactions. In dentistry, the relationship between dentist and patient is paramount. Introverted dentists can leverage their abilities to listen attentively, empathize with patients’ concerns and establish trust over time. By focusing on the quality of these individual connections, introverted dentists can create a welcoming and supportive environment within their practice. Although large social gatherings can be daunting for introverts, it is sometimes necessary, especially for continuing education classes or dental conferences. Introverted dentists can approach these occasions strategically, setting specific goals for interactions and focusing on quality connections rather than quantity.

Effective communication is key in dentistry, whether explaining treatment options to patients or collaborating with colleagues. Introverted dentists may benefit from employing strategies that play to their strengths. This could involve preparing scripts or outlines for common discussions, which allow for smoother interactions. Additionally, incorporating active listening techniques can demonstrate genuine interest and empathy, fostering stronger connections with patients and colleagues alike.

Introverted dentists can also enhance their practice by cultivating a calming atmosphere that reflects their personality. This might include designing a soothing office space, incorporating soft lighting or playing relaxing music. By prioritizing patient comfort and relaxation, introverted dentists can alleviate anxiety and enhance the overall experience for those under their care.

Maintaining a healthy work-life balance is crucial for introverted dentists to prevent burnout and preserve their well-being. Setting boundaries, scheduling downtime to recharge, and engaging in activities that align with their interests and values can help introverts replenish their energy reserves outside of work. My wife is also a dentist and a fellow introvert. When we both have busy and exhausting days at work, we each understand our need to have a low-key and relatively quiet evening at home.

My wife often tells me about the system that she implemented in her office to help keep her social battery from draining too quickly. Like all of us, she has patients who are genuine joys to have in the office — those who make you smile when you see their name on the schedule and who can give energy back to you. On the other hand, she has a handful of patients who are draining emotionally and mentally. She has a system of designating the latter set of patients as her “peaches.” She has her front office trained to only put a maximum of two peaches on her schedule a day. She has found this system helps keep her social battery (and her sanity) intact by the end of the day. Though she also says, “As I get older, I’ve also become better at fielding the possible peaches before they join the practice. It’s important to protect your peace, especially in your office where you spend most of the day.”

While the dental profession inherently involves social interaction, introverted dentists possess unique strengths that contribute to their success. By embracing solo tasks, nurturing meaningful connections with patients and employing effective communication strategies, introverted dentists can excel in their careers while remaining true to themselves. By prioritizing self-care and finding balance, introverted dentists can navigate the world of dentistry with confidence and fulfillment. ♦

Gerard Scannell, DDS, is a general dentist practicing in his hometown of St. Petersburg, Florida. To comment on this article, email impact@agd.org

Ensuring Dental Team Compliance: A Guide to Infection Control Protocols

By Amrita Feiock, DDS, FPFA, FICD, FACD

Infection control is paramount in dental practices to safeguard the health and well-being of both patients and staff. With the potential transmission of pathogens such as bacteria and viruses — including the still-present COVID-19 — maintaining rigorous infection control protocols is non-negotiable. However, effectively implementing these protocols requires more than just establishing rules; it involves getting the entire team on board and fully familiarized with the protocols.

As always, education is the most important part of any new system that you introduce to your office. Educate your team members about the importance of infection control and the potential consequences of noncompliance. Conduct comprehensive training sessions covering various aspects of infection control, including hand hygiene, personal protective equipment (PPE) usage, sterilization techniques and environmental disinfection. Make sure the training is interactive and includes practical demonstrations to enhance understanding. Many companies offer both in-office and virtual training to support your efforts.

Communication is key to ensuring everyone understands their roles and responsibilities regarding infection control. Clearly articulate the protocols, guidelines and expectations to the entire team. Encourage open dialogue, and address any concerns or questions they may have. Regularly communicate updates or changes to protocols, and provide opportunities for feedback to foster a culture of continuous improvement. Make sure that all protocols are labeled and posted in a place where they are accessible to all team members. As a leader, demonstrate a commitment to infection control by adhering to protocols yourself. Your actions speak louder than words, so consistently follow hygiene practices, wear appropriate PPE and prioritize cleanliness in the workplace. Equip your team members with the resources they need to implement infection control protocols effectively. This includes supplying adequate PPE, such as masks, gloves, face shields and gowns, as well as ensuring access to hand hygiene stations and disinfectants. Invest in high-quality sterilization equipment, and regularly maintain and calibrate them to ensure efficacy. Assign a team member to monitor the amount of PPE that you have. Some companies allow you to place automatic orders so you don’t have to worry about running out prematurely. This is especially helpful if your practice has multiple locations and providers.

Infection control protocols are constantly changing, and so are continuing education requirements. It’s important to stay

abreast of the latest developments in infection control practices and regulations by providing ongoing education and training opportunities for your team members. Encourage participation in relevant workshops, webinars or conferences, and consider sponsoring certification programs in infection control for interested team members. Investing in continual learning not only enhances knowledge and skills but also demonstrates a commitment to excellence in patient care. Encourage an empathetic and patient-centered approach to infection control when you reinforce the importance of meticulous adherence to protocols. Remember, these protocols are not just about compliance with regulations; they are primarily aimed at ensuring patient safety.

Acknowledge and celebrate adherence to your protocols by recognizing individuals or teams that demonstrate exemplary compliance. This could include verbal praise, certificates of recognition or other tangible rewards. We enacted an “Employee of the Month” program and celebrated team members in our offices and on social media. By highlighting and reinforcing positive behavior, you reinforce the importance of infection control and motivate others to follow suit.

Finally, recognize that infection control protocols may need to evolve in response to emerging threats or changing circumstances. Stay flexible and adaptive in your approach, and be willing to adjust protocols as needed based on new evidence or guidelines. Solicit input from the team when making changes, and ensure that everyone is adequately trained on any updates. By fostering a culture of compliance and continuous improvement, you can create a safer and more hygienic environment for both your team and your patients. ♦

Amrita Feiock, DDS, FPFA, FICD, FACD, is in private practice with her father, endodontist Rohit Z. Patel, DDS, PC, in Westchester County, New York. To comment on this article, email impact@agd.org

Chronicling the Paths of Internationally Educated Dentists

By Carrie Pallardy

Dentists from all over the world have come to practice in the United States. That journey, different for each person, is a long and complicated one. They must navigate the logistics of immigration and then throw themselves into the fierce competition for limited slots in dental school programs. While the logistics alone are daunting, internationally educated dentists must also contend with leaving their home countries and establishing their lives in the United States.

Five internationally trained dentists shared their stories with AGD Impact.

Coming to the United States

Different people have different motivations for immigrating to the United States. Sireesha Penumetcha, DDS, MAGD, graduated from M.R. Ambedkar Dental College in Bangalore, India. She had ambitions to become a doctor from a very young age, inspired by her uncle and grandfather. Penumetcha never planned to study or work abroad, but a family work opportunity changed her course when her husband was offered an engineering position in the United States. Penumetcha finished her internship and moved to the United States a year later on an H-4 visa (a visa granted to spouses or dependents).

Mohamed Attia, DDS, MAGD, also set his sights on becoming a doctor when he was a child. As he grew up, he found his passion in dentistry. Attia trained to become a dentist at Alexandria University in Egypt. He earned his dental degree, and then he went through residency programs.

“At that time in Egypt, dentistry was mainly about if you have so much pain and your face is swollen, then you go to the dentist,” he shared. Attia wanted to practice general dentistry, preventive dentistry and cosmetic dentistry, which helped inform his decision to come to the United States in 2004.

That same year — just one year after the United States–led invasion of Iraq — Muhalab Al Sammarraie, DDS, began his dental training at the University of Baghdad College of Dentistry. He graduated in 2009, followed by a rotation and residency program. Al Sammarraie practiced in Iraq for two years.

“Everything flipped upside down after 2003 in Iraq. It became very dangerous. The future was unknown for most people in my generation,” he said.

While training to become a dentist, Al Sammarraie also worked as a human resources manager with the U.S. Agency for International Development. This work gave him the opportunity to apply for a special immigration visa. He arrived in the United States in 2013.

Manasvi Patel, BDS, graduated from dental school in Mangalore, India, in 2019. In 2012, she visited extended family in the United States, an experience that, in part, helped her decide to immigrate. However, Patel’s move was complicated by the timing. She came to the United States in 2021, in the thick of the COVID-19 pandemic.

Sireesha Penumetcha, DDS, MAGD

Mohamed Attia, DDS, MAGD

Manasvi Patel, BDS

Muhalab Al Sammarraie, DDS

The logistics of coming to the United States to train in dentistry are complicated. Internationally trained dentists must secure a visa. Nonimmigrant visas allow temporary stays, while an immigrant visa lays the groundwork for permanent residence.1

An H-1B visa, for example, is a nonimmigrant visa that allows people to work in a specialty occupation. 2

Dentists coming to train in the United States may be able to obtain a student visa, such as an F-1 visa. Optional Practical Training allows F-1 students to work in their area of study. 3

Securing the paperwork and making the physical journey are just the beginning of the long road ahead.

Applying for Programs

Dentists who have been educated in another country but want to practice in the United States can’t just make the move and start seeing patients. Each state has different laws, but there are a few common requirements that internationally educated dentists must

meet to practice in the United States.4 They need to have a degree from a dental program accredited by the Commission on Dental Accreditation (CODA). They need to pass the Integrated National Board Dental Examination, and they must pass a clinical assessment. Dentists who have a degree from a program that isn’t CODAaccredited need to apply for an advanced standing dental education program. Internationally trained dentists can gain their DMD or DDS through one of these programs within two to three years.5

The American Dental Education Association Centralized Application for Advanced Placement for International Dentists (ADEA CAAPID) can help internationally educated dentists find programs. The Boston University Henry M. Goldman School of Dental Medicine’s (GSDM’s) advanced standing program is the largest in the United States, accepting 100 students per class.6

The application criteria for advanced standing programs can differ. Some programs only accept U.S. citizens or permanent residents, another potential hurdle for internationally trained dentists.

My Path to Practicing Dentistry in this Incredible Country

By Hans Sperling, DMD, FAGD, FICOI

Igraduated from dental school at Pontificia Universidad Javeriana in Bogotá, Colombia, in 1992. In 1993, after completing the Colombian mandatory one-year clinical practice at a government-sanctioned nonprofit, I enrolled at the University of Texas (UT) Health Science Center at San Antonio in its six-month preceptorship program in oral and maxillofacial radiology.

UT issued me a J-1 visa, which meant, after the program, I was required to go back to live in Colombia for at least two years.

I returned to Bogotá and started my private dental practice in 1994. In 1995, I returned to the United States as a visitor to take the national board exams, then returned to Bogotá afterward. I did the same process for the second part of the national boards. After passing both exams in 1996, I applied to international dental programs at Tufts University, Boston University, University of Pennsylvania, Case Western Reserve University and Loma Linda University. I was invited to interview at each program and had to make multiple trips from Colombia to attend them.

I was accepted to all of the programs I applied to except Loma Linda. I chose Tufts because they offered me a regular student visa, which allowed me a path for a green card. In my opinion, Tufts had the most organized international standing program. The program was supposed to be two years and three months, but I was able to complete all my requirements in 18 months. They allowed me to graduate with the regular class of 1999. (I still had to pay full tuition, of course.)

After graduating from Tufts in May 1999, I took the Florida boards and moved to South Florida, where I began working as an associate at a dental support organization. My employer sponsored me for my working visa. Eight years later, I was able to move on and open my own practice in Hollywood, Florida, where I have been for the last 17 years.

A Challenging Path to Citizenship

When I moved to the United States in 1997, I was married and had an 18-monthold daughter. I had a student visa and my

wife had a nonworking visa, so we had no income. I was not a U.S. citizen, which meant that we only qualified for private loans with high interest. A very good friend of mine — a U.S. citizen — was incredibly kind and cosigned for my student loans.

At that time, most of my classmates chose to work part time as dental assistants or hygienists while in school to supplement their incomes. I did not do that because I knew that if I doubled down and applied myself, I could complete my educational requirements early and be able to start working as a dentist much sooner.

This was the right choice for me because, after graduating in 1999, I was

Advanced standing programs also typically require applicants to take the Test of English as a Foreign Language (TOEFL).

GSDM, for example, requires a minimum score of 90 on this test for an applicant to be interviewed, according to Janet Peters, DMD, clinical professor of general dentistry and faculty liaison to the GSDM DMD Advanced Standing program.

Some programs require internationally trained dentists to take a bench test, an evaluation of practical and clinical skills.7

With relatively small program sizes, the competition for the available slots in advanced standing programs is intense. “GSDM received over 2,000 applications for its DMD Advanced Standing program last year,” Peters said. “It’s very competitive.”

Patel passed her national boards and the TOEFL and then began applying for schools. “It took me two years to get in. I actually got accepted to Meharry School of Dentistry in Nashville, Tennessee,” she said, and she ended up enrolling in the program.

While she was applying, Patel worked as a dental assistant to gain an understanding of how dental offices worked in the United States. She worked in a general dental office as well as an oral surgery office. She will be licensed by the end of 2025, and her goal is to work in private practice with oral surgeons.

Gaining that clinical experience in the United States, along with strong GPAs, can make internationally trained dentists attractive candidates for advanced standing programs. “We look at the letters of recommendation. We look at clinical experience in their original country. We definitely look for assisting experi ence in [the United States] because practice is very different here than other countries, and we find that very valuable,” said Peters.

The interview and admissions process and timeline varies depending on the program. The advanced standing program at GSDM has rolling admissions. The program begins interviewing in June, and the first round of acceptances are sent out shortly afterward.

able to move to Florida sooner. I had the support of my family and was able to start working as a dentist and make a lot more money than my classmates.

After graduating from Tufts, I received an F-1 visa. This was a one-year visa given to students at the end of their program so they could get practical experience in the United States in their field. After that year, my employer sponsored me, and I was able to obtain an H-1 visa. This visa allowed me to work legally in the United States for three years with a renewable period of three more years. During this time, I was able to apply for a green card. My visa situation meant that I was committed to my employer — good or bad — until I could get a green card. My wife again had a nonworking visa and, by then, we had two children. The first time I applied for a green card, during my first three-year term with the H-1 visa, the application was denied. The stamp on my rejection letter was dated Sept. 11, 2001.

We changed immigration attorneys and applied again.

The second time around, the application was again denied, and we received a letter stating that the decision was irrevocable and final. Our immigration attorney told us that this must have been

a mistake, and he proposed we sue the immigration department. We proceeded to file a lawsuit, and, as they reviewed our file, our petition for immigration was approved. That was the most stressful time of my life. I had almost no hope of staying legally in the United States and had begun to consider moving to other parts of the world because economic and political instability made Colombia no longer an option for us.

In 2005, eight years after we first applied, we received green cards.

My American Dream

Everyone must make the decision that best suits their life. I know many dentists who moved to the United States first and then found a way to obtain visas, validated their degrees and got dental licenses. I know people who did not attend formal dental school programs and still got their dental licenses. I know people who went into specialty programs and obtained their licenses, but I also know a lot of people who moved to the United States and haven’t been able to validate their dental degrees at all. I knew, based on my personality, that what I needed to do was move to the United States once I had secured a path to legal immigration and be able to

practice dentistry anywhere in the country.

My American dream has come true. Now, I am a proud U.S. citizen. I am happy and grateful that I live and practice dentistry here.

All the hard work and stress trying to get where I am today was well worth it. I have my own dental practice, I work alongside my wife of 31 years, and we have two amazing daughters who have had the opportunity to live and grow up in this incredible country.

“We’re always looking at our strongest applicants,” Peters explained. “The nature of the rolling admissions process means that some applicants may receive offers of acceptance immediately after they interview, and, for others, it may take four weeks or three months.”

Applicants may also be waitlisted; a slot could open if another candidate is delayed due to visa issues or finances.

Getting into a program is a huge step forward, but internationally trained dentists still face additional challenges. “The next hurdle after getting admitted was the cosigner for the student loans. When you are new to the country, how can you find someone to cosign a $300,000 loan?” said Penumetcha. She decided to move from New York to California to train for her boards there.

“My first job was a miracle. I had called just one company, and the president said she would be on vacation the next week, so she interviewed me in New York, where I was living,” Penumetcha shared. “I got the job and literally moved across the country within two weeks.”

“After finishing the bench test, I was able to do the state boards and

The process of applying can be long and frustrating. Al Sammarraie received a rejection letter from an advanced standing program advising him to consider changing careers. He did not leave his chosen profession in his home country even when his personal safety was threatened, and he had no intention of leaving it in the United States. Within a couple months of that rejection, he was accepted by a different program.

Training for Internationally Educated Dentists

Once an internationally educated dentist is accepted to an advanced standing program, they have two to three years of intense study ahead. At GSDM, advanced standing program members spend a lot of time in the simulation learning center.

“They’re doing all the same procedures as the four-year students,” Peters said. “We have a full simulation learning experience before they enter clinic, and then, in their second year, there’s still didactics, rotations and patient care. We prepare them for the boards, the CDCA [Commission on Dental Competency Assessments], the licensing board.”

Internationally trained dentists can also explore the possibility of undergoing their training in a residency program instead of an advanced standing program.

Attia completed a residency in Egypt and then two others when he arrived in the United States. “Every residency program had a different technique and different setting,” he said. “I’m very happy I got that education. It made me who I am today.”

Residency programs allow internationally trained dentists to pursue postgraduate training in a specific area, but this is only an option in a few states. Most states require dentists to have a dental degree from an accredited dental school in the United States.8

As internationally educated dentists pursue their path to licensure, they are likely to discover differences between training in their home countries and in the United States. Al Sammarraie noticed a significant shift between studying and demonstrating knowledge.

“In Iraq, we used to memorize things. When I had a test, they would ask me to, for example, talk about biology or a certain topic. Whatever I memorized, I put it there in writing,” he said. “Whereas, in the United States, it’s more about you understanding the concept.”

As Patel works through her training, the approach to patient management and communication has stood out. “Communication is top-notch over here, and I think that’s something that I’m learning and working on,” she said.

Starting to Practice

Understanding the varying state regulations can be a challenge for internationally trained dentists as they consider where to apply for their training and where they will eventually practice. When Attia arrived in the United States, the process was not very clear. “It took a lot of time to figure out … OK, what do I need to do in order to get my license?” he said.

Today, he practices general and cosmetic dentistry in Alexandria, Virginia. Penumetcha runs her practice in Elk Grove, California. Al Sammarraie also practices in California, and he leverages the skills he built in human resources to train other people in the field.

In addition to the rigorous clinical demands of their training, internationally trained dentists must also learn the business of dentistry in the United States.

Many dentists must learn how to work within the U.S. dental insurance system. “In India, we don’t really have the concept of dental insurance. Pretty much everybody pays out of pocket,” said Patel.

Internationally trained dentists may also need to adapt to the administrative aspects of dentistry in the United States. “A surprise was the amount of time we spent on documentation and forms, which seemed very tedious,” said Penumetcha. “We also never received any training on starting a business, so there were a lot of unknowns we had to learn the hard way.”

Preparing for the Experience

The experience of immigrating to the United States is unique to each person who decides to make the journey. Some people leave their home countries for reasons they never expected, while others are following a lifelong dream. Whatever the motivation, internationally trained dentists are faced with the challenges that come with training and getting licensed in the United States while also adjusting to the life and culture of a new country.

Making that kind of massive change can feel isolating. With their families and friends still in their home countries, many immigrants may feel alone. But there are ways to build support networks.

“Reach out to any foreign-trained dentists who pass through the area,” Attia recommended. Connecting with other internationally trained dentists — both those who are in the same early stages of their U.S. careers and those who have long practiced in the states — can help those new to the United States find peers and mentors who understand what they are experiencing and trying to achieve.

U.S. universities attended by internationally trained dentists may also have resources. GDSM, Peters shares, has an international chaplain, a student affairs team and behavioral health resources. The International Students and Scholars Office helps international students obtain necessary paperwork. Universities also have student groups that bring people with shared experiences and interests together.

Al Sammarraie found a community in San Diego. “I found San Diego, which has a large population of Iraqi people. I will still see people who speak the same language, who share some of the same emotions,” he said.

That community grew as time went on. “The dental community was very helpful. In the beginning, [it] was Iraqi people, then it expanded as much as my time in the country expanded. I got to know people from all different countries,” he continued.

While every internationally trained dentist will have their own experience, there are some common success factors — resilience and work ethic chief among them. Adjusting to life in a new country, competing for programs with limited space, and experiencing rejection and setbacks demand a lot.

“At some point, you will question yourself, so you have to be ready for that,” Al Sammarraie said. That resilience, that willingness to persevere, can be invaluable.

“To be able to live and dream with so many abundant possibilities and resources is worth it, and there is no stopping you if you can uproot and travel across the seas with your dreams and hard work in tow,” said Penumetcha. ♦

Carrie Pallardy is a freelance writer and editor based in Chicago. To comment on this article, email impact@agd.org

References

1. “Student Visa.” Travel.State.Gov, U.S. Department of State, travel.state.gov/content/travel/en/us-visas/ study/student-visa.html. Accessed 1 April 2024.

2. “H-1B Specialty Occupations, DOD Cooperative Research and Development Project Workers, and Fashion Models.” U.S. Citizenship and Immigration Services, U.S. Department of Homeland Security, 25 March 2024, uscis.gov/working-in-the-united-states/h-1b-specialty-occupations.

3. “Optional Practical Training (OPT) for F-1 Students.” U.S. Citizenship and Immigration Services, U.S. Department of Homeland Security, 27 March 2024, uscis.gov/working-in-the-united-states/students-andexchange-visitors/optional-practical-training-opt-for-f-1-students.

4. Licensure for International Dentists, American Dental Association, ada.org/resources/careers/licensure/ licensure-for-the-international-dentists. Accessed 1 April 2024.

5. “Foreign-Educated Dentists.” ADEA: The Voice of Dental Education, American Dental Education Association, adea.org/godental/non-traditional_applicants/foreign-educated_dentists.aspx. Accessed 1 April 2024.

6. “ADEA CAAPID® Programs.” ADEA CAAPID® Program Finder, ADEA, programs.adea.org/CAAPID/programs. Accessed 1 April 2024.

7. Bench Test Prep Course for International Dentists, International Dentist Central, internationaldentistcentral. com/bench-test-prep-course-for-international-dentists/. Accessed 1 April 2024.

8. Dental Residency Programs for Foreign-Trained Dentists, International Dentist Central, internationaldentist central.com/dental-residency-programs-for-foreign-trained-dentists/. Accessed 1 April 2024.

Doing It Right the First Time: A Look at Implant Surgical Guides

By Michal Christine Escobar

The use of implant surgical guides in dentistry is a crucial topic that impacts the precision and efficiency of implant procedures. When made and used correctly, these guides can offer remarkable accuracy in determining optimal positions and angles for implant placement. If a dentist who places implants decides to use a surgical guide, he or she must answer many questions: What type of guide should be used? Should it be made in-house or ordered from a lab? Should freehand implant placement be considered instead of a guide? Overall, understanding the nuances of implant surgical guides is paramount for dentists aiming to deliver precise, efficient and patient-centric implant treatments.

Advantages: Precision, Comfort, Revenue Boost

An implant surgical guide is a custom-made acrylic resin piece designed to fit snugly over adjacent teeth or completely on an edentulous ridge, featuring a precise hole indicating the implant’s intended location.1 These guides offer dentists numerous benefits. For instance, dental implant sites might be difficult to see or access, which could lead to incorrect placement. However, an implant surgical guide allows for “maximum precision and accuracy.”1 Similarly, surgical guides make future restorative complications less likely.2 Surgical guides contribute to more comfortable and faster surgeries, which mean less-invasive procedures and fewer follow-up appointments.1 Surgical guides also offer an additional revenue stream. Using CDT Code D6190, Radiographic/surgical implant index, the average cost to the patient is about $300.2 However, the cost to the dentist is closer to $200 (if made in a lab) or $20 if made in-house.2

Drawbacks: Visibility, Over-Reliance, Fabrication Time

Some drawbacks exist when using implant surgical guides. “Visibility is more difficult, so you need to be very sure they are seated correctly and anchored well,” said Ross Isbell, DMD, MBA, AGD Impact Testing the Tools columnist. “There is also a risk that there is too much trust in the guide and that the user doesn’t do as much to confirm placement and angulation of the drills or implants throughout the process.”

Isbell said appropriate radiography can prevent complications in reconstruction or failure of the implant.

“Guides are only as good as the person who designs them and the preparation and accuracy of the materials provided to the fabricator,” said Timothy F. Kosinski, DDS, MAGD, AGD editor. Understanding the final prosthetic fabrication is also very important. “Depending on the design selected — full-arch implantretained prostheses versus implant-retained overdentures — there needs to be a specific interocclusal space. Not realizing this fact can make fabrication challenging or impossible for the dental lab. Surgical guides have come a long way in helping dentists feel more confident in proper implant placement, but they are not a panacea, and practitioners need to be in control of the process,” he said. When using surgical guides, drilling on a slope or against a hard plate could deflect drills without the dentist realizing it.2 Since successful implant surgery is dependent on the use of cool saline and not overheating the bone, dentists should be highly aware of the fact that guides get in the way of copious irrigation.2

And, of course, surgical guides require fabrication time, notes Eric G. Jackson, DDS, MAGD, FICOI, FASD, FICD, FADI, FPFA. This means gathering records, taking radiographs and creating a design, in addition to the actual production of the guide.

“You can’t create a guide on the fly, so that’s a major reason why not every single case can or should have a surgical guide,” said Jackson.

Surgical Guide Varieties: Supports and Types

Implant surgical guides are essential for surgeons seeking precise guidance on drilling osteotomies and thus preparing the bone for implant placement.1 Utilizing digital impressions or imagery, the guide creates remarkable accuracy in determining the optimal position and angle for the dental implant procedure.1

While the benefits of surgical guides are abundant, a “clear, universally accepted classification” of these guides does not exist.3 However, D. Salem, a dental/oral and maxillofacial prosthodontist with a private practice in Brisbane, Australia, performed an extensive literature review in the Journal of Dentistry and Oral Health and proposed a new classification for surgical guides. The new classification would allow for three types of surgical guides: a free guide, an access guide and a precision guide.3

The “free guide” would be to show where the tooth center point is. The “access guide” would guide the first drill only; whereas the “precision guide” would guide the whole drilling sequence. Once the restoring practitioner decides on the type of guide, then the support during the surgical phase comes next. This will depend on the dentition and required stability and accuracy of the guide. There are four possibilities there, namely: tooth supported, [soft] tissue supported, both tooth and [soft] tissue supported, or [soft] tissue supported with an accessory fixation for edentulous cases. To cover for some of the designs that currently exist, the access and precision guides can have fixed guidance or removable guidance where the guiding mechanism can be removed.3

Until clearer classification systems are universally accepted, it may be simpler for dentists to use the familiar terms: pilot, guided and fully guided.

A pilot guide offers dentists comprehensive guidance for positioning, angle and depth during dental procedures.2 These guides usually feature a 2.0 sleeve size, enabling dentists to insert their pilot drill through the sleeve for precise drilling.2 After ensuring the correct position, angle and depth, the initial drill is made, and then the guide is set aside, allowing the dentist to complete the osteotomy according to their preferred technique.2 According to Kosinski, these guides must sit completely properly without any rocking, and they are especially beneficial when implants need to be parallel or nearly parallel.

“Even though we’re trending toward making everything in-house, it’s important to keep in mind that the quality of those inhouse guides will be very dependent on the practitioner’s experience, which could be very limited.”

— Eric G. Jackson, DDS, MAGD, FICOI, FASD, FICD, FADI, FPFA

Guided implant surgical guides provide precise positioning, angle and depth information. These guides feature larger sleeves, allowing dentists to utilize drills of different widths and achieve complete angulation throughout the entire osteotomy procedure. 2 While these guides are particularly effective for creating parallel bridges and adjacent implants, they do have limitations. For instance, the thicker sleeve width of 7 millimeters may not be suitable for all spaces, and some patients may find it challenging to accommodate drills of varying widths

up to 24 mm in their mouths. 2 Additionally, these guides can be more costly to design and may necessitate a separate guided drill kit. 2

With fully guided drilling, everything is done through the guide, including the implant placement itself.2 These guides “constrain the pilot drill, osteotomy drills, implant placement and depth [… and] often present the least risk of knockout errors or implants shifting during placement due to the redundancy of physical constraints they provide throughout the entire placement procedure.”4 According to Kosinski, proper and complete positioning of these guides should always be evaluated before the patient is excused because a small error in the posterior placement can result in a major error in the anterior.

Stackable guides are a type of fully guided implant surgical guide comprised of several removable layers that can be stacked on top of each other to “provide greater accuracy and precision during implant placement than traditional surgical guides.”5 These guides streamline surgical procedures by eliminating the need for repeated guide adjustments during surgery. This not only reduces surgical time but also mitigates the risk of complications, ultimately improving patient outcomes. Stackable guides are wellsuited for a broad spectrum of implant procedures, encompassing single, multiple and complex cases.5

Each guide also requires some form of support to ensure the accuracy and stability of the surgical guide.2 There are three main types of support: tooth-borne, soft tissue–borne and bone-borne, each serving specific needs in fully guided procedures.2

Tooth-borne support is considered the most predictable, as it utilizes the patient’s own stable hard tissue and at least three to four healthy stable teeth (that are not in the implant site’s way) to support the guide securely.2

Soft tissue–borne support is often used for edentulous patients or those with severely compromised teeth. This support type is beneficial for cases not requiring alveoloplasty.2

Bone-borne support is more complex, involving bone segmentation based on precise cone beam computed tomography (CBCT) renderings of the patient’s jawbone. This support type may require significant flap elevation and is suitable for dentists experienced in larger surgeries. However, it offers an exceptionally close fit for the surgical guide after alveoloplasty, allowing for precise implant placement.2

Essential Equipment for Creating Surgical Guides

To create an implant surgical guide, dentists start by taking a CBCT scan to assess the patient’s oral structure. For initial scans, a full field of view is recommended to detect any potential issues. Next, dentists use an intraoral scanner to generate a digital STL file, which is then imported into specialized software for guide creation. 2 This software overlays the STL file onto a 3D model of the patient’s jaw, improving accuracy for intraoral visualization. Using this model, dentists devise a treatment plan based on anatomical considerations and nerve mapping. 2 Then, a meticulous wax-up is necessary. The wax-up

is crucial for adjacent implants or multitooth spans, ensuring proper spacing and alignment. Dentists also cross-check CBCT data and 2D radiographs to avoid biological conflicts and confirm optimal buccolingual and mesiodistal dimensions. Finally, the guide is designed to fit snugly over the STL model, ready for 3D printing or fabrication by a dental lab. 2

Clinical Choices: Lab vs. In-House Methods

When dentists do decide to create an implant surgical guide, they must decide if they’ll have a dental lab fabricate it or if they’ll make it in-house. Before choosing, they need to consider a few important factors. A lab-created guide will generally take more time to create and will cost much more, especially if the lab is asked to both design and manufacture it, according to Isbell. If the dentist designs the guide, however, the price of manufacturing will be cheaper.

The higher price tag for lab-created guides also means the guide will be created by experienced technicians, Jackson says. For dentists who design their own guides, the technicians may even offer some advice on how to improve specific designs and tips on how to create better designs in the future.

“I’m a big proponent of dental labs,” Jackson said. “Even though we’re trending toward making everything in-house, it’s important to keep in mind that the quality of those in-house guides will be very dependent on the practitioner’s experience, which could be very limited.”

Kosinski noted that, before choosing to make surgical guides in-house, dentists should keep in mind that “training and experience are needed to fabricate proper surgical guides. As with any dental procedure, practice makes perfect, but any discrepancies in fabrication could be disastrous. Therefore, it is critical that the dentist both feels confident and is competent in design and fabrication. There can be no errors in fabrication.”

Dentists who are willing to create guides in-office — and make the investment either in a 3D printer and the resin the printer requires or in software and mills — will find that the price per

“As

with any dental procedure, practice makes perfect, but any discrepancies in fabrication could be disastrous. Therefore, it is critical that the dentist both feels confident and is competent in design and fabrication. There can be no errors in fabrication.”

— Timothy F. Kosinski, DDS, MAGD

guide will be significantly cheaper compared with a lab-created one, and fabrication time will be much faster as well, Kosinski says. However, before making the investment, Kosinski cautions dentists to first evaluate how many guided surgical procedures they perform on a regular basis to determine if there will be a true return on investment.

Embracing Flexibility: The Benefits of Freehand Implants

While implant surgical guides are highly valuable tools for the dental community, freehand placement of dental implants remains a viable option. For example, freehand placement allows the practitioner to diagnose, plan and place implants without having to wait for a guide to be fabricated — which is highly valuable in an emergency situation, Kosinski notes.

“Implants have been placed by skilled clinicians for a very long time without a guide,” Jackson said. “Not every case is so complicated as to need a guide. Plus, when you use a guide, you’re asking a patient to spend more time and money — you’re driving up the cost of care. So, dentists should be judicious.” ♦

Michal Christine Escobar is a freelance writer based in Chicago. To comment on this article, email impact@agd.org.

References:

1. “Implant Surgical Guide — How to Create Them with the Use of Dental Software.” 3Shape, 3shape.com/ en-us/digital-dentistry/dental-software/implant-surgical-guide. Accessed 26 April 2024.

2. Vorholt, Steven. “The 3 Types of Surgical Guides [And How to Make Them In-House].” YouTube, uploaded by Henry Schein Dental, 17 Nov. 2023, youtube.com/watch?v=KlkVSFvD8EU.

3. Salem, D. “Surgical Guides for Dental Implants; A Suggested New Classification.” Journal of Dentistry and Oral Health, vol. 6, 2019, pp. 1-8.

4. Stanley, Robert. “A Comprehensive Classification System for Dental Implant Surgical Guides.” Dentistry Today. 12 April 2022, dentistrytoday.com/comprehensive-classification-system-for-dental-implant-surgicalguides

5. “Stackable Surgical Guides: The Next Generation of Implant Placement.” Let’s Talk Guided, letstalkguided. com/2023/10/11/stackable-surgical-guides-the-next-generation-of-implant-placement. Accessed 13 May 2024.

Self-Instruction

Subject Code: 690

The 10 questions for this exercise are based on information presented in the article, “Doing It Right the First Time: A Look at Implant Surgical Guides” by Michal Christine Escobar on pages 14–17. This exercise was developed by members of the AGD editorial team.

Reading the article and successfully completing the exercise will enable you to:

1. An implant surgical guide is a custom-made _____ piece designed to fit snugly over adjacent teeth or completely on an edentulous ridge, featuring a precise hole indicating the implant’s intended location.

A. polyvinyl siloxane

B. acrylic resin

C. ethylene-vinyl acetate

D. alginate

2. Using CDT Code _____, Radiographic/surgical implant index, the average cost to the patient is about $300.

A. D6180

B. D6185

C. D6190

D. D6195

3. The cost of a surgical guide to the dentist is closer to $_____ (if made in a lab) or $_____ if made in-house.

A. 200; 20

B. 300; 30

C. 400; 40

D. 500; 50

4. When using surgical guides, drilling on a slope or against a hard plate could deflect drills without the dentist realizing it. Surgical guides are designed to allow for copious saline irrigation.

A. Both statements are true.

B. The first statement is true; the second is false.

C. The first statement is false; the second is true.

D. Both statements are false.

• understand the benefits of implant surgical guides and compare their use with freehand implant placement;

• evaluate which cases may benefit from the use of implant surgical guides; and

• determine whether the return on investment supports making this purchase.

This exercise can be purchased and answers submitted online at agd.org/selfinstruction

Answers for this exercise must be received by June 30, 2025.

5. All of the following are surgical guide categories proposed by D. Salem in the Journal of Dentistry and Oral Health except one. Which is the exception?

A. access guide

B. free guide

C. precision guide

D. tracking guide

6. Pilot guides usually feature a _____ sleeve size, enabling dentists to insert their pilot drill through the sleeve for precise drilling.

A. 1.0

B. 2.0

C. 3.0

D. 4.0

7. _____ guides are a type of fully guided implant surgical guide comprised of several removable layers that streamline surgical procedures by eliminating the need for repeated guide adjustments during surgery.

A. Tiered

B. Stackable

C. Compound

D. Multilayered

8. The three main types of support for surgical guides are tooth-borne, boneborne and _____, each serving specific needs in fully guided procedures.

A. soft tissue–borne

B. accessory-borne

C. full arch–borne

D. dual arch–borne

9. Tooth-borne support is considered the least predictable. Bone-borne support may require significant flap elevation; however, it offers an exceptionally close fit for the surgical guide after alveoloplasty, allowing for precise implant placement.

A. Both statements are true.

B. The first statement is true; the second is false.

C. The first statement is false; the second is true.

D. Both statements are false.

10. Which of the following represents the correct order of steps to creating an implant surgical guide prior to 3D printing or fabrication of the guide?

a. Create a meticulous wax-up.

b. Use an intraoral scanner to generate a digital STL file, then overlay the STL file onto a 3D model of the patient’s jaw.

c. Take a CBCT scan to assess the patient’s oral structure.

d. Cross-check CBCT data and 2D radiographs to avoid biological conflicts and confirm optimal dimensions.

e. Devise a treatment plan based on anatomical considerations and nerve mapping.

A. b, c, d, a, e

B. e, b, c, d, a

C. a, c, d, e, b

D. c, b, e, a, d

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Spotlight on 2024 FAGD, MAGD and LLSR Recipients

Each year during AGD’s scientific session, the organization hosts the prestigious Convocation Ceremony for the year’s Fellowship, Mastership, and Lifelong Learning and Service Recognition (LLSR) recipients. These honors highlight the dedication to the craft of general dentistry that recipients demonstrate, and holders of the awards and recognition can be considered the top of the profession. AGD Impact spoke to several of this year’s recipients and asked about their motivations, their strategies for tackling the requirements of these accomplishments and their advice for other general dentists who are pursuing these marks of professional recognition.

AGD Impact: What inspired you to pursue AGD Fellowship, Mastership or LLSR?

Bernardino O. Elizondo, DDS, MAGD, LLSR recipient: I was in practice for about 20 years and had reached a point of burnout that was affecting my professional satisfaction. Luckily for me, I attended a course on early-intervention orthodontics with Dr. Brad Williams, who was pivotal in my becoming a member of AGD again and picking up my pursuit of Fellowship. Later, I began the process for Mastership, where I met Drs. Tony Menendez and Jim Haddix, who inspired me to continue to work toward LLSR. All of the dentists I have met in the AGD MasterTrack programs and our leadership have been highly inspirational and encouraging to my pursuit of becoming a lifelong learner.

“All of the dentists I have met in the AGD MasterTrack programs and our leadership have been highly inspirational and encouraging to my pursuit of becoming a lifelong learner.”

— Bernardino O. Elizondo, DDS, MAGD

Yin Hsu, DMD, MPH, MAGD, LLSR recipient: The whole journey started out with a flyer from the University of Florida’s Comprehensive Dentistry Program, which I received in September 2009. At that time, I had been teaching voluntarily at the Tufts University School of Dental Medicine, and I was challenged by the students about whether my knowledge was current enough. I began a whole dentist-renewal journey. I looked at the structure of the FAGD and MAGD program tracks and thought they were perfect for me. After I achieved Mastership, I could not stop the learning process because the more I know, the more I realize I do not know.

Steven Blake Spoto, DMD, FAGD: My inspiration to pursue my AGD Fellowship came from my father and late grandfather. As dentists, they not only served as mentors for me, but also as

advocates for the importance of organized dentistry and AGD. My grandfather was a founding member of his local chapter, and my father completed his Mastership because of the mentorship he received through AGD. Upon graduating from dental school, I wanted to make AGD a large part of my career, and pursuing Fellowship seemed like a natural first step.

“CE and awards like those offered by AGD encourage us to become the best versions of ourselves, and, in turn, we can offer our best to the patients who depend on us.”

— Steven Blake Spoto, DMD, FAGD

What are some obstacles you faced while fulfilling the award requirements?

Marc K. Nakamura, DDS, MAGD: Being from Hawaii, I have very few opportunities for hands-on training, and flying to meetings and courses is costly. In my early years of practice, raising a family took precedence, and traveling was not in the budget.

Spoto: One of the more difficult parts of attaining my Fellowship was studying for the Fellowship Exam. I completed the exam during my one-year advanced education in general dentistry residency. Finding a way to balance the requirements of the residency along with studying for the exam took some time and effort.

Jennifer S. Bell, DDS, MAGD: Finding the time and deploying the financial resources to complete the MAGD award does require some strategic planning. I was close to completing many of the requirements when the COVID-19 pandemic hit, and many of the in-person continuing education (CE) options were no longer available. It certainly delayed my ability to complete the award requirements in the time I had previously anticipated.

“By taking time to learn deeper about each subject, I feel I have become a more well-rounded general dentist who can speak comfortably about most disciplines within dentistry.”

— Jennifer S. Bell, DDS, MAGD

Jill Pucel-Koopman, DDS, FAGD: Overcoming obstacles is just a part of life. As a practice owner, mother of three children, wife and daughter, my days are extremely busy. Each day, I set out to help create positive experiences and outcomes for both my personal and work families. Because of this, the most challenging obstacle is finding time. Time is precious, and one needs to set aside time for personal development. When we grow personally and professionally, this helps us become more confident in our abilities and share knowledge with others.

“The importance of awards in dentistry helps to showcase to the public the commitments that we as general dentists make to lifelong learning and the continual pursuit of bettering patient care in their communities.”

— Jill Pucel-Koopman, DDS, FAGD

In what way(s) did earning this award strengthen your dentistry skill sets, enhance your career and/or grow your practice?

Humberto Nunez Gil, DMD, MAGD, LLSR recipient: After you become a Master of AGD, you are measured at a new level in every single aspect of your professional career.

“After you become a Master of AGD, you are measured at a new level in every single aspect of your professional career.”

— Humberto Nunez Gil, DMD, MAGD

Elizondo: I strongly believe that earning my Mastership and LLSR have helped me stand out in my community and profession. I feel that the requirements for achieving these awards make us better dentists by enhancing our professional skills and keeping us abreast of advancements in technology and procedures. The LLSR requirements helped reinforce my knowledge and strengthen my skill set to keep me at the top of my profession.

Spoto: I vividly remember getting ready to start my first operative procedure after my residency and being nervous to start without supervision. Completing the requirements for my Fellowship helped me become more confident in my existing clinical skills and knowledge while continuing to learn and grow. What I learned from fulfilling the CE requirements has enabled me to expand my scope of practice and give my patients higher-quality and more complete care.

Bell: The MAGD requires a dentist to spend time in each discipline of dentistry. Without that motivation, many of the subjects would not be areas I would naturally pursue. By taking time to learn deeper about each subject, I feel I have become a more wellrounded general dentist who can speak comfortably about most disciplines within dentistry.

How did you feel when you achieved AGD Fellowship, Mastership or LLSR?

Eric K. Cheung, DDS, MAGD: It hasn’t sunk in yet. I feel I have a bigger responsibility now that I learned more, and I need to both apply my new knowledge and always continue to learn more. During

the path to Mastership, I formed my own dental assisting school, so I will be able to contribute back to our profession.

Elizondo: I felt an immense sense of pride and achievement at every award level I have completed. I feel that I am promoting the improvement of general dentistry and the quality of care to our communities by achieving these award levels, as well as encouraging other dentists to work toward these goals.

Hsu: It is such an exciting moment when we get recognized with our Fellowship and Mastership awards on stage with all our friends and families. After that, the momentum carries on through LLSR — once, twice and three times. Lifelong learning is part of my career now, and the flames of passion to pursue more understanding of the trade and life just get stronger. The urge to know more, learn more and make more friends will never stop.

Pucel-Koopman: Earning the FAGD award is something I’m internally proud to achieve. I’m not a boastful person, so many people are not aware of the commitment I’ve made to my practice, patients and family. Continual learning and changing is just a part of life. Now, I cannot wait to achieve the next level!

Why are CE and obtaining awards like AGD Fellowship, Mastership and LLSR crucial in dentistry?

Elizondo: Staying up to date and knowledgeable on the latest technology and techniques is crucial for the advancement of our capabilities and improvement of the quality of care we provide our patients. Pursuing these award designations encourages and reinforces foundational knowledge as well as strengthens our skills. I love how our profession recognizes AGD’s award designations due to the rigorous requirements to achieve them.

Nakamura: Constant education helps me keep up. I feel that I have gone through multiple paradigm shifts that really changed the way I learned dentistry, and, without keeping up with these shifts, I would be in the Stone Age.

Pucel-Koopman: Earning specific designations helps elevate dentistry as a whole. The importance of awards in dentistry helps

to showcase to the public the commitments that we as general dentists make to lifelong learning and the continual pursuit of bettering patient care in their communities. AGD membership is special because it provides a focused organization for general dentists to address important advocacies and relevant CE and professional development.

Spoto: During the last two years of dental school, my clinic team leader frequently quoted L.D. Pankey, who said, “A dentist owes his patients no less than to be a continual student.” CE and awards like those offered by AGD encourage us to become the best versions of ourselves, and, in turn, we can offer our best to the patients who depend on us.

What’s your advice for AGD members who are pursuing or considering pursuing their AGD Fellowship, Mastership or LLSR?

Judith A. Belitz, DDS, MAGD, LLSR recipient: Many of the state AGD chapters have MasterTrack programs that combine both Fellowship and Mastership opportunities. This allows for mentoring as well as networking with fellow dentists — it’s a great way to learn with and from others. I would strongly urge any general dentist to pursue these awards, as it strengthens our profession as a whole.

Spoto: It seems overwhelming at the start, but it is so worth the time and effort. Start with CE classes that you think you could implement tomorrow in your practice. Learning new skills is worthwhile, but I got the most value out of classes that I could implement immediately.

Bell: There will never be a great time to make this a priority, as our lives will always fill up with lots of other demands, but you must do this for yourself. Find an accountability partner whom you can take along on the journey. Whether it takes you a few years or a decade to accomplish, you will never regret making your professional growth a priority in your career.

For more information on achieving AGD Fellowship, Mastership and LLSR, visit agd.org/continuing-education-events/ get-recognized.

Testing the Tools

By Ross Isbell, DMD, MBA

For Filling Without Drilling

Curodont™ Repair

vVardis vvardis.com

In the world of preventive dentistry, topical fluoride has been our mainstay for years. While silver diamine fluoride has been a game changer, there are other revolutionary remineralization products coming on the market. Curodont™ Repair by vVardis is such a breakthrough. A 2018 study by Alkilzy et al. found that using its proprietary monomer-peptide 104 technology in addition to fluoride varnish has resulted in 80% caries arrest over a six-month treatment window, as compared to 34% with varnish alone. It uses a low-viscosity liquid with a high affinity for hydroxyapatite to conservatively provide a scaffold or biomatrix to actively recruit calcium and phosphate ions and create new hydroxyapatite crystals. Calling this process “guided enamel regeneration,” vVardis aims to change the chemistry and philosophy we use to combat carious lesions like white spots.

Curodont Repair has very little flavor and is at most slightly minty. It has a light, fresh feeling when contacting soft tissues, similar to rubbing alcohol, but without any pain. The flavor and sensation can be noted in the mouth for about five minutes. Its primary ingredient is 0.05% sodium fluoride, and it can be used on patients of all ages and medical histories. The applicator sponge is about 10 millimeters and becomes flimsy after it is wetted, which is awkward for placement but great for dispensing as much liquid as possible. Each box contains 10 applicators, and no additional armamentarium is required, but this is significantly more costly than fluoride varnish and should be treatment-planned as an additional adjunctive procedure, not as a replacement for topical application of other bioactive ions.

Oh Yeah, Reach for the Kool-Dam

Kool-Dam™ Pulpdent® pulpdent.com

The instructions for use state that anesthesia and a rubber dam are optional. However, the procedure takes about eight minutes, so cotton rolls or an Ivoclar OptraGate should be used if you choose not to use anesthesia. If the patient has sensitivity, and local anesthesia will be used anyway, I recommend placing a rubber dam. After determining your isolation method and getting it in place, the next step is to prepare the tooth surface. First, clean the biofilm and pellicle from the lesion and the surrounding area with a cotton pellet soaked in 3% sodium hypochlorite for 20 seconds, and then rinse. Then, etch with 35% phosphoric acid for 20 seconds, rinse, and pat the tooth dry with gauze. Open the sealed bag to prepare the single-use 0.1-milliliter applicator capsule, remove the stopper clip, and press the capsule together to join the brush/sponge with the treatment liquid. That process will take about 20 seconds. Then, press the wetted applicator onto the lesion to dispense all of the liquid. There is enough liquid for two Class V white spots or two Class IV interproximal lesions. Wait five minutes without having the patient spit or rinse, and recommend minimal liquid consumption for the next hour.

It is very exciting to see systems like Curodont emerging that enable us to perform a filling without drilling. I haven’t been using this product very long, so I can’t vouch for its esthetic results, but it seems like this may be an effective and even more conservative approach than resin infiltration techniques in the narrow space between preventive and restorative techniques.

An oldie but a goodie, the Kool-Dam™ block-out resin from Pulpdent® remains a critical part of my armamentarium for a variety of procedures. Unlike most flowables, the flexibility of Kool-Dam makes it great for working with rubber dams and moving with them while not breaking its hold. That being said, it is also easy to grab and break out after you have completed your procedure. Since it is blue, you won’t confuse it with your other restorative materials. It is easy to sculpt around gingiva and works well in the presence of liquids, so blood and saliva are not a problem. In my practice, we primarily use it for endodontic procedures to perfect the seal of the rubber dam around a tooth. We also use Kool-Dam when we want to protect the gingiva for bleaching treatments. Lastly, it works well as a smallarea isolation for anterior restorations. If you need an effective and inexpensive resin to create an easier and more perfect restorative and isolation situation, reach for the Kool-Dam.

Ross Isbell, DMD, MBA, currently practices in Gadsden, Alabama, with his father, Gordon Isbell, DMD, MAGD. He attended the University of Alabama at Birmingham (UAB) School of Dentistry and completed a general practice residency at UAB Hospital. Isbell has confirmed to AGD that he has not received any remuneration from the manufacturers of the products reviewed or their affiliates for the past three years. All reviews are the opinions of the author and are not shared or endorsed by AGD Impact or AGD. To comment on this article, email impact@agd.org

A Worthy Adhesive Upgrade

BeautiBond and BeautiBond Extreme

Shofu

shofu.com

The Shofu BeautiBond adhesive has been around for a long time, but the BeautiBond Extreme revamp is worth a look. With an ultra-fine 5-micrometer film thickness and a dual-curing ability, the “quad-adhesive” technology is quite versatile. Delivered in an opaque single-patient-use well that can be dipped into repeatedly with a micro brush, it is a solution for bonding that is easy to clean up and dispose of. In my experience, there is enough adhesive for up to five restorations per patient. Prior to restoration and bonding, ensure that you have adequate isolation, and then roughen or clean the surface to be applied. Rinse the site, air-dry, and apply a single layer of adhesive. Air-disperse the adhesive until there are no visible rolls or droplets, and light-cure for 10 seconds. Then apply cement or composite directly onto the adhesive-coated surface. If you are using this material to treat hypersensitivity or for immediate dentin sealing, follow the steps previously outlined until you get to the restoration step, then simply remove the unpolymerized layers with an alcohol swab. I prefer BeautiBond Extreme in anterior restorations where a slim bonding margin will create more esthetic edges and in deep posterior restorations where I need dual-cure capabilities.

In the August issue of AGD Impact

• Improving the Working Relationship with Your Dental Lab

• Profiles of Master Ceramists

• Convincing Patients to Put Themselves First

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