by Shannon Brinker, CDA CDD and Laura Hansmann Pistoia, DA.

The role of dental restorations used for provisional and indirect restorative procedures has changed dramatically in the past several years. These restorations are no longer regarded as temporary restorations but rather as provisional restorations with distinct functions and purposes. Provisional restorations have become a vital diagnostic and assessment tool to evaluate function, color, shape, contour, occlusion, periodontal response, implant healing, and overall esthetics. An accurate fit and margination is essential to insure and maintain pulpal health.

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By Raj Upadya

There is much more to a healthy mouth than preventing and treating decay and gum disease alone. There are other factors that are critical to long-term predictability of a healthy mouth that will allow you to enjoy a better quality of life and better overall health. The well-trained eyes of a different breed of dentists that completely examine a patient are the key to determining the signs of problems before they become painful symptoms. If you wait to treat a condition until symptoms have developed, you have often missed the opportunity for conservative therapeutic options; thus treatment choices will also become much more costly and involved.

There is a scientifically based rest position for your jaw joint, called centric relation, that has been repeatedly proven to be accurate and stable through not only research, but also through patient experiences, and with trial and error of repeated dentistry. If the joints, muscles and teeth have not been working in harmony with respect to their proper positions you can find extensive damage to the teeth, the joints and muscles. This can lead to dental needs for a patient, sometimes in the absence of symptoms. Masticatory physicians are trained to see and diagnose these conditions when they are signs, before they proceed to becoming debilitating symptoms. This approach may be occasionally viewed by traditional dentists as overtreating, though in reality we are being more conservative in the overall dental life span of the patient. (Figure 1)

Figure 1

OCCLUSAL DISEASE (OD) is a common dental disorder that is usually painless in its nature and involves the development of a traumatic or pathologic bite as a result of an erosive disease process. It (OD) is now considered the highest risk factor for and cause of tooth loss. If teeth have worn through the strong outer enamel layer to the soft core, the bite has become unstable, though you may not even be aware of it. The mouth gets its stability from the back teeth supporting the front teeth, and the front teeth protecting the back teeth, working together in unison from a relaxed jaw relationship. The wear through the enamel into the softer inner tooth creates an unstable stopping position for the teeth so that they are no longer able to function adequately. Lack of enough strong teeth with intact enamel or teeth that have drifted out of their proper position overloads the system as well. Quite often, this does not cause any pain but the effects on the teeth, gum, bone and mouth are very destructive as a whole. At one point, it was thought that it was normal for the teeth to wear out and shift over time. Wear that is confined to the outer layers of enamel and has occurred slowly over time can be, in some cases, considered normal. Wear through the strong outer enamel into the soft internal core, however, is considered pathologic, as it has advanced through the entire protective layers of the tooth. (Figure 2)

Figure 2

Unfortunately, pathologic wear and unstable bites have been routinely misdiagnosed and under-diagnosed by the dental profession. It is often the underlying cause of many problems that we see and, regretfully, is most often left untreated. As a result, a large volume of emergency-based, reactive single tooth general dentistry is performed. This self-perpetuating cycle continues as the work that is subsequently performed then prematurely fails because the underlying cause of destruction has not yet been addressed, once again resulting in overall frustration. Eventually, the front teeth often will break from the excessive forces placed on them. This lack of diagnosis and correction is a huge disservice to our patients because many of the problems that develop were and are preventable. Theories of this alarming increased prevalence of worn and displaced teeth include increased use of processed acidic food and/or drink, clenching and grinding, abrasive toothpaste and pathologic bites. Even though the initial cause is somewhat uncertain, the effect is truly becoming epidemic. (Figure 3)

Figure 3

Criticism of masticatory physicians usually comes from not truly understanding the philosophy. Just ask a masticatory physician who was once also in the dark about how to provide dentistry that doesn’t break down and can last through your lifetime with proper care. Consider a masticatory physician the upper level of competency and predictability in delivering dental care. But most importantly, they care so much about their responsibility to their patients’ care and health that they have often sacrificed greatly. These dentists have gone back to school to advanced dental education institutes to learn how to perform dentistry accurately and with predictability. Just like technology, medicine and all other industries that continually learn more to provide better products and service to enhance consumers quality of life, so has dentistry learned that there is more to dental care than decay, gum disease and making things look pretty. Most of the masticatory physicians themselves were tired of watching dentistry they had performed on patients fail. They did the best they could with what they learned in dental school and they cared for the patients well by trying hard not only to fix problems and make the solutions last but without creating other problems along the way. (Figure 4)

Figure 4

The Complete Exam starts far before the patient even enters the dental office - it is a process. The well-trained office:

1. Conducts a telephone interview learning about patient expectations of the dentist, past dental experiences and explains the individuality given to each patient and the practice philosophy and care that they provide.

2. Sends a welcome packet to learn about the patient so that they can prepare for the first visit by customizing their approach to the patient’s needs and concerns. It also allows the practice to share their philosophies and set the proper expectations for the experience and the type of practice that one is entering.

3. The day of the appointment, time is spent with the Doctor clarifying the information provided and learning in more detail about patient needs and health goals. A review of the medical history, dental history and any concerns about dental health and past dental experiences.

4. Together the Doctor and patient care assistant spend anywhere from 1 to 2 hours performing a thorough comprehensive diagnostic exam. Typically recommendations for treatment are not discussed at this exam. The exam is for information gathering to study the findings and work out a plan for getting the patient’s mouth maintainably healthy for the rest of their life. This initial exam is not a quick periodic check by the doctor in the hygiene column — it is an involved diagnostic process that involves the patient’s input and opinions.

The exam should include a diagnosis of the entire Masticatory System not just teeth or symptoms. The System includes the joints the muscle, the supporting structures and the effect they have on the health of the teeth. The working harmony of all of these parts defines health.

5. A discussion with the patient at the end of the exam to review initial findings and what needs to be done to determine recommendations to get you healthy. This could include:

Diagnostic Records

• X-Rays - Examining for decay, infections, lesions, bone height
• Models of your teeth – To study the jaw, muscle and teeth relationship
• Photographs – As important as radiographs. Used to study detailed relationships of the teeth, and help in esthetic diagnosis as well
• Panoramic X-Ray - To study further unseen problems (Figure 5)

Figure 6

6. A complete study and diagnostic work up by the Doctor analyzing all the information gathered at the exam and the records taken. Often a Doctor will completely work the case out on a before and after set of models determining a plan to achieve health and ensuring the long-term results instead of practicing and playing guesswork in the patient’s mouth.

7. The second appointment will be the time for the patient and Dentist to review the information he has prepared and determine the best plan of action to get healthy. These doctors want the patient to understand the problems and make sure they agree with the solutions. They welcome all the questions, concerns and want to understand the patient’s circumstances. Most of the time a comprehensive approach to dental health can be spread out over several years. It is the role of the Dentist to determine with the patient the areas that are in need of immediate attention and the areas that can be deferred or are elective. Not everything is necessarily urgent.

8. A dentists who will maximize any insurance benefits you may have but will not allow the insurance companies to have control over what is necessary to get you healthy. These dentist believe the decision should be between you and your dentists once you both have a clear understanding of what is necessary to get healthy and what insurance restrictions may prevent that.

9. A discussion with you about the time and cost involved in obtaining a healthy mouth. The treatment plan can only be successfully executed as a partnership, therefore your circumstances and budget will be taken into consideration as you and the Doctor plan for your health. Once you both are ready to move forward, a special arrangement of payment will be made for the time, care, skill, knowledge and judgement of the Doctor to make your investment predictable.

Important questions to ask patients:

Have you experienced:

1. Teeth that are sensitive to cold?
2. Teeth that have shifted in any way?
3. Teeth that feel chipped, jagged or rough?
4. Teeth that appear worn or are shorter than you remember?
5. That you have clicking or popping of your jaw joints?
6. That you suffer more often from headaches?
7. That you clench or grind your teeth?
8. That you have sore, tired jaw muscles?

Table 1 - The Complete Examination

• Patient Chief Concern/ Desires
• Medical/ Dental History
• Soft Tissue Exam/Oral Cancer Screening
• Periodontal Charting/Assessment
• TMJ Evaluation:
• Doppler Auscultation (5MHz Ultrasound)
• Joint Vibration Analysis (JVA)
• Piper Classification
• CR Load testing
• Muscle of Mastication Palpation Results
• Dental Exam Findings: Caries, Faulty Restorations, Abcesses, etc.
• Occlusal/Functional Findings
• Esthetic Assessment

Table 2 – Signs of Stability and Instability

Signs of Stability:

1. Even tooth contacts in CR
2. Anterior guidance that immediately discludes the posterior teeth in all mandibluar movements
3. Stable TMJs
4. Teeth that are in harmony with the neutral zone and envelope of function.
5. No pain/sensitivity

Signs of Instability: 

1. Excessive tooth wear into dentin
2. Unwanted tooth migration
3. Broken/fractured teeth
4. Excessive mobility
5. CR-MI discrepancy
6. Tooth hypersensitivity

Oral Cancer Exam
The areas of your cheeks, tongue and the floor of your mouth.

IDEAL: 

No Lesions, growths or discoloration. Dentists diagnose a large percentage of oral cancer annually allowing it to be caught early. Masticatory physicians have trained their hygienists to exam for oral cancer at each hygiene visit.

Diagnostic Measures

• Visual and physical inspection by the Doctor and Hygienist
• Tissue fluorescence with VelScope or

Joint Health Exam
The joint that positions your jaw in opening and closing.

IDEAL: 

The joint position in its socket with the disc, fluids and ligaments all in proper form. Health defined by no popping, clicking, grating noise, pain to the touch or pressure of joint loading or deviation in opening and closing.

Diagnostic Measurements

• Screening History of Joint Health
• Blood Flow Evaluation
• Ear Symptom History
• Ligament Health
• Disk Health
• Jaw Range of Motion Exam
• Noise Detection Exam

Muscle Health Exam
The Muscles that open and close your jaw

IDEAL:

All muscles working in harmony by turning on and shutting off at the proper time and place while the putting the joint in the proper position and contacting the teeth all at the same time with equal force and intensity.

• Muscle Health defined by no pain or tenderness to the touch of the muscles.
• Diagnostic Measurements
• Physical touch or palpation of Head Muscles
• Touch of Neck Muscles
• Open and Closing Patterns
• Touch of Facial Muscles
• Touch of Cheek Muscles

Biting System Health Exam
The relationship of your teeth to the current joint and muscle position.

IDEAL:

For proper muscle and jaw position, when chewing food your teeth should all contact at the same time with equally intensity. Your back teeth should separate and your front teeth should contact guiding your lower jaw in left to right and front to back motions. This ideal relationship of your jaw, muscles and teeth are critical in the distribution of the 600 pounds of force from the muscles when chewing and talking.

Note: There are cases where the ideal described is not achieved and a patient may have adapted to the position of jaw, muscles and teeth relationship. The concerns then becomes is the adaptation destructive to the teeth and the joints.

Diagnostic Measurements

• Upper and Lower Jaw Relationship
• Equal Force Tooth Contact Exam – Points of contact defined
• Chewing and Talking Movements Tooth Contact
• Chewing and Talking form with tongue, cheek, and lips
• Unconscious Habit Movement Exam (i.e. bruxing, clenching, grinding)

Gum, Bone and Root Health
The supporting structures that hold your teeth in place.

IDEAL:

The attachment of your gums to your teeth should be tight enough to clean between that space with a toothbrush and the bone around the tooth should be at a height that keeps the teeth tight in their place. Otherwise bacteria can live and cause infections, eat away at bone then loosening teeth. The roots should be attached to the teeth. Health defined as a 3 millimeter space between tooth and gum, no bleeding, no puss, gums pink in color, no root or bone exposed, roots attached to teeth.

Diagnostic Measurements

• Measurement of Gum attachment to teeth
• Recording of bleeding points
• Root Height Exam
• Gum Levels to teeth
• Bone Support – X-rays

Teeth Health Exam
The signs and symptoms of the conditions of the joints, muscle, biting contacts, gums, root and bone are viewed on the teeth. These symptoms can be painful or non-painful depending on the damage. Much like Diabetes, High blood pressure or Clotted arteries.

• Tooth By Tooth Health
• Looseness
• Cracks
• Fractures
• Shifting of teeth
• Missing Teeth
• Erupting Teeth
• Strength of teeth and existing dentistry performed
• Worn teeth
• Contour/Shape
• Seals of existing restorations
• Color
• Notches in enamel at gumline

 Conclusion

There is a pot of gold at the end of the rainbow… a complete exam leads to a complete diagnosis, which does translate to profitability for the practice, and the most ethical care that the patient can receive… Without doing the exam, you cannot make the diagnosis, so you won’t be able to present or produce the treatment.

by Dawn Wiedow, CDA, RDA, EFDA, CODA, EMT-B, PA

According to Wikipedia a Dental assistant is one that helps the dental operator (dentist or other treating dental auxiliary) provide more efficient dental treatment. Dental operators can focus more time on providing treatment when assistants oversee the necessary, albeit sometimes menial tasks, by effectively becoming the operator’s extra hands. In other words, we do more than just suck up spit!

As this article was designed for the modern dental assistant to have a complete understanding of contemporary esthetic procedures in order to provide their patients with beautiful, functionally correct dentistry and along the way achieve personal and professional growth. A guide for you to use to help empower you to advance you r understanding of the possibilities that lie ahead of you, all you have to do is to embrace them.

Records

Performing the records gathering process, you will learn what to do, who will do it, and why it is THE key component to the complete care restorative practice. Dr. Peter Dawson, of the Dawson Academy, has always said, failure to treatment plan is planning to fail… With the complexity of today’s treatment plans, proper case planning is absolutely essential for a successful outcome. It is crucial that during the records appointment, that we look for signs of instability as well as visualize any changes we may need to make to the patient’s dentition; to either help them attain a specific esthetic change, or solve an underlying functional problem. Mounted diagnostic study casts are critical to this examination process. (Figure 1; the Combi II by Whipmix) By using a properly mounted case on an articulator, looking at digital photographs, reviewing a full series of x-rays, and all other pertinent clinical information (Figure 2 and 3) Flexitime Putty by Heraeus Impressions in 3M Direct Flow Trays) we will have all of the tools for the restorative doctor/assistant team to properly work up, diagnose and then treat the patient. While a full occlusal analysis, utilizing mounted diagnostic models, is not required for every patient, it is needed for any patient that is considering advanced restorative procedures, elective cosmetic/esthetic dentistry, or any patient that has signs of instability (tooth wear, mobility, migration, tenderness to muscle palpation, or issues with the temporomandibular joint).

Digital Photography

Digital cameras are becoming a standard piece of equipment in a modern dental office and part of a comprehensive treatment plan. There are literally hundreds of digital cameras available today, but only a small number are acceptable for dentistry and the details required for functional intraoral photography. It is and has become one of the most valuable tools we have.

Most offices that incorporate digital photography into their daily practice find out that they cannot practice effectively without it. With a complete digital system, instead of the dentist simply describing the problem or issue at hand, both the patient and dentist can view the images on a computer monitor at the same time. This enhanced communication leads to greater production for the dentist and satisfaction for his patients. Empowering the patient to help them understand their own mouth and its condition.

Diagnostic wax-up

After the diagnostic casts are mounted, duplicate a second set of models for a diagnostic wax-up. Using the digital photographs and mounted casts, the functional and esthetic requirements visualized by the restorative team are then transferred to the diagnostic wax-up. Have the patient bring in a photograph of a smile they like – theirs from earlier days or anyone else’s. I find that is they look through magazines, and old pictures of themselves, they feel more confident about their decisions and direction in which their treatment will be going. They are driving their treatment, which is wonderful, as they then feel more confident on they choices they are about to make. This allows the entire dental team including the laboratory technician to visualize the patient’s expectations. Some practices choose to have the laboratory prepare and wax-up the case to ideal esthetics and function. If you are asking the laboratory to do your mock-up, they need to understand that the provisional restorations are both doctor and patient approved. It should be noted that the diagnostic wax-up is our best estimate of the final outcome. This approved esthetic mock-up will be used as a matrix for preparation guides and provisional fabrications. Therefore you will most likely always perform final contouring of the provisional restorations (Figure 5 Voco America’s Structure Provisional material in the mouth for optimal functional and esthetic success.

The Laboratory Rx

When writing the laboratory prescription, start with identifying the patients name, age, sex and the tooth numbers to be restored. Prescribing the specific type of restoration and material choice(s) is also important.

As an example, a Crown, Bridge, Veneer, Inlay/Onlay, Maryland Bridge, Partial, and Denture should be precisely dictated as such:

Please Fabricate Zirconium (IPS e.max) restorations 5-12, 20-28

1.) Mount model of temps with face-bow and enclosed bite registration
2.) Mount lower die model with record marked upper temps/lower temps
3.) Mount upper die model with record marked upper preps/lower preps
4.) Fabricate labial matrix and custom guide table
5.) See pre-op, prep, and provisional photos
6.) Shade B1, with mild incisial translucency

Fabrication of exquisite provisional restorations, Yes, provisionals, they are NOT just temporaries,

This is the key component for predictability in the restorative process and the ability to adjust them for ideal esthetics, phonetics and function is a key function of the process.

One of the most important decisions we have to make, with regards to optimum esthetics and function, is the precise position of the maxillary incisors. Much has been written about this, yet most of the information regards where the incisial edge should be placed vertically. The Rest Position and The verbal E sound are important to look for when designing a smile, yet it does nothing to tell you if the incisial edge is too far forward (buccal) or to far back (lingual) in relationship to the lip. The maxillary teeth need to be far enough forward to provide proper lip support, and have a proper two-plane contour to allow for proper closure of the lips. The lip closure path, described by Dawson (Figure 4), allows the lower lip to comfortably close around the Incisal 1/3 of the maxillary incisors. Positioning the Incisal edge horizontally is also critical for creating a lingual contour that will provide functional harmony. The lingual contour has to be steep enough to disclude the posterior teeth, but also be in harmony with the envelope of function.

Dental Materials Update:

There is tremendous respect for the manufacturers and research organizations that are trying to make it easier for all dental professionals to become more efficient, effective, productive and profitable while at the same time insuring clinical performance. I have learned that dentistry is a science as well as an art. Although as assistants we have to be familiar with the literature and clinical performance, their needs to be more emphasis on how materials perform even before they get to the chair let alone to the mouth. You can have a great product from a clinical research point of view, but if dispensing is poorly designed, storage conditions are impractical, or instructions overly confusing. It might not even make it into the workflow. research that affects my role most is more on the ergonomics and design features. Making placement and delivery more consistent, predictable and successful.

Have a Great Attitude, and yes, SMILE!!!

The focus of this presentation was not just to review the clinical aspects of what we do, but I wanted to inspire all dental assistants and encourage them be great leaders in the comprehensive diagnostic and restorative plan. We are a crucial part of the patient’s decision-making process.

What does it mean to be a great leader? Well if you are an assistant, just look in the mirror.
As assistants, we can get burned out on the day-to-day routines, the stressful issues of patient care and endless mind reading while assisting the doctor. Add to that trying to control supplies, run on time, clean and sterilize instrumentation, communicate with patients, the doctor, the lab as well as the front desk and keep track of cases coming and going and equipment maintenance and you get a sense of the assistant’s world…. Boy! Do they make it look effortless or what!

The assistant tends to be the cheerleader in the office, keeping things fun and lightweight for everyone. Patients tend to listen and en trusts us with their care and treatment. To be their voice, a link to the Doctor. We can do so much more is just allowed.

Repeatedly I’ve had doctors say to me, I’d love for my assistant to do this, but she just won’t do it and the assistants then say, I wish I could do what you’re doing, and neither group knows where or how to get to what each wants. Dentists need to encourage, support and direct their dental assistants. If I didn’t have doctors along the way say, Dawn, you can do anything; I would not be where I am today. If given the chance you would be surprised how many of the assistants would step up tot he bat, and take the reins, and rum with it. Not only would your assistant grow, but the My friend Kirk Behrendt from Act Dental said great leaders listen (more than talk) to cultivate a workplace in which they not only change lives of patients everyday, but also positively influence the lives of each team member and assistants need to accept more and more responsibilities, lead by example and work within the team to participate effectively in nearly every step of a restorative process.

Talented team members yearn for a practice in which they can see a better picture of themselves now and in the future. They can see how this practice can make them better in so many ways and vice versa. This betterment isn’t limited to simply technical skills development, it is often much more that that.

There are relationship built between Dr.’s and Assistants, Assistants and patients, a trust, empowering the assistant to help guide and educate the patient to make the best decision for them, cluing them into all the options they have available, which to the patient is invaluable, and commended.

We are a hidden resource that is just beginning to be tapped.

Don’t hide your skills, embrace them, use them, hone them in, and fine-tune them. enroll in CEU courses that ignite the fire in you. It is so rewarding when you do, as not only do you benefit, but so do those you treat.

by Bruce Lachot, DDS and  Kent Loo, DMD

Drs. Bruce Lachot and Kent Loo are state-of-the-art general dentists providing cosmetic and restorative care in Scottsdale, Arizona. The dental office provides many important specialized services such as LANAP laser periodontal treatment, CAD/CAM restorations, Invisalign, endodontic treatment and implant placement. With two Dentists on staff and four full-time hygienists, the office is busy and consumes a substantial amount of dental products.

As a high-tech/high-touch dental office, the Doctors have experienced tremendous growth through the years and with that growth have endured the rising costs associated with their supply management. Having the proper supplies on hand at all times is a necessity to offering their patients the best possible care. Read more

How many times do you go home from work and you have a story about your day that isn’t so up beat? It could be anything from a great case that went in your operatory and the doctor failed to compliment you on it, a team member not working as much as you did today or even a case that you presented and treatment was accepted. Does this sound like something that you have experienced?

One simple system implementation can change the way that you walk out of work, the way that your day is done. ‘The Afternoon Meeting” is a structured format that takes about 15-20 minutes and allows the day to be celebrated, numbers and goals to be discussed, treatment that was closed to be brought to everyone’s attention and even the failures of the day to be addressed.

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T he dreaded single central restoration is often a challenge for the dental team to communicate the shade correctly to the laboratory on the first go around. For the dental laboratory, it is the most common reason for a remake. It is not unheard of for some practices to charge 2 to 3 times what a normal restoration would cost, simply because of the time and effort put into getting the restoration shaded correctly, as it could entail a re-shade at the lab, and or remake of that restoration. Color perception is subjective by nature and many variables can affect how the final shade is chosen. Some dentists will send the patient to the lab for a custom shade. Read more

The Pursuit of Excellence

“People who have accomplished work worthwhile have had a very high sense of the way to do things. They have not been content with mediocrity. They have not confined themselves to the beaten tracks; they have never been satisfied to do things just as others do them, but always a little better. They always pushed things that came to their hands a little higher up, this little further on, that counts in the quality of life’s work. It is constant effort to be first-class in everything one attempts that conquers the heights of excellence.” ~Orison Swett Marden~

How do you avoid mediocrity in your staff and practice when it seems that everywhere we look, mediocrity is the accepted norm? Good enough is the new standard, set by those who don’t want to stretch themselves. In general, in a group, people will often sink to the lowest common denominator to keep the peace. That makes it imperative that you make certain that your lowest performer is well above average, or you will find your staff infested with so-so-itis. Read more

A picture is worth a thousand words is a proverb that refers to the idea that complex stories can be described with just a single still image, or that an image may be more influential than a substantial amount of text. When we take photography in our practice, we don’t have to say anything. It is so much easier to show the patient what we are talking about and they are able to visualize the key points as to the treatment plan.

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When asking Dental Assistants how many uses a rubber dam in their practice, it shocking to see the show of hands. Studies show that only 15% of dental offices use rubber dam for adhesive procedures. Excuses come up such as; it takes too long to place, we just use cotton rolls, retractors get the same results. With so many new and innovative dams introduced, dam placement takes minutes. Why take chances? Read more