Complex Restorative Dentistry

CASE REPORT: COMPLEX RESTORATIVE DENTISTRY

By: Joe F. Maltsberger, DDS Complex restorative dentistry requires a detailed approach to every step of treatment. Appropriate data must be gathered to facilitate a proper diagnosis and critically evaluate different treatment approaches. Discussions with the patient (and spouse if possible) along with photos and models of previous similar cases will allow the patient to choose the treatment they want, and will also facilitate development of a written financial arrangement. Once treatment has been determined the dentist can work out a detailed sequence of treatment and an appointment schedule based on the patient’s needs and preferences. Complex restorative treatment is within the reach of many dentists, but it requires a commitment to detail, extra training, finding and working with an exceptional lab, and a desire to do what is best for the patient. Your professional fulfillment and enjoyment is virtually guaranteed as you see beautiful and long-lasting results and, most importantly, a happy and satisfied patient. A thorough accumulation and review of all relevant data is critical to the success of any complex case. This process involves consideration of the following areas:

• Registration/Insurance Issues

• Medical History - A detailed history, including a thorough patient interview and calls to medical providers as necessary to gain knowledge of any medical conditions that could be pertinent to the treatment. • FMX – A 20-film full mouth series to fully examine root tips, interproximal areas, and the bone levels of every tooth. In cases where gagging or tori are problems, a panoramic x-ray may be needed as well. • Periodontal Probing – Probing/ documenting six measurements around each tooth, and recording any areas of bleeding, recession or mobility. • Hard and soft tissue evaluation - This includes a cancer evaluation of the head and neck, as well as carefully documenting all caries or tooth anomalies.

• TMJ Evaluation/Occlusal Evaluation

using Mounted Models – Mounting accurate upper and lower arch models on a semi-adjustable articulator with facebow transfer and a centric relation bite using the Lucia Jig. • Intraoral/Extraoral Photographs -

A minimum of eight photographs is recommended.

• Patient interview – The interview outlines the patient’s objectives and goals, allows for a consideration of treatment alternatives and budgetary matters, and may reveal other hot button issues pertinent to treatment recommendations.

CASE REPORT

A 50-year-old female presented to my office with no evident medical issues or current medication history. The following is a brief summary of examination findings: FMX revealed multiple restorations, but no evident decay. Bone levels appeared within normal limits, but there were areas of severe wear, most notably in teeth #21-28. Periodontal probing found no pockets exceeding 4mm; there was minimal bleeding with probing and no mobility or other periodontal concerns. Hard tissue examination revealed no caries, but an upper right bridge was broken in the pontic area (#4) and the wear noted on the radiographs was corroborated intraorally. This was a red flag that she was grinding her teeth at night (and possibly during the day); along with associated muscle problems this could affect any new restorations. TMJ evaluation produced reciprocal clicks in both joints. The muscles were very tense, and it was difficult to manipulate her jaw into centric relation. There was muscle sensitivity upon palpation of the left and right anterior temporalis and masseter muscles; the patient reported headaches in these areas 2-3 times per week. There was no deviation upon opening. Her mounted and articulated models showed a discrepancy between centric occlusion and centric relation. She had a mutually protected occlusion with canine lift on both sides, a 7mm overbite, and a 3mm overjet. Extraoral photographs showed prominent spacing between her upper central incisors, a high lip line, and color variations in her teeth due to tetracycline staining, poorly matching restorations and failing composites. (Figs 1-3)

Her concerns about the gap between her upper centrals and the color variance in her upper teeth were reinforced during our interview. In addition, she wanted her teeth to be lighter. I explained that to get the results she desired would require multiple crowns in the upper arch, placed in correct position when finished, so that the final result would be fully functional as well as esthetic. I informed her that she might need to wear an appliance at night for the rest of her life; she would also need to commit to an aggressive preventative plan with consistent daily care at home and regular visits to our office for cleaning and check-ups.

TREATMENT PLAN

Based on these findings the following comprised the elements of my

proposed plan of treatment: • Prophylaxis and thorough instruction/ training on proper oral care at home • Anterior Bite Splint (ABS) • Major Equilibration

• Diagnostic Wax-up- 11 units • Eight lithium disilicate crowns (E-Max) layered with feldspathic porcelain • One three-unit zirconia bridge layered with feldspathic porcelain • Aggressive 6-month preventative program

ANTERIOR BITE SPLINT/MAJOR

EQUILIBRATION I made slight adjustments to the bite to correct the CO/ CR discrepancy and lateral interferences. Once the equilibration was completed, we constructed an ABS. The patient’s masseter muscles were so tense it was difficult to manipulate her mandible into CR. If the mandible is not in CR then the bite registration will be inaccurate, which would make the diagnostic wax-up inaccurate creating a serious foundational issue. The ABS worn nightly will force the muscles of mastication to relax at night; the equilibration will help them to relax during the day. After two weeks of ABS therapy, I took a new CR bite and checked it for accuracy.

DIAGNOSTIC WAX-UPS FOR CROWNS

The ideal plan was to crown the upper arch, first molar to first molar. We would wax up the centrals in an ideal esthetic position, and then work out the occlusion to be functional and stable. This approach will address the coloration issue and would also simplify the case by using the patient’s second molars to maintain VDO while prepping the other teeth. The diagnostic wax-up was critical to verify the details of upper arch reconstruction and determine if this was possible without opening the VDO.

PREPARATION/TEMPORIZATION

Since this was an all-porcelain esthetic case, proper reduction was critical for strength and beauty. Retention form is also critical because full-porcelain crowns are not as retentive as PFM (porcelain-fused-tometal) crowns. I reduced only the amount needed for an E-Max crown. If I had any concerns that there would not be enough tooth structure for long-term retention, I would prep the upper model in the lab to evaluate retention.

All preparations were completed in one sitting, carefully stopping at the tissue level with no cords in place. A two-cord technique was used to acquire accurate final impressions. An intra-oral stent was used to check for proper reduction and to fabricate all 11 temporaries. The centric relation interocclusal record was taken. Proper trimming of the temporaries with proper emergence profile, room for tissue in between the preps, and excellent marginal fit, combined with a high polish allowed for healthy non-bleeding tissue around each individual tooth when the final crowns were seated. New photos of the finished temporaries were sent to the lab.

FINAL SEATING/ X-RAY EVALUATION

At the seating appointment each crown was tried in and the margins and occlusion checked. I never seat a crown until the margin is nearly non-detectable. I cemented the E-Max crowns and zirconia bridge with Multilink (Ivoclar). After final seating, an FMX of the upper arch was taken to check that all margins were properly sealed properly with no cement left under the tissue. A new ABS was fabricated and the patient was instructed to wear this appliance every night.

DISCUSSION

Had we needed to change the VDO this case would have been much more difficult. The second molars were critical guides into Centric Relation at the proper VDO. Also, because of the prior work to relax the muscles of mastication our inter-occlusal records for the lab were accurate and easy. Because the diagnostic wax-up was accurate both esthetically and functionally, the crowns functioned very nearly as the lab and I had anticipated, and the patient was pleased with the appearance. The Anterior Bite Splint (ABS) is a great appliance for allowing the muscles of mastication to rest at night. Fitting on the upper six anterior teeth, it is only in occlusion with the four lower incisors, forcing the condyle to be seated firmly in the socket on both sides and ensuring that the patient is in Centric Relation. Two important points to consider when using this appliance: 1.The patient can wear it no longer than eight hours in a 24-hour period. If worn longer, there is a risk of hyper-eruption

of the posterior teeth causing some profoundly serious problems. You must explain this carefully to the patient, and you must have a signed informed consent that is VERY clear about the problems this appliance can cause. 2.If the patient has an intra-capsular TMJ problem this appliance will make their joint hurt. They must immediately stop wearing it; a different approach would be needed for such patients.

FOLLOW-UP AND OUTCOME

Since late 2014 when the restorations were seated there have been minimal problems. The crown on #10 came off once due to an occlusal interference; since its adjustment there have been no recurring problems. A few other occlusal adjustments were needed to make the patient completely comfortable. This case is now over six years old and the patient is quite pleased with all aspects of the treatment. The change in her appearance has been dramatic. (The post-op photos were taken four years after seating crowns.) She is involved in an aggressive biannual preventative program with our dental hygienist Lashel Thulin, RDH. She is meticulous with daily home care and diligently wears her ABS every night. In this case our objectives were fully met: A happy and comfortable patient, positive professional fulfilment, a wonderful posttreatment relationship between the patient and our dental team, and an excellent longterm prognosis. (Grateful acknowledgement is extended to Functional Esthetics [Kyle Swan, CDT], Lewisville, Texas for the excellent laboratory work they provided on this case.) ABOUT THE AUTHOR: Dr. Joe Maltsberger is a 1981 graduate (with honors) from the University of Oklahoma College of Dentistry. Born and raised in Pawnee, OK, his dental practice (Innovative Family Dentistry) is located in Oolagah, his home for over 35 years, where he is also involved in numerous community and charitable activities. Maltsberger loves the artistry and detail of dentistry, and says, “providing lifechanging treatment is the most exciting part of my job.” He enjoys travelling, back packing, and some occasional golf, but mostly spending time with Terri Jo, his wife of 40 years. The Maltsbergers have four children and 11 grandchildren.

OKLAHOMA COVID-19 RESPONSE: FOCUS ON VACCINES

By: Jana Winfree, DDS

Remember March 2020? The first reported COVID-19 case in Oklahoma was on March 7. On March 11, the basketball game in OKC between the Thunder and the Jazz was cancelled resulting in the shutdown of the NBA season. Then came Spring Break. Students were excited, parents confused – What do you mean a two-week Spring Break?!? Public testing began in March, and the first reported death to COVID-19 occurred on March 19. By the end of the month, there were 565 confirmed COVID-19 cases and 23 deaths in Oklahoma. To our dismay, this was the beginning of an unfathomable health crisis that changed the way we exist in the world. Thanks to PH experts, messages for prevention of COVID-19 are universal. Since COVID-19 is a novel coronavirus, when it arrived there were unknowns about transmission, susceptibility, progression and treatment. Much has been learned. As the one-year anniversary approaches, we continue to mask, wash our hands and social distance. Dentists sought guidance on how to serve their patients during a pandemic. Using reputable sources, the Board of Dentistry and the ODA compiled verifiable guidance to safely practice dentistry while mitigating the risk of infection to staff and patients. As expected, guidance is adapted with practical experience gained as the pandemic progresses. Thanks to science, vaccines for COVID-19 are available for mass use. In Oklahoma, the first COVID-19 vaccine was administered on December 14, 2020 to an RN who works in the emergency room at the Integris Baptist Medical Center. During the two months following, 681,466 total vaccine doses were administered (477,397 prime doses and 204,069 boost doses) according to the Oklahoma weekly epidemiological report dated February 18.

COVID-19 vaccines available in Oklahoma.

There are two vaccines with Emergency Authorization Use (EAU) in the US – Pfizer and Moderna. Johnson & Johnson may achieve EAU by the end of February 2021. The Adenoviral vector vaccines are cheaper and easier to store – their approval will be welcome in the vaccine effort. There are many other drug companies developing vaccines. The following chart was created with information found online. This information is subject to change as clinical knowledge expands. For example, Pfizer is seeking ways to eliminate the ultra-cold storage requirements, allowing for greater accessibility to the vaccine. Age requirements may change as trials are completed on adolescents and teens.

COVID-19 vaccine eligibility. By now, most are familiar with the four phases for the vaccine rollout. An overlapping approach is used, meaning anyone who is eligible remains eligible in subsequent phases. A clear timeline is difficult to predict. However, when Phase four arrives, everyone that wants a vaccination will have an opportunity to get it. Phase one included nursing home residents and emergency healthcare workers. Phase two (which we are currently in) includes those over age 65 and healthcare workers providing direct care services (such as dental professionals) – these two subgroups are receiving vaccine. Starting February 22, those with co-morbidities, and teachers/ staff (grades pre-K – 12) will be eligible. The goal is to have PODs (Points of Dispensing) for pre-K – 12 teachers and staff completed before Spring Break. Phase three will include teachers and students outside of pre-K – 12 (such as colleges/vocational technology schools) and essential business/industry workers. Phase four is for everyone. Neither of the currently approved vaccines can be re-frozen. No vaccine should go to waste, which is why occasionally vaccines are given to those in close proximity, regardless of which phase they are in. These deviations happen when there are extra doses; vaccinating a person is vastly preferable to throwing a dose away. Keep in mind, every dose injected protects the community. I worked a boost POD on February 19 in Grady County for people over age 65. My duties included preparing needle draws, administering shots, and monitoring post-injections. I’m not sure how many shots were given, but it was more than 800. Several people showed up without an appointment hoping to receive their second vaccination (some because they had missed an appointment during the winter weather event).

A handful were successful, but others were out of luck because the vaccine supply was depleted. People traveled relatively long distances and were pleased with the smooth flow and friendly, competent nurses. The overwhelming gratefulness of family members assisting their loved ones and those getting their boost shots was reminiscent of those attending an OkMOM event. Two takeaways: 1) For Pfizer and Moderna, boost shots can be given up to four days prior to the recommended interval of 21 and 28 days, respectively; there is no maximum interval for either vaccine; and 2) Drawing that last precious dose from a vaccine vial requires experience and skill. COVID-19 vaccine POD sites. The availability of vaccine appointments depends on vaccine supply and the number of providers available to administer the injections. With Pfizer and Moderna, the supply must include vaccine for boost shots. At this time, the demand is greater than the supply resulting in appointments being quickly booked. Supplies have been limited, delaying PODs and pharmacies from having adequate vaccine. More providers are on the horizon and soon more product will be available. This information is fluid.

• State portal – the scheduler for most county health department-administered

PODs: vaccinate.oklahoma.gov • OK County and Tulsa County Health

Departments – check their websites/ postings. OK County may use vaxOKC. com or SignUpGenius; Tulsa may use the state portal. • Walmart/Sam’s Club – 43 locations in Oklahoma are or will be offering vaccines; check their corporate websites. • Walgreens and CVS – assisted vaccination efforts in long-term care facilities. Check their websites for updates on when they will have vaccination available for the public. • Clinics/Medical facilities/etc. – check local pandemic providers, social media, and local news sources for PODs in your area.

Immunity and our role. Once a person has completed the appropriate vaccine doses, the expected efficacy level of immunity will occur in ten days to two weeks. It’s unclear how long this immunity lasts, to what level, how effective the vaccine is on variants, and if annual boosts will be recommended. As Vaccines do not cure or treat disease. Rather, vaccines make us less susceptible to getting sick and lessen the severity of disease and death thus making transmission more difficult. Herd immunity occurs when enough persons in a population are immune from an infectious disease to prevent community spread. Herd immunity protects both the most vulnerable and society as a whole. The percentage of those who are eligible yet hesitate or refuse to receive the vaccine is uncertain. These individuals, by their inaction, put themselves and others at risk.

As healthcare providers, our words and actions matter. It’s our responsibility to stay informed, cite credible sources and promote prevention. Trust public health experts. The vaccines are safe and effective. Encourage your staff, patients, family and friends to get vaccinated. Be a role model. Be the light in the darkness and always speak the truth. Oklahoma COVID-19 data. Oklahoma produces a weekly COVID-19 epidemiology and surveillance report as well as daily updates. The reports are comprehensive and are comprised of daily, weekly and cumulative data, including cases, vaccines, hospitalizations, deaths, demographics, and much more.

You can sign up to receive the reports electronically. Links to multiple coronavirus resources are available at coronavirus. oklahoma.health.ok.gov.

Persons age 60 and above accounted for 95% of the deaths; 57% of those deaths were male. For vaccines, 638,966 prime doses have been administered and 368,851 persons have completed the series. Johnson & Johnson’s Janssen vaccine has achieved Emergency Use Authorization (EUA). ABOUT THE AUTHOR: Dr. Jana Winfree has been the State Dental Director at the Oklahoma State Department of Health since 2008. As the State Dental Director, her duties include dental public health efforts for the state: community water fluoridation, oral health surveillance, dental education, acting as subject matter expert and administering the state Dental Loan Repayment Program. Dr. Winfree graduated from the University of Oklahoma College of Dentistry in 1985 and earned her Master of Public Health from the OU College of Public Health in 2015.

DON’T GET CAUGHT IN

Original article written 2.22.2021 Update, 3.8.2021: Since the article was THE RAIN. written, there have been changes made in the way COVID-19 deaths will be reported in Oklahoma. The state Disaster Relief will begin using CDC death certificate reports Assistance for Dentists rather than reporting cases confirmed via a full investigation. This upcoming change will result in higher and timelier death counts. As of March 7, 2021, there have been 428,007 cases and 4,534 deaths.

Collect What You Produce: WHEN PATIENTS COMPLAIN ABOUT YOUR FEES

By: Cathy Jameson, PhD | Part nine of a ten-part series

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” (Maya Angelou) January is a perfect time to analyze the critical factors of your business, including your fee schedule. National fee surveys are usually published in January and this can help you determine how appropriate your fees are for your area and type of practice. You may be concerned about increasing fees due to the pandemic or other factors that may be impacting your practice. At the same time, your costs of operation have probably risen over the past year. For example, it is estimated that the average cost of infection control per patient has increased twofold from $15.00 to $30.00.

You may also be concerned that patients will complain if there is any kind of fee increase. You may fear losing patients to other practices that charge less. However, no matter where you set your fees, some patients will regard them as too high even though most people don’t really know or understand the fees for dental procedures. But complaining about a fee doesn’t mean that they don’t want to proceed with treatment; it may just mean that they need help with a way to pay. There are only three ways to increase profit margin: [1] increase production; [2] decrease costs; and/or [3] increase fees. If your costs of operation have increased, your profit margin will go down unless you increase production or raise fees.

ANALYSIS OF FEES

We recommend that you analyze fees every six months to determine if your costs of operation (including individual dental procedures) have gone up and to respond appropriately and logically. Such analyses may but will not necessarily result in widespread fee increases. If your analysis indicates that fees should be adjusted upward, do so – as long as your fees are equitable, in line for your area, and reflective of the quality of care you are offering. If you continually update and upgrade your services most people will not even recognize that you have adjusted your fees.

THE LAW OF SUPPLY AND DEMAND

Many practices today are so busy that they are stressed to the max, so much so that they can’t even imagine putting in the time necessary to clean up their systems. The “busyness” of such practices and their dayto-day demands are holding them hostage. They are seeing large enough numbers of patients that they are having a hard time seeing them expediently. New patients are put off much too long; hygiene patients are not seen in a timely manner; major procedures are deferred far into the future because the appointment book is stuffed full of smaller appointments. Being too busy can squeeze patient time, increase overhead, and produce stress. You and your team need to orchestrate a plan to increase revenue while decreasing both the costs of operation and the stress level. Focusing on your practice’s fulcrum -- thorough diagnosis, careful and complete treatment planning, and well organized and presented consultations -- will lead to more comprehensive care, longer appointments, and less stress for both you and your patients. And if you are too busy and cannot see patients expediently, the law of supply and demand is in your favor. It’s under circumstances such as these that you should consider increasing your fees. You may lose a few patients in the process but you will be able to focus more intently on gaining higher levels of case acceptance and getting your practice under control. You must get out of the habit of thinking that high numbers of patients per day is the only way to be productive. What matters is how much dentistry you are doing in a day. Our Model of Success at Jameson Management includes seeing fewer patients each day, doing more dentistry per patient (when and where appropriate) and seeing those patients for fewer visits, minimizing the number of team members while maximizing their talents, increasing (and sharing) profits, and decreasing stress.

RAISING FEES: WHEN AND BY HOW MUCH?

Increasing fees by 10% may cause a small percent of patients to go elsewhere. However, according to Dr. Charles Blair, a leading authority on dental insurance coding, if a practice’s overhead is 65%, it would have to lose 22.3% percent of its patient family before bottom line profits would be negatively impacted. In this case, a 10% across-the-board fee increase (with no additional overhead items) would increase bottom line profit over 28.6%. If you want to increase profitability by increasing your fees, you must be prepared for possible negative response by some patients. A few of them may decide to leave your practice to go to a lower-fee competitor. (In our experience, this rarely happens.) You and everyone on your team must believe in the equitability of your fees. You should also agree that seeing fewer patients each day, doing more dentistry per patient, and seeing patients for fewer visits are desirable goals.

INSURANCE AND FEES: USUAL AND CUSTOMARY

If a patient receives a letter from an insurance company inferring that your fees are above usual and customary the patient could be understandably confused. This is a prime example of a third party intruding on the doctor/patient relationship. You would be upset if the patient developed a misconception about the legitimacy of your fee. Your team could also conceivably become “gun shy” about dealing with upset patients. The following steps can help deal professionally with any complaints your patients may have about your fees. 1.Have your entire team practice the verbal communication skills necessary to manage patient objections.

2.Create a letter that can be sent to patients to address any protests about “usual and customary.” 3.Develop a letter to send to insurance companies and to the state insurance commissioner to protest their intrusion into the patient/dentist relationship.

SUMMARY

Obviously, you don’t like to have patients complain about your fees, and you certainly don’t want to lose them to someone else offering lower fees. In reality, this happens much less than you might imagine. The dentist/patient relationship is usually so personal that your patients’ trust in you and your team will be sufficient to retain them if they perceive that your fees are equitable for the services they are receiving. Do not let those few patients who may give you a hard time influence your fee decisions. A small handful of such patient protests will not cause you to go belly up; but not raising your fees when your costs of operation increase could do so.

Set your fees to match the excellence and quality of what your practice offers to your patients. Make adjustments as necessary to respond to any situations that affect your practice income. Study and develop the necessary communication skills to fully and accurately present your fees and where necessary the rationale behind them. You may be surprised how much this step alone can overcome patient objections. In closing, provide care you are proud of and let your fees stand as a clear indication of your practice of excellence. ABOUT THE AUTHOR: Cathy Jameson, PhD, is the founder of Jameson Management, Inc., an international management, hygiene, and marketing firm which offers proven management and marketing systems for helping organizations improve in a positive, forwardthinking culture. Jameson holds a doctorate in management from Walden University where she focused her research on transformational leadership. She has been inducted into the College of Education Hall of Fame and is a Distinguished Alumna of Oklahoma State University. She serves on the Board of Governors there. Jameson has been named one of the top 25 Women in Dentistry and has received Lifetime Achievement Awards from the Excellence in Dentistry Organization and from the Academy of Dental Office Managers. She was a finalist for the Stevie Award for outstanding entrepreneurial women. She is a member of the American Association of Female Executives, National Speaker’s Association, Academy of Dental Management Consultants, National Society of Leaders and Success and Chi Omega Women’s Fraternity. Jameson has lectured in all US states and in 31 countries. She has had over 1,500 articles published throughout the US and the world. She is the author of eight books, including the 3rd Edition of her bestseller, Collect What You Produce and Creating a Healthy Work Environment. These can be purchased from Amazon.

For more information on Dr. Jameson’s lecture or personal consulting services, contact her at cathy@jamesonmanagement.com. For more information on the consulting services of The Jameson Management Group, contact

www.info@jamesonmanagement.com or www. jamesonmanagement.com

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