The more complex the dental treatment plan gets, the more challenging the process becomes. Adding in interdisciplinary care with multiple specialists adds another layer of complexity. We need to clearly plan our sections, and clearly communicate the outcomes we hope for from the other providers.

The Challenges

One of the challenges has been communicating to my orthodontist my visual for the results. The other challenge has been how to visualize tooth movement to optimize my restorative. What has helped me tremendously is doing an ortho setup as well as a restorative wax-up.

My Process

This is a process I use when planning complex cases involving orthodontic and restorative that has helped create clear expectations for everyone.

1. I start my aesthetic treatment planning by drawing white shapes and lines on photographs of the teeth to determine the desired tooth proportions and gingival aesthetics. I’ve blogged about this before in these two articles: Tooth Proportion Aesthetic Ratio and Where the Pink Should Be. I also draw lines on photographs to determine the Anterior Segment Aesthetic Ratio.
2. When a complex restorative case involves orthodontics, I want a clear sense from my white lines of where I want the teeth moved so I can optimize my restorative. I will send a set of preoperative models to the laboratory and ask them to do an ortho setup. Multiple copies of the ortho setup allow us to move the teeth and do a restorative wax-up on the moved teeth. Once I examine the wax-up I decide if the teeth look the way I visualized they would. Do they have the right length to width ratios? Do they have all gingival margins in the right positions? If I were to just do a carved restorative wax-up, I wouldn’t understand if the tooth movement is helpful. If you are not familiar with ortho setups, I recommend reading this article from 2012.
3. Once I have the teeth positioned in an ortho model the way I think will be best for my restorative, I send my orthodontist the model to communicate exactly where I want the teeth moved. The orthodontist provides feedback on what will be involved to get those movements. Based on that, I can balance the risks and benefits of alternative treatment plans and discuss with the orthodontist whether restorative treatment should occur at the very end of orthodontics or be done in phases during orthodontic treatment.

Before I come up with a treatment plan, I always do certain things in a certain order. That structure has allowed me to feel confident that I can treatment plan any case that walks into my office. That structure, or process, affects how I approach my exam, make my diagnosis, and ultimately make my treatment plan.

The process begins by looking at the following five areas during the patient exam. I gather information in each of these areas in the following order:

1. The patient parameters of the case
2. The aesthetic parameters of the case
3. The functional parameters of the case
4. The restorative parameters of the case
5. The biologic parameters of the case

The first area I look at is the patient. What is the patient interested in? What are the patient’s circumstances, temperament, and dental health objectives? What is the patient’s current understanding of their dental health? How does that compare to my perception of their dental health? After answering these questions, I then move on to the four technical areas.

The first technical area I look at is the aesthetics of the teeth, gingiva, skeletal structure, and face. I then look at function, including the jaw joints, muscles, occlusion, and airway. The third area I look at is the restorative parameters of tooth structure, missing teeth, and the restorative materials and restorative techniques previously used in the mouth. And finally, I look at the biologic parameters, including caries, periodontal, and endo.

When I do my examination, I want information gathered in all five of these areas. When I sit down to do my exam diagnosis and treatment planning, I have all of that information in front of me and I’m going to always consider the five areas in the same order as I proceed with diagnosis and begin treatment planning.

When I plan the stages of treatment that will occur, the treatment sequence is in the order that is most appropriate for the case. For example, if the patient has a biologic health condition, perhaps, the need for a root canal or significant perio inflammation, I’m going to treat that condition at the front end of the treatment sequence, and not in the order in which I gathered information and reviewed it. The most appropriate treatment sequence will be the order in which I need to do restorative procedures to most predictably achieve the total best outcome.

Although my “structured approach” may not be the same as yours, I thought sharing mine with you could be of benefit to you. By establishing a process in which you gather and consider information in all five areas (Patient, Aesthetics, Function, Restorative, and Biologic), you will have all the information you need to consistently do diagnosis and treatment planning with efficiency and confidence.

For more information on this topic, I encourage you to take Treatment Planning and Case Presentation with me on June 11th – June 12th. This is a phenomenal way to solidify your knowledge and spend two days in sunny Key Biscayne, FL.

I was at the Ontario Dental Society meeting giving a presentation on occlusion, and I was asked one of the most common questions I receive when discussing anterior-only appliances: “What about tooth movement, either eruption or intrusion? Isn’t that a risk with these devices?” The answer is, yes there are risks, as with everything we do. Let’s consider the risks and how we can minimize and avoid them.

There are many types of anterior-only appliances, temporary and long term. Popular temporary anterior bite splint appliances are QuickSplint® and the Best-Bite™ Discluder from WhipMix®. NTI-tss Plus™ from NDX® National Dentex Labs is designed as a permanent anterior only and then there are the Kois Deprogrammer, Spear style deprogrammer, Lucia jigs, regular deprogrammers, Dawson B-Splints and so on. They are designed so that when the patient bites in MIP, they only touch on the front. When the patient goes into any excursive position (right, left, forward or back), they can only touch in the anterior—plastic to plastic or teeth to plastic.

We love anterior-only appliances because of their efficiency and effectiveness in eliminating posterior contact and allowing TMJ muscles to optimally relax. But we do worry about tooth movement, so how do we evaluate the risk and how do we minimize it?

There are a couple of pieces to this puzzle. We know that super eruption of the back teeth may occur if the appliance is worn more than ten hours a day, consistently over many days, even weeks, in a row. This means the risk is minimal with nighttime wear only for eight hours a night. Since we do not want patients to wear these types of appliances 24 hours a day, a patient in acute pain might be best helped with an anterior-only appliance for nighttime and a different type of appliance for daytime.

There is also a risk of lower tooth intrusion. There are two ways to deal with that. One is to make sure they have contact from canine to canine to distribute forces. Another is to make the upper anterior discluder against an appliance on the bottom that is called “a slider.” This is essentially a thicker version of an Essix retainer on the bottom to distribute the forces. I have made these appliances for many years and have not observed a problem in my own practice. I had one patient with significant deprogramming who could only touch on her first point of contact, but that was not due to tooth movement. It was because of total elimination of her masticatory muscle memory.

If you are concerned about tooth movement, I recommend making the upper discluder on a full arch Essix and then put the patient in a full arch lower Essix (lower slider) that will distribute the forces. That will prevent the problem of super eruption and should significantly minimize potential for intrusion, even though you only have midpoint contact. This is a great way to moderate the risks of tooth movement for patients who are going to wear an anterior-only appliance long term.

I would like to add, that any time you put a patient on appliance therapy, you need to see them for post-op appointments. You need to verify the appliance is working—that their signs and symptoms are going away or minimizing. And, you need to check their occlusion and mandibular position. So, I always plan multiple follow up appointments and include those in the appliance therapy fee. Even when the patient and I think everything is going great and they are wearing their appliance only at night long term, I ask them to bring their appliance to every Hygiene appointment for professional cleaning. This reminds us to ask how things are going with their appliance and gives me the opportunity to check their occlusion and make sure there are no negative consequences of the therapy. I also tell my patients to call if they notice any change in their bite. “We need to have you come in and check that right away.”

In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

How long does a dental crown last? The answer is, “It depends.” In this blog, I will review how I manage answering this question for my own peace of mind and to reduce disappointment for my patients.

All of us can think about crowns that are currently in our patients’ mouths that have been in four decades or more…crowns that are doing fine. Sometimes, we look at a bite wing of one of these restored teeth and see space enough “to drive a truck” between the margin and the natural tooth structure. Yet, the crowned tooth is fine with no caries.

We also can think about crowns in our patients’ mouths that needed to be or now need to be replaced within five years or under…perhaps, even within two years. Some of these crowns were carefully and beautifully done.

We have a habit of thinking: The better our skill is, the greater is the longevity of the crown. We need to get away from this generalization because there are numerous factors that impact longevity.

Yes, the dentist’s skill is a factor as are the amount of time and energy we put into making it exquisite, the quality of the laboratory, and the materials. But the other part of the equation is that we put dentistry into the mouths of human beings, and human beings come with risk factors. The most common reason we replace a crown or filling is recurring caries. We see some patients who have new carious lesions every time we see them in the dental chair. They are at high risk. At the other end of the spectrum, we have patients who have not had a carious lesion in multiple decades. The functional risk of the patient is the second primary risk factor. We have patients who can break any type of crown, and we have other patients who have no evidence of functional risk.

What do I say to my patients? I tell them dentistry does not last forever, and there are challenges in predicting the lifespan of their restorations. I do not say, “When your crown fails at some point in the future, it will need dental treatment again.” Instead, I say, “We’re going to treat this tooth with a crown. At some time in the future, it will need treatment again.” Then I say, “The most common reason why a crown needs to be replaced is dental decay around and under the crown, and what we know about you is that you tend to get cavities [or not get cavities]. The second most common reason we replace crowns is that they break. The materials cannot withstand the forces. And what we know about you is that you are tougher on your teeth [or not as tough on your teeth] compared to many other people. “

This type of conversation makes most dentists nervous. They fear the patient will not want to do the crown if the patient knows they will eventually need to retreat the tooth. That has not been my experience. The reality that cars do not run forever does not stop us from buying a new car. The knowledge that your roof will last 10 to 14 years does not stop us from replacing the roof. The reality that the tooth will need retreatment in the future does not stop us from having it treated now.

Setting realistic expectations results in less patient frustration, sadness, and disappointment. It also lessens conflict between the dentist and patients. I want my patients to understand the reality that dentistry does not last forever. It all has a lifespan, just like a car or washing machine. Any tooth we treat will need to be treated again. I also want them to know their risk factors for decay or breakage relative to other patients. Is it high? Is it low? Is it somewhere in between? We can then have a conversation about what they can do and what we can do together to minimize those risk factors.

Ferrule is a critical factor in being able to plan the prosthodontic phase of treatment for an anterior tooth that has had endodontic therapy. It is also an ingredient in predicting the longevity of the tooth and restoration. Yet, given this level of importance, it is often misunderstood and overlooked.

What is tooth ferrule?

Ferrule is the amount of natural tooth structure we have left on an anterior tooth on which we are going to do a post-core and crown. Knowing the amount is integral to knowing how we are going to seat the crown and it gives us ballpark information about the longevity of that restoration. We look at the natural tooth structure of the tooth on the buccal and the lingual.

The amounts of the natural tooth that are left on the mesial and distal don’t matter. We don’t measure them. They don’t help us at all with retention and longevity.

On the buccal and lingual, we look at the height of the natural tooth structure, measuring from the margin of the crown prep up to where the core starts. We also look at the thickness of that natural tooth structure, measuring from the outside surface of the crown prep to the inner surface where the post space begins. We measure the height and thickness, both buccal and lingual. We then use the smallest number. If we have less tooth structure on the lingual, then the ferrule is determined on the lingual. If we have less thickness than we have height, then the ferrule is determined by the thickness.

Wherever the place is where we have the least natural tooth structure, that now becomes the ferrule we use when we start to think about how we are going to treat this natural anterior tooth.

How does ferrule impact restorative decisions?

The amount of ferrule impacts restorative decisions such as:

• Bonding versus cementing the post
• Bonding versus cementing the crown
• Doing a post at all
• Predicting longevity after restoration

Guidance for these decisions has been formed from substantial research published by the University of Washington School of Dentistry in Seattle that looks at the longevity of the post-core based on the amount of ferrule and whether we bond or cement.

If we have minimum ferrule (1.0 to 2.0 mm) and we want to get the maximum longevity for the anterior restoration, we should bond the post-core and then bond the crown with a dual-cure resin bond system that adds strength to the restorative material, like NX3 Nexus™ Dual Cure from Kerr, Multilink® Automix from Ivoclar Vivadent, or G-CEM LinkForce® from GC America. There are lots of choices of systems you can use, but we need to etch, prime, and bond for high bond strength. We need to keep in mind that even though we are increasing the longevity of the restoration by bonding, the restoration on minimal ferrule will not last as long as a restoration on a greater amount of ferrule.

If we have 2.0 to 3.0 mm of ferrule, we can choose whether to bond the post-core and cement the crown or to cement the post-core and bond the crown to get the same longevity as the tooth with 1.0 to 2.0 mm of ferrule treated by bonding both the post-core and crown. When we have 2.0 to 3.0 mm of ferrule, we can increase the longevity of the restoration even more if we bond both the post-core and crown.

If we have greater than 3.0 mm ferrule, we can cement both pieces without affecting longevity.

If we have 4.0 mm or greater of ferrule, the question becomes whether we need to do a post-core on this tooth or do a fully bonded restoration.

Key Points to Remember

• The amount of ferrule we have has a strong impact on the longevity of the restoration.
• We can increase the longevity when we have less ferrule by bonding both pieces, the post-core, and the crown.
• When we have very little ferrule, we need to understand that we have a reduced longevity for the post-core restoration, even in the face of bonding.
• The amount of ferrule is one of the strongest indicators of how long an anterior crown will last, as well as whether we have bonded or cemented. How long a crown will last involves additional factors I will discuss in another blog, How Long Do Crowns Last?

I think pre-operative rinsing is here to stay. Science supports it is effective against viruses, including COVID19. And it is easy to do.

Pre-operative rinsing has been discussed in dentistry for a long time, especially before hygiene visits. Today this is an even more relevant conversation, and we are examining its efficacy again with renewed interest. Here are three to consider:

Hydrogen Peroxide Mouthwash

We know hydrogen peroxide works. It is highly effective against the virus and is recommended as a pre-operative rinse right now. A readymade hydrogen peroxide mouthwash is Peroxyl. You can also take 1% hydrogen peroxide and mix it 50/50 with a flavored mouthwash. The required time for effectiveness is a minimum of 30 seconds. Some publications are recommending the patient rinse with hydrogen peroxide for two 30-second cycles. If 30 seconds is too long for a patient, they can increase the number of times they swish for fewer seconds. You can set a timer to guide the patient and make sure the patient is swishing at least 30 seconds in total.

Iodine Based Mouthwash

The literature indicates iodine based rinsing solutions are also highly effective against the virus. There are iodine based mouthwashes you can purchase for use in your practice. As some people are allergic to iodine, you will need to carefully screen patients before use, asking if they have a known or suspect allergy. Can they have betadine on their skin? Can they eat shellfish? If iodine should be avoided, then you will want to use hydrogen peroxide.

Chlorhexidine Mouthwash

The process of rinsing with chlorhexidine before an appointment and/or adding chlorhexidine so it comes through the water spray of a Cavitron or Ultrasonic Scaler is not new news. For a long time, we have been using chlorhexidine mouthwash as an adjunct to oral hygiene following periodontal treatment. There is science that chlorhexidine kills microbial cells withing 30 seconds of contact in the sulcus biofilm, but is it effective as an antimicrobial pre-operative rinse to reduce the risk of COVID19 exposure? We do not know. We cannot point to the science that would tell us it is equally effective against the virus as other options. However, I have heard studies are underway with good clinical results so far.

When we send tooth color or shade information to the dental lab, the most important aspect is the value. This is the light reflectiveness of the tooth. We describe it as looking bright or gray. Choosing value is important, and it is often overlooked.

Value is the amount of light reflected off of an object. Low value occurs as light goes through an object or is deflected away from our eyes. High value occurs as light is reflected back to our eyes. Teeth that are lower in value appear grayer. Teeth that are higher in value appear brighter.

Value was difficult for me to choose until I started using the VITA 3D-Master Linearguide system that uses the same designators as the VITA Toothguide 3D-Master system, but additionally has a dark gray card that allows you to make value comparisons from 0 (zero)–the most reflective, to 5–the least reflective. I just put the dark gray value lineation card (shown above) against the patient’s teeth and move it from right to left to find the value that has the same light reflectiveness as the tooth. Based on the value I choose, the VITA 3D-Master Linearguide tells me which cards in the system to use to select the chroma and hue.

In 2017 the American Dental Association adopted a policy encouraging dentists to screen patients for sleep-related breathing disorders (SRBD). This includes assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to a physician as appropriate. When this happened, I called my friend Dr. Steve Carstensen, who is at the forefront of sleep dentistry and asked him what we should implement in our dental practice. One of the tools he suggested is a quick and easy visual assessment called a Mallampati score.

The Mallampati score is one of four things we now do in my practice as a four-part sleep screening. (In Dr. Kelly Brummet’s recent PankeyGram article, she wrote about what this score determines and how she uses it in her practice, so you will want to go back and read that article as well this one.)

We have laminated copies of the Mallampati visualization chart (see below), which we printed from the Internet. We used these for visual reference in both of my operatories and the hygienist’s operatory. To make a visual assessment of the back of the patient’s mouth, say to the patient, “Open wide.” You don’t depress the tongue. The patient doesn’t say “aah.” The patient just opens wide. Then you look to see which of the four Mallampati images most closely matches what you see and give the patient a 1 through 4 score based on the image.

This is just a simple way to see if we think anatomically the patient can move air past the base of the tongue. My hygienist and I do this in conjunction with the STOP BANG questionnaire, Epworth Sleepiness Scale and asking about nose breathing.