practical prosthodontics for the dental team · brush or tepe sub-gingival therapy 8 week review ....
TRANSCRIPT
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Practical Prosthodontics for the Dental Team
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BSSPD means a lot to me
Peter Briggs BDS (Hons) MSc MRD FDS RCS(Eng)
Consultant / Senior Lecturer QMUL / Bart’s Health Trusts (London)
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• The likelihood of a UK dentist facing some kind of regulatory challenge (i.e. by the GDC) is much greater than for:
• Dentists anywhere else in the world – including USA • UK medical practitioners (3.5 times risk) • Any other kind of registered healthcare professional in
the UK • Any other dentists, anywhere else in the world – period!
2015 Prosthodontic Risk for the Dental Team
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2015 pyramid of risk: top of the dental pops
Endodontics
C & B
Periodontology
(or missed perio)
Nerve Damage
Implants
Orthodontics
Veneers
Oral Surgery
Effective team work reduces risk
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Where are the Pros / Endo interface risks? Let’s look at me in action – there for the grace of God go I
2015
2015
2015
Abbott 2004
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Knowing what is predictable to restore – TRI And what is not! – are too many restorable teeth being extracted?
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2015 Terminal abutment – team needs to bring in their ‘A game’ – lots of new things to help
Foundation (perio / endo), core design, preparation, impression , static jaw registration, temporisation, crown construction, try-in,
cementation and polish
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Agreed Team Standards
E-max Monolith UR6 – single strategic RCT’d tooth
Walton Dental Arts
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What is your diagnosis and what should be done?
Never let the sun go down on pus – knowing what antibiotics will and will not do?
Systemically unwell? - need to find out with a thermometer
Where are the Pros / Endo interface risks?
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Knowing what antibiotics will and will not do and knowing how to use LA to numb ‘hot’ pulps
Only 50% of IDBs will fully work with hyperaemic mandibular molars – will need top up
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Where are the risks – C & B?
• Abutment condition and prognosis • Static Jaw Registration / Occlusion • Impression quality & fit • Posts / Cores – as abutments • Aesthetics / shade / shape / margin etc
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Prevention & Identification of Identifying Partial De-Cementation
Conventional Bridges (Briggs et al 2013)
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Christensen, G. J. J.
The use of porcelain-fused to metal restorations in current dental practice:
a survey J Prosthet Dent 1986;56:1-3
75% of dentists questioned used porcelain on the occlusal surfaces of premolars and molars most or all the time for their patients
Honesty
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73% of the same dentists would use metal occlusal surfaces for their own teeth or those of their family – the friends or family test has been around for a long time!
Christensen, G. J. J.
The use of porcelain-fused to metal restorations in current dental
practice: a survey
J Prosthet Dent 1986;56:1-3
My suggestion: mix and match – where is in the best interest of patient
Honesty
Walton Dental Arts
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Team Standards – Impression quality The Use of Gingival Retraction Cord
Seems that we struggle Storey and Coward (2013)
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We as a team must know what is an acceptable / decent impression in 2015 – many C&B complaints relate to suboptimal marginal fit / recurrent caries
and sensitivity – your nurse should be able to tell you yes or no – before your technician
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Plan A: Single Retained Gingival Retraction Cord
• Pack dry cord apical to the preparation margins • Take the impression with cord in place • The impression then has to come out!
Walton Dental Arts
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Plan A: Single Retained Gingival Retraction Cord / Injectable Expansion Matrix
• Occasionally the cord will come out with the impression - it can be easily peeled out without problem • The cord can be left in after impression taking to facilitate construction of provisional restorations • Remember to remove the cord before the patient leaves!
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Plan B(1) – I like the yellow tip for moderate cases
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Electro-Surgery / Diathermy / Radio Waves (Moderate)
• Sub-gingival margin(s)
• Thick (and often inflamed) gingival tissue which has rolled over the preparation margin
• Need for good quality impression in one visit – instant trough around tooth in which impression material will flow – time is money to patients and dental practices in the real world
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Plan B(2) – aggressive use of electro-surgery with good biological width and attached
gingivae – to create ferrule
Optimise coronal height
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Plan C • Where you cannot create 3mm of crown height
with shortened teeth – e.g. broken down tooth / #’d tooth / tooth wear – with soft tissue loss alone
• Where thick gingival and connective tissue are not primarily responsible for the issue
Crown Lengthening Surgery – moving the ‘whole attachment apparatus’ level up the
root of the tooth
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Agreed Team (Band) Standards for dentist, nurse, technician
• Flash of impression material around the tooth/ teeth
• No ‘blows’ in essential areas (e.g. margin)
• No drags in essential areas
• Support for the impression material – especially distal tooth
Impression Standards
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Post Crowns - Metal or Glass-Fiber?
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Walton Dental Arts
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Maximise Ferrule
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Post and Crowns – a team game
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End cutting post burs can create signif greater deviations from the centre of canals compare to non end cutting burs like - Gates Glidden (Gegauff et al 1988) Therefore safest to use measured GGs first to remove (mostly by
heat) the GP and then prepare / cut a post channel within the root
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Why is cementation and seating of posts so important?
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The ‘Moshonov’ Gap to be avoided
Team work: nurse, technician & dentist
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Greater risk of periapical infection when there is a radiographic space between the root filling and the post
(Moshonov et al 2005)
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No Gap - 83.3% PAH normal GAP 0-2mm - 53.6% PAH Normal GAP greater than 2mm - 29.4% PAH Normal
Team work: mind the gap
Walton Dental Arts
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We need to get the cement right down the root and not just place on the post to wipe up and out coronally when you insert the post!
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Spiral Filler
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Assuming the root intact, good 5mm RCT, decent ferrule, decent length post, a single crown, no deep localised pockets and
treatment done well - then one is looking at a very high survival of single and multi-rooted teeth supporting single fixed
restorations (Salvi et al 2007)
33 Team work must ensure good execution – ‘band’ standards
Walton Dental Arts
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• Implant cases of all kinds
• Allegations of a failure to diagnose and adequately treat periodontal disease
The two significant things to note about the UK picture compared to other countries at present
are the prominence of:
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• Tooth position
• Face and Lip support
• Flangeless denture try in – can give patient to take home
• Agreeing aesthetics and then attempting to deliver – bone graft to create enough facial and upper lip support without denture
Aesthetics - Fixed or Removable? Starts with Prosthodontic Team Planning
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The Team: patient, dentist, technician, nurse, family and friends
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Assess how much dento-facial support you lack ( lip and mid face support) and can this be returned with fixed
Prosthodontics or do you need a flange?
36 Appearance & Speech
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As a team you do not want to do all of this and find at the end that the upper lip and face ‘is still flat’
(unhappy POP)
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Team planning is the gateway to success for both sides
Team work: CAD CAM Titanium screw retained superstructure
Walton Dental Arts
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Implants can be disappointing – remember that the planning should always be driven Prosthodontically
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Diagnostic wax up to dictate tooth position, relate this to bone anatomy (+/- CBCT), make stent, XYZ team execution
Walton Dental Arts
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Team work – think XYZ responsibility
What are you aiming for Screw-retained or Cemented?
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We often blame (someone else’s) restorative work for causing ginigival inflammation – remember crowns are usually over-contoured compared to natural teeth and therefore tend to
deflect toothbrush bristles over the gum – we do not usually need to replace them to resolve this problem - even when they are far
from perfect
We cannot control inflammation
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Home cleaning and care is the Treatment – it starts with a tooth brush and a patient - we all need to be able to show and motivate people how to brush their teeth
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The effect of supragingival plaque control on the progression of advanced periodontal disease. J Clin
Periodontol. 1998;25:536-41. Westfelt E et al.
‘…..Inflamed and bleeding sites are the most at risk of long-term deterioration….’
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Periodontitis - The Concept of Healthy Pockets
Surely, we should be most interested in maintaining attachment levels - but why does everyone ‘over focus’ on pocket depths?
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Patient’s must be shown how to clean under the pockets – single-tufted brush or Tepe sub-gingival therapy 8 week review
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Patients must ‘earn’ their RSD followed by Supportive Periodontal Therapy SPT - if lots of inflammation (means poor OH) – it’s a waste of time. It is no use starting with the scaling!
• When I cannot make the patient bleed with the tools I have given to them they are doing their best – means that they are controlling their inflammation
• If my probe makes them bleed – they then need professional help
• RSD for pockets of 4mm or more
Patients must earn their right to RSD
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Summary: A Successful Team for Prosthodontics
• Able to communicate with patients and each other • Follow your instincts – ‘….be careful of this patient I think that they will be
impossible to please…’ • Well informed – share information – compliment each other’s weaknesses • Develop your culture and ‘band’ standards – what are you all about? • Trust each other and know that your view may not be agreed with but will be
heard • Remember that there is no ‘I’ in team • Share and deflect the glow of success • All learn from disasters and share the blame • Prosthodontic Outcome and standards will be dictated by the weakest member
of your team
hodsollhousedental.co.uk