When I was growing up in dentistry, Dr. Omer Reed was hands-down the best teacher of clinical dentistry and practice management. Over the years, I attended many of his courses and learned about systems and consistent results in seating inlays, onlays, and crowns by primary intent. I took my team with me to many of these courses, and they learned how to be the best by systemizing all of the practice. We would take home the information that Omer presented and process it until we were able to put it to use and call it our own.
In order to grow in dentistry or probably any other profession or job, I believe we must be able to be comfortable enough to question everything we do. As I empowered my team, they became better at asking "what if?" about the systems and procedures that we had put in place. Change became a constant in our practice. I feel that this type of attitude keeps us excited and energized. Our ultimate goal was to help our patients keep their teeth for the rest of their lives.
When we are doing any procedure, we need magnification. In the last 10 years, we have seen this part of the dental industry make many changes, not the least of which are the cool and very comfortable frames that are available today. In order to be properly fitted for magnification, you need to be properly measured for distance and declination. The distance is best measured when you are in your practice treating a patient. While you are sitting with a patient, get into a comfortable position with your back and neck straight. Then have your dental assistant measure the distance from your eyes to the mouth.
Declination is the angle at which the magnifier is glued to the glass. This is an extremely important measurement that will determine whether you are able to sit comfortably during long restorative procedures. This measurement will help you avoid being out of position. A large number of companies are in the market to sell magnification today. Be sure the one you buy from understands these principles.
You might consider having your dental assistants and hygienists fitted for magnification as well. My assistants say they can really see what I am doing while I prep teeth now and thus are better prepared for the next step since they wear magnification too. My hygienists were hard to convince, but when they finally tried them on a 30-day trial, they did not want to send them back, so I bought them!
Your back, arms, and legs need proper support as well so that you can easily stay in the proper position to be comfortable throughout any procedure. Many stools will help you maintain a good balance for your entire body. You may have to spend a little more money, but how much is your comfort worth? Be sure the team member who sits across from you is sitting comfortably as well. And don't forget about seating for your hygienists.
I am a great believer in presterilized disposable burs and diamonds. I have been using them for more than 30 years. You and your patient deserve a sharp cutting instrument every time. If you are using "reusable burs and diamonds," you have no idea how many times you have used them. I have asked your dental assistants many times during seminars how they know when to get a new diamond, and they all tell me: "When the doctor says the one he is using is dull." That is a poor system!
I buy my diamonds in boxes of 25 per size. I get my best price if I buy 100 at a time. I can mix the sizes in that block of 100 or more. Most all of the major diamond manufacturers today have disposable diamonds and burs. Dr. John Molinari has tested supposedly cleaned and sterilized burs and diamonds many times and found that they still grow bugs. Simply put, burs and diamonds cannot be cleaned and sterilized — another reason to go disposable. Your assistants will love you when they begin throwing them away after a procedure, and they will save time too!
Many dentists still pack cord before taking impressions. I am one of those dentists who hates packing cord. I now use astringent chemicals to control the gingival tissue. Over the past few years, a number of new products has come onto the market. They all do what they are intended to do, but some do it better than others. Look for a product that is easy to inject and position the material into the sulcus. Also look for a product that uses aluminum chloride as the astringent.
Here are some tips for great impressions. Always use tray adhesive. I know it is messy. If you do not use it, the great impression you took might come off the tray and distort the impression. If this happens, then Murphy's Law will guarantee that it will be under the prepped tooth impression, and your crown will not fit when it comes back from the lab. When filling the tray, always keep the tip in the material to avoid bubbles. When placing the wash, always keep the tip in the material to avoid bubbles. There are some great new syringes that can be filled with wash material directly from the cartridge and be used up to 12 hours later.
The last tip is to coordinate the placement of the wash and the seating of the tray. If the wash has been placed and the tray is still being filled, you are in trouble. Remember that this is a chemical reaction and the tray and wash materials must come together at the proper time for the chemical reaction to take place. Whenever we receive a new impression material, we always read the instructions, paying particular attention to mixing, working, and setting times. Then we practice using timers for each procedure so that we know exactly when to start filling the tray, when to start the wash, when to sit the impression, and when to remove it from the mouth.
The latest change in impressions is the virtual impression. This takes the impressions that most patients dread out of the system. The teeth are simply scanned and the scan is either milled in the office for same-day dentistry or it is sent to the lab to make the restoration. Most companies will now sell a scanner system only, but you can add other technology later to upgrade. This gets you into the digital impressions at a much lower investment. Your patients will love you for it.
There are now bioactive materials on the market that will do things we once thought impossible. These materials allow you to do indirect and direct pulp capping, a pediatric pulpotomy, seal perforations, and internal and external resorptions. You can also use them as a base for deep carious lesions. In all of these situations, the bioactive materials will cause dentin to remineralize and to save a tooth from root canal treatment. It will also preserve pulpal vitality.
To simplify your bonding technique, be sure to check out the new universal adhesives. They are much less technique-sensitive and have fewer steps to follow when they are applied. Your assistants will love them.
With all the new materials being used for crowns and bridges, a number of new materials have been introduced for the cementation of these materials. It certainly looks like the porcelain-fused-to-metal (PFM) crown is dead. In the January 2014 issue of Dental Economics, Dr. DiTolla wrote that Glidewell Dental Laboratory is being requested to use the PFM in only 10% of the cases they receive.
I hope this article has helped to give you some ideas to simplify your practice and to provide better care so that your patients will keep their teeth for the rest of their lives.
Joseph Blaes, DDS, practices in St. Louis, Missouri. He is a Fellow of the American College of Dentists and currently serves on the board of the American Academy of Dental Practice Administration. Since 1996 he has served as the chief editor of Dental Economics
