Tissue Management For Dental Restorative Procedures - Part 1

You're listening to the Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. This will be a two-part series that will explore tissue management techniques for the dentist and patient with the goal of optimizing dental prosthetic outcomes. Today, which is part one, will include pre-prosthetic tissue management regimens for the patient, diagnosis and periodontal evaluation, and biologic provisionalization as a key to optimize tissue health. Our guest is Dr. Robert Lowe, who maintains a part-time private practice in Charlotte, North Carolina. He publishes and lectures internationally on aesthetic and restorative dentistry. And Dr. Lowe is also an assistant professor in the Department of Oral Rehabilitation at James B. Edwards College of Dental Medicine, Medical University of South Carolina in Charleston, South Carolina. Dr. Lowe, it's a pleasure to have you on Dental Talk. Bill, it's always a pleasure. Good to hear from you. So thanks for joining us for this because I know you've got a busy day out there and we're all busy. We appreciate your insight on this important topic, actually, which is tissue management. So to begin, what are some elements of the initial patient pre-treatment evaluation that are often missed that can have a profound effect on the long-term outcome of a case? Well, Phil, I think the number one thing to look at is perio, perio, perio. And I can't overemphasize that. I think in most private practices, particularly when new patients come in and whatnot, and they're introduced in the hygiene appointment, and the doctor doesn't have a lot of time to do a screening, some of these things can be missed. I mean, we're trained to look for caries and perio disease, and the hygienist will clean the teeth and do some pocket measurements and whatnot. I find that a real thorough period diagnosis, looking at the amount of attached tissue versus the amount of keratinized tissue, there is a difference. I think a lot of doctors forget that the part of the pocket that they measure, although that tissue is keratinized, it's not attached. So when considering crown and bridge or prosthetics, the amount of attached tissue that's available is important and needs to be considered. Also, the patient's overall hygiene and ability to keep their teeth clean. A lot of times we're, I think, jumping into doing restorative before some of these early criteria are met. And who does the pretreatment evaluation? Is that the dental hygienist in your practice? Actually, my practice still is a little bit unusual. I've actually run full circle. I started practicing in 1983 out of a residency in Chicago. I graduated from Loyola in 1982. It was a new office with me and my dental assistant, Mary, and everything that I did, she didn't do, and everything that she didn't do, I did. I did all of my own hygiene. I did all of my... My examination appointments were an hour to an hour and a half where I'd collect data, take models, take x-rays to a thorough hygiene screen or a perio screen, a TMJ screen, occlusal examination. And these are things that are, I think, important in making a good diagnosis. And then we start getting busier with hygienists and we start having, you know. the hygiene checks and things like that, and I think we lose a lot of time. So to answer your question, sorry in a roundabout way, and in my practice, patients come in the door with a 90-minute appointment with me to do clinical photographs, x-rays, TMJ screen, perio exam, occlusal screen, and I get all of this information together. And then if I have time, I clean their teeth or I bring them back and clean their teeth and discuss the findings. So let me ask you this. How does the patient's ability to maintain their tissue health, and this is, of course, at home, affect the quality of dental treatment with today's materials? Well, I tell you, Phil, it goes hand in hand. People have to understand one thing. They ask us two things, how much it costs and how long is it going to last? you know, costs are relative based on, you know, overhead. How long things last, I tell patients, look, I can stack the deck in your favor, but if you don't change the oil under the hood, this is not going to last. So the pre-treatment examination and evaluation and post -treatment follow-up with the patient as far as home care and giving them the tools to make home care not only something that they'll do, but something that will benefit the long-term life of the restoration is critically important. So do you think in many cases that's kind of not ignored but undervalued, making sure that that tissue is healthy before direct and indirect restorative procedures are carried out? Well, my fear is that it is undervalued to the patients. And in today's world where, you know, it's all how many patients I can see per day, what the production is. I mean, people will say that doing your own hygiene and exams is not productive. Well, I'll tell you, it's one of the most productive things I do because I find work and I book treatment. It's not something I can do when I'm in the middle of a bridge prep and run into a hygiene check for three minutes. So I think it is undervalued. And the important thing is to get the patient on the home care track right away. And we've been using... implements like Sonicare toothbrushes for years. I mean, the technology in Sonicare has been amazing, and people use that. And one of the other things, and we'll talk about a little bit through the course of our podcasts this time and next time, is a new product from Philips called Power Flosser. If you ask people on their medical histories how many times they brush and floss a day, most people will put down twice a day, this, that, or the other. And you know right away whether that's accurate or not. That's one of the reasons why in my initial appointment, I take photographs. I need a photographic document of how the patient presents before we treat them so that we can refer back to that. We have a snapshot in time. We can look at... um progress and things like that so i take all these pre-treatment x-rays and photographs and then i review those with the patient you know you can show them where they're having problems with home care where they're where they're building up tartar or plaque where they're not effective with uh keeping their teeth clean and most of the time it's in the posterior and we we start out there and give them those instructions On all of my rehab cases, I give them a Sonicare toothbrush as part of the treatment package because once we're done, they've got to maintain. So it's important in any, I think, treatment, whether it's a single tooth, quadrant, or full mouth, to get them off on the right foot as far as being able to take care of your good work. Yeah. I had tooth number 30 done a couple of months ago, a single crown, and the temporary that was put in caused two episodes of PCOR. I do have my one-third molar in there. Between 30 and 31, I had this incessant inflammatory response from food impaction because the temporary that she put in didn't make contact well and it was never checked by the dentist. I wasn't real happy, but it turns out that the final gold crown, which they put in, I went to gold is beautiful and I'm having no problems at all. So, but during the period of getting that gold crown, which was like five weeks, I had to wait, um, tells me something about the provisional restoration. So in your experience, how does the provisional restoration affect tissue health during treatment? That's a good question because I tell you, you know, and I, I teach, I'm back teaching it. at MUSC at James Edwards College of Dental Medicine in Charleston, South Carolina. And I tell you, I've been teaching on provisional restorations for four decades. And whenever I hear a dentist say, you don't want to make the temporaries look too good because the patients don't come back, it makes me cringe. The provisional restoration is the key to tissue management. The provisional restoration must seal the margin. must have proper contours at the tissue, proper interproximal contacts, occlusal contacts, because you don't know what, you know, it may be only five weeks, but if a patient's waiting for a periosurgery or a root canal to heal, or if they're waiting for an implant to integrate, they may be in provisionals for longer than five weeks. And in your case, you had a gold crown placed. Well, gold crowns placed with certain types of cement are are a little bit less likely to have problems with blood and saliva, in other words, with moisture. But a lot of our restorations that we place today with resins are absolutely sensitive to those things. So having healthy tissue by having a good fitted provisional is absolutely essential so that when the doctor comes back to deliver the crown, you're not dealing with a bloody mess. Yeah. And if it wasn't for me being a dentist, syringing, my own embrasure there between 30 and 31 and i had actually i had actually take that temporary off three times while i had it i went back to them it was a bad experience it's not only a bad experience but it's just it was painful you mentioned the sonic care uh from phillips do you find that that's something that's significantly different than recommending manual toothbrushes well i've always been for whatever the patient will use and use religiously. But I tell you, I've used Sonicare in my practice and in my own home since before Sonicare was Philips. Back in the old days, it was Optiva or something like that. Was that the first company? I think before Philips bought it. A sonic toothbrush like that, that actually has the ability to clean beyond the bristles is so important, particularly. If the crown doesn't have a perfect contour if the original doesn't have a perfect fit You've got a better chance to keep those areas hygienic than if you're you're not and it's the same thing with manual flossing I mean, I think manual flossing is important, but a few years ago now Philips came out with this little device called air flosser and it it shot these little propelled streams of, I used to put Listerine in my little reservoir and I'd go between the teeth and it was like an air blast, you know, pushing this material through the tooth embrasure to keep them clean. I was a big user of air flosser and gave those to all my patients too. Now this new device, power flosser, it's like air flosser on steroids. I mean, it's unbelievable. How does the power flosser work? Well, the power flosser actually has a tank and a reservoir, and you put warm water in there. And the tip is a special tip that directs the stream of water in four different directions, toward the occlusal, toward the embrasure, toward the gingival. So I'm pretty sure in quoting that the studies that are done show about 180% higher removal of plaque and debris with this device. So you go back to your situation with provisional restoration that might not have great contacts and whatnot. Having something like a power flosser to keep the gingival embrasures clean during that five weeks is certainly going to help up the game as far as managing the tissue for the delivery appointment when the crown is finally finished. Yeah, yeah, I wish I had that because, I mean, personally, I don't think I should be managing the tissue. myself to that degree where it's so inflamed because of an insufficient provisional. I think the dentist should have made it so that it more resembled the final restoration, not only for patient satisfaction, but as an evaluation that, yes, this five weeks, do you have any problem? Do you have any occlusal problems? Do you have any TMJ problems? That's part of the assessment, I think, before cementing something impermanently. But thank goodness it worked out well. But yeah, I would have loved to have this power flosser. instead of me suffering for five weeks with this thing. I think it is definitely going to make a difference. And I think it's between the Sonicare and Power Flosser for home care after the definitive restorations are delivered are going to help the patients maintain a periodontal health and low bleeding index and inflammation and all those things that cause not only restorations, but the patient's dental health to decline over the years. So we're going to wrap up this podcast, Dr. Lowe, because we have a second one, the second part of it, this two-part series, which goes more into tissue management related to registration of master impressions and so forth for indirect restoration. So we're going to do that. But just to wrap this one up, it seems to me that the key thing is thorough, comprehensive evaluation pre-treatment. So let's decide what... situation is as far as the status of the soft tissue of our patient and not to proceed with procedures preemptively where we don't have that tissue under control because the long-term prognosis is probably not going to be as good. I don't think a lot of dentists are doing their own cleaning and scaling and root plating like you, Dr. Lowe, where you can manage that as closely. But I think the message is clear that that has to be done somehow in the office. Well, and that's okay whether the dentist is doing it or not. That's okay. But at the end of the day, their name's still on the door. So if they're not, they need, you know, as I'm telling my students now, again, you need to know what healthy looks like before you can make a determination whether or not the situation is not exactly healthy. And it's not just about whether the gums are bleeding. I mean, we see people with recession and things like that. call that age appropriate, things like that. It could be occlusion, it could be other issues, lack of firm tissue around the gums. If we're going to be doing crown and bridge and restorative procedures on patients, the management of the tissue is definitely one of the key factors in maintaining long-term health. Yeah, no, I agree 100%. Thanks very much, Dr. Lowe, and we'll see you on the next podcast. All right. Take care, Phil. Always good talking to you.