The Dentist's Network #85

Louis Malcmacher
DDS MAGD
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Making Extractions Fun… and Profitable?

Extractions definitely are not on the “Top 10” list of procedures many dentists like to do. Most dentists usually start to panic when we see an extraction on the schedule. Oftentimes, we are uncomfortable performing extractions or refer them out because they can be challenging and unpredictable. We have all experienced the “snapping” sound of a fractured root tip or having to dig around to get the tooth out. These challenges make extractions unprofitable, disruptive to the treatment schedule, and stressful for our patients and for us.

As I travel around the country and talk to dentists, many of us are no longer referring out certain procedures we normally would because we want to keep as much of the production as we can. With over 20 million teeth extracted each year in North America, more and more general dentists are extracting teeth again. The problem is, we do not find extracting teeth to be fun because of the unpredictability, and one broken root tip can ruin our production for the entire day.

Just over two years ago I was introduced to a revolutionary new concept in exodontia - the Physics Forceps from GOLDEN|MISCH that solves the problems we encounter when extracting teeth. The Physics Forceps are a set of instruments for extracting teeth atraumatically, in a predictable, fast and better manner than with our conventional armamentarium. With the Physics Forceps, I am able to extract teeth predictably and therefore profitably. Because of the biomechanical principles applied to these instruments, I no longer break root tips and I am able to more predictably preserve the extraction site, improving patient care. Can you imagine that this is the first advancement in exodontias in 150 years?

The first time I used the Physics Forceps, I was in disbelief of how easy it was. After one minute, the tooth literally just elevated in the socket and was loose. I had to look at my assistant to make sure she saw the same thing. Then we performed our 2nd extraction, same result. I was amazed. My patient was even more amazed that the tooth was out. All of this in less than 2 minutes. How could extracting a tooth be so simple, when we have made it so hard on ourselves for all of these years?

When we have the correct instruments, techniques and materials, dentistry is fun and rewarding. The Physics Forceps make extractions fun and profitable. The reason why the Physics Forceps work so well is the biomechanical rationale: they act like a simple, first class lever. One force is applied with the beak on the lingual aspect of the tooth or root. The second force is applied via the “bumper” which is placed on the alveolar ridge at the approximate location of the mucogingival junction. The handles of the Physics Forceps are not squeezed, just held, and a gentle but steady rotational force is applied through a small amount of wrist movement (about 3- 4º of rotational force). Then a steady pressure is applied in this position for about two minutes. As the instrument is allowed to do what it is intended to do, an element of “creep” allows the bone to slowly expand and the PDL to release. Once this occurs, the tooth will disengage and rise approximately 1-2mm occlusally. The tooth is now hanging in the socket and can be delivered with a hemostat, rongeur or conventional forcep.

For those of you that have heard me lecture before, you have heard me say that to consider a new product or technology for my practice, I run it through a simple test. I ask: is it faster than what I am currently doing, is it easier and is it better? For the Physics Forceps, it is all of this and so much more. They have been a welcome addition to my practice armamentarium. Because they are simple, predictable and non-surgical, they have become my go-to instrument for even the most difficult extractions. In the past, I was referring out more extractions than I was doing just because of the unpredictability and time involvement – it just wasn’t worth it for me to keep it in the office. Well, not in this economy, and not now that I have the Physics Forceps.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, Dr. Malcmacher is a consultant to the Council on Dental Practice of the ADA.

Interested in having Dr. Malcmacher speak to your dental society or study club? Click here. To reach Dr. Malcmacher, email him at DrMalcmacher@thedentistsnetwork.net or call 1.800.952.0521.

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Dr. Ryan Swain
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Why General Practitioners Should Be Doing Ortho

How many patients with crooked teeth do you have in your dental practice? That may seem like a strange question, but think about it for a minute. How many of your adult patients have mal-positioned teeth and aren’t thrilled about their smiles? If you’re like most dentists, there are a significant number of patients in your practice that fit into this category and are currently doing nothing about it! You know the story; they do nothing because they don’t want to wear metal braces for years and they aren’t interested in an expensive and potentially aggressive set of veneers.

Some dentists have tried to solve this common dilemma by offering orthodontic treatment with clear aligners to the patients in their practices. However, the majority of dentists that offer this treatment have been frustrated by aligners and don’t feel like they’ve found a great solution for their patients. Common frustrations with aligner therapy include: lack of control, high cost, longer than expected treatment times, poor patient compliance and proficiency requirements.

There is an orthodontic option that is replacing clear aligners as the go-to orthodontic solution for general dentists. It’s called Short Term Ortho and it is remarkably straightforward. Short Term Ortho (STO) utilizes clear brackets and tooth colored wires to give patients the smiles they want in an average treatment time of just 6 months. The goals of treatment are exactly the same as treatment with clear aligners, but the cases can be finished much faster and with much more control, simply because brackets move teeth more efficiently and more predictably than aligners.

The two biggest obstacles for adults who are considering orthodontics are: wearing metal braces, and lengthy treatment times. Treatment with clear aligners overcomes the first of these two obstacles, but tooth movement with aligners is relatively slow. STO is an extremely attractive option for patients and dentists because it overcomes both barriers. Tooth colored brackets and wires are inconspicuous and 6 months is a very reasonable treatment time. Furthermore, profitability is maximized because the lab fees are low (1/3 the cost of most aligner cases) and chair time is minimal (most of the procedure can be delegated). Typical case fees for STO cases range from $3000-$5000 so they are similar to traditional orthodontic cases. So, the potential for profitability is great because of the short treatment times.

At this point, you’re probably wondering how these cases can be treated in an average time of 6 months. The answer is simple: patient focused treatment goals. Most of the tooth movement that is needed to provide our patients with great smiles can be accomplished very easily in an average of 6 months using brackets and wires. With low force Nickel-Titanium wires, we can comfortably and predictably create a symmetrical and esthetically pleasing smile. What we, as dentists, aren’t attempting to do with STO is completely revamp the occlusion. The primary objective is to solve the patients’ chief cosmetic complaints, and correct the aspects of tooth position that detract from the esthetic appearance of the smile.

The beauty of STO is that it is systemized and easy to learn. Once a patient accepts treatment, their impressions and case script are submitted (Six Month Smiles-Rochester, NY). Bracket specialists position the brackets in the precise locations on the patient’s models. A set of custom bonding trays is then created. The trays are included in the Patient Tray Kit which is returned to the office. The Patient Tray Kit contains all of the items that are needed to treat that particular patient, including the tooth colored wires, orthodontic ties, bonding agents etc. The Six Month Smiles bonding trays make placement of the brackets as easy as seating a set of bleaching trays. After the adhesive is cured, the trays are peeled off and the brackets remain on the teeth in the ideal positions. Most of the bonding process can be delegated to dental auxiliaries. The patient is then seen for an adjustment appointment every 4 weeks. At these appointments, the teeth are evaluated and any needed changes are made. These changes could include conservative interproximal reduction, refreshing of the orthodontic ties or placement of slightly larger archwires. Most STO cases involve a simple “small, medium, large” 3-wire treatment sequence. Treatment is complete when the patient and the treating dentist decide together that the initial goals have been accomplished. Doctor time can be absolutely minimal, which adds to the attractiveness of the procedure.

In short, STO takes the complexity out of orthodontics for general dentists. General dentists enjoy safe, streamlined and systematic procedures and STO meets all of these criteria. It is growing like wildfire around the world because it is easy to learn and easy to implement. When we as dentists discuss options with our adult patients, traditional orthodontic treatment should always be considered. However, when adult patients refuse traditional treatment, STO provides patients (and dentists) with a fantastic and rewarding alternative option.

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs. Dr. Swain can be reached at Drswain@thedentistsnetwork.net

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Chris J. Lampert, DMD
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Doctor, My Tooth Was Fine Until You Worked On It

The following is a letter I received from a referring doctor discussing a common clinical question.

Dear Dr. Lampert,

Recently, I prepared a tooth for a crown that was asymptomatic prior to treatment, asymptomatic during temporization, and then developed acute symptoms shortly after cementation of the final restoration.

From the patient’s perspective it appeared that my treatment caused the problem. The tooth ultimately required endodontic treatment in your office to alleviate her symptoms. In this particular case the tooth had an old, large, leaking amalgam restoration with recurrent decay prior to treatment.

This type of situation seems to happen to me more often than I would like to admit. How should I explain this to the patient and what is the best way to prevent this from occurring?

This letter describes a situation that as an endodontist, I encounter on a routine basis. I receive a referral where the patient has a recently restored tooth that is now symptomatic, and the patient asks me if their dentist did anything wrong. I find that it is best to alleviate the patient’s concerns quickly by letting them know that this is an unavoidable and often unpredictable consequence of the restorative process. I also attempt to restore the patient’s confidence in their dentist by letting them know they are in very good hands with their general dentist and that everything was done correctly. I can say encouraging words about the restorative dentist that they can’t say about themselves. Most patients are very appreciative of this reinforcement and second opinion. They leave with a better feeling about the situation than when they arrived.

From a clinical standpoint, whenever a crown is replaced with a new crown, a large restoration is replaced with a crown, or a deep restoration is placed, there is a chance that the pulp will not survive the restorative process. Teeth with signs of defensive biological processes such as pulp stones, calcified chambers, and condensing osteitis have been exposed to prior stress. The added stress of the next restorative procedure may push the pulp over the edge and lead to endodontic symptoms.

If the patient experiences any abnormal thermal sensitivity or chewing sensitivity during the time the tooth is in a temporary crown, the likelihood of symptoms increasing following the cementation of the permanent restoration is very high. The temporary phase is a good indicator of how the tooth will feel following cementation of the final restoration. Teeth that require a deep preparation in the cervical region, particularly on the buccal surface, are more prone to developing pulpal symptoms. This is a result of the anatomical position of the pulp chamber in this region, especially in premolars.

Another way to minimize post-operative endodontic symptoms is to conduct pre-treatment pulp testing before any restorative procedure that requires aggressive preparation. It takes 15 seconds to determine pulpal vitality on most teeth and is recommended before treatment is initiated. Determining vitality will prevent the placement of a new restoration on a necrotic tooth. Placing a restoration on a necrotic tooth is a toothache in the making - it is just a matter of time before the tooth becomes symptomatic. Another reason for determining pulpal vitality is to get a baseline on thermal sensitivity to use as a comparison if post-treatment symptoms arise. When a tooth is highly reactive to cold stimuli and requires a deep preparation, post-treatment cold sensitivity is very predictable.

From a patient management standpoint, before any invasive restorative procedure (anything other than a conservative preparation) the patient should be informed that future endodontic treatment is a possibility. The patient needs to be aware that most of the time a tooth will survive the restorative process just fine, however, at times a tooth may become symptomatic following the placement or replacement of a restoration. If endodontic treatment is subsequently needed, then they should not be surprised.

Although we cannot always prevent or predict post-restorative endodontic symptoms from occurring, we can prevent the misunderstanding from occurring by communicating well with the patient. Let the patient know that future endodontic treatment is not up to you or them, but is up to the tooth. I work with referring doctors that tell every patient following a crown preparation procedure that endodontic treatment might be needed if the tooth develops post-treatment sensitivity. Preparing patients for the least favorable outcome and delivering the best outcome is much better for creating patient satisfaction and patient loyalty to you and your office.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University. He can be reached at drlampert@thedentistsnetwork.net.

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