Ian E. Shuman, DDS
A patient makes an appointment with his physician, complaining of extreme abdominal pain. After an examination, the doctor goes over his diagnosis and planned treatment with the patient.
Doctor: "Well, I'm afraid you'll need an emergency appendectomy."
Patient: "An appendectomy?"
Doctor: "Yes. And we'll need to schedule the appointments right away."
Patient: "Appointments?"
Doctor: "Oh yes. We'll schedule you for two, maybe three visits to get this done."
Patient: "Two or three visits?"
Sound ridiculous? Now think about how you schedule patients for restorative treatment in the same quadrant. Are your patients in the one-crown-a-year club? If you had multiple-failing restorations requiring full coverage, would you do them one at a time, slowly, over the span of many years or all at once by quadrants? Would you want your appendix removed little bits at a time?
As the average age of our patient population dramatically increases, the vast wasteland of fractured, leaking amalgams and composites, cracked cusps, busted marginal ridges, open contacts and endodontically-treated teeth increases as well. The chances are great that any patient over the age of 40 will have multiple-failing large restorations in a single quadrant. Teeth treated by the old patch-and-fill school of therapy are rapidly deteriorating. The associated caries —both seen and usually unseen— make the need for comprehensive treatment a challenge. Make no mistake: this is not about selling! It is about the ethical responsibility to fully diagnose and treat without hesitation in the best interests of the patient. When it's broke, fix it, and in the appropriate situation, a sound treatment option is the full-coverage restoration.
While full reconstruction provides the best model for restoring the "orally tattered," the price and time involved can present a significant barrier to treatment acceptance. An ideal alternative is treatment by quadrants ... and there are many excellent reasons for providing this level of care (See Figure 1).
With these benefits, there is an ever-growing variety of crown-and-bridge treatment options and materials choices. These expanded options include cast gold, porcelain-to-metal, stacked porcelain, pressed ceramics, 24-karat gold alloy substructures, and lab-processed composite resins. Even tooth preparation can vary from the ultraconservative no-prep technique to the heavily prepared full-reduction with shoulder margins. In addition, the advanced alternatives that implant therapy now offers have increased the restorative playing field to the tune of "Have It Your Way." Here is how you can integrate the quadrant-dentistry model into your practice.
Practice management
* Making it big!
The first step in diagnosis and treatment-planning is visual examination. Patients are unaccustomed to seeing their teeth magnified 40 times, but a macro image of the quadrant — taken with a digital camera and displayed on a computer monitor — can accomplish this easily. This information is a powerful way to simultaneously diagnose and treatment-plan, demo it to the patient, have a "before" image for your records, and print or email a copy to the insurance company. Interested in learning about digital photography and imaging? Dr. Tom Hedge offers an excellent continuing education course on this subject.
* Amateur radiologist
The flip side to imaging is the X-ray, and nothing speaks louder than digital radiography. Using far less radiation than traditional dental X-ray film, an entire quadrant of teeth can be viewed with a few images. Caries and other conditions become clearly delineated, and versatile software allows image enlargement, magnification, and color enhancement, providing a dazzling view that can turn any patient into an amateur radiologist! Now that we have their undivided attention, it's time to review the actual treatment.
* Don't dictate; educate!
Patients hate being lectured to about their dental care. It is far easier to explain the possible courses of treatment in a predictable, repeatable manner. Remember, we are healers and educators, not salespeople. Educating the patients with chairside tutorials — such as the CAESY system — has streamlined this educational process. The DVD explains the cause for conditions, diagnoses and treatment possibilities, and many of the restorative clips demonstrate conditions based on quadrant views. With a full understanding of the benefits of quadrant dentistry and a willingness to undergo treatment, patients usually have one question: How much will it cost?
* Dental savings and loan
Because quadrant dentistry comes with a bigger price tag than single units, handling the money question is critical. One of the most superb, highly crafted works on the step-by-step techniques and methods for discussing money can be found in the "Office Magic" series by Dr. Pat Wahl and Lorraine Hollett. Their techniques have eliminated billing from our practice and improved patient relations, allowing us to spend our time in more positive ways. Remember, the sign on your door says "dental office," not "dental bank."
Let's start with insurance. These plans are like the coupons on a cereal box or a small yearly allowance from mom and dad: you know you'll get something, but it won't be much! We assign the insurance benefits directly to the patient, maintaining the insurance relationship between them and their carrier.
Payment options: For large cases, we offer our patients two primary methods of payment.
Option 1: If the patient chooses to pay in full by cash, check, or credit card at or before the first treatment visit, we offer a 5 percent "bookkeeping courtesy." No muss, no fuss, no billing!
Option 2: Patients have the option of financing their care using a professional loan service, such as Care Credit, Dental Fee Plan, or HelpCard. For a percentage of the total dollars financed, (anywhere from six to 10 percent), a credit approval is made in minutes. Depending on the terms and amount borrowed, patients can pay their loan interest-free for three to 12 months.
So, they've signed on the dotted line and can't wait for that new quad smile! Here are some practical tips for the clinical management of quadrant crown and bridge.
Clinical management
* Timing is everything!
A $6 Radio Shack timer was one of the finest investments I ever made. Any procedure with a setting time such as impressions, provisional materials, cements, and even anesthesia onset should be timed. Over the course of a year, a simple countdown timer will save days worth of squandered minutes.
* Pre-op preparation
If the occlusion is sound, a full-arch, triple-tray impression is made to record the units prior to quadrant preparation. A medium body polyvinyl such as Perfectim Flexi Velvet (J Morita USA) — with a setting time of 30 or 90 seconds — or a polyvinyl "alginate substitute," such as Mixstar Blue (Zenith DMG), can rapidly create highly detailed impressions for making provisionals. The impression is saved and can be reused in the event the patient requires a remake. For replacing missing teeth, a pontic tooth can be mocked up intraorally using a Styrofoam pontic (Proviponts, Ivoclar). This clever material is wedged between the abutment teeth, the Styrofoam is formed into occlusion, and an impression is made.
When rehabilitating a damaged quadrant, a successful outcome is vastly increased if the case is mounted to the desired vertical and centric and waxed to the correct specifications. Using duplicated study models, a laboratory can greatly assist you in determining the end result.Using the "Dentist Diagnostic System" (Aesthetic Porcelain Studios), one model is made with the teeth prepared to ideal specifications, while the second model bears the newly created dentition in white wax. This second model is used for patient consultation and to create a vacuform stent or impression for temporization.
* Do you feel like I do?
Giving a "good shot" painlessly and imperceptibly is a potent practice-builder. We now have a decent arsenal of tools that makes the process comfortable and the anesthesia profound. Anesthetics such as the pH neutral Citanest (Prilocaine) with no burn, and the new fat-penetrating Articaine (Septodont), have elevated local anesthesia to an art form. When used appropriately with devices like the Vibraject (a "touch sensory" overloader that blocks pain transmission), intraosseous anesthesia, and the renewal of the modified PDL block, patients never have to squirm again.
* Preparation
By using fresh burs and heavy irrigation, preparations can be accomplished quickly and comfortably. Using rapid bulk-reduction, cross-cut burs, such as the ULTRA series or the TDA diamond series by S. S. White, reduces tooth structure smoothly and swiftly. Follow these with a bur designed for idealizing the margin ... and preps are done in no time!
* Final impressions, temporary teeth
To capture exquisite margins and exceptional detail, the H&H technique, developed by Dr. Jeff Hoos, uses an initial heavy-bodied impression, followed by a wash of a light bodied material. A full-arch triple tray is a must when restoring quadrants using this technique. It is integral to preserving occlusion. Then, the final step is fabricating provisional restorations.
By the way, acrylic is out! It's stinky, tastes bad, and can occupy about 20 minutes of your valuable time making temps. Bis-acryl composite is in. It's odorless, tastes better than acrylic, and a quad of temps can be created in under three minutes. Enough said — now get out there and start treating those quads!
Figure 1Quadrant care offers the ability to:
1) Anesthetize the area once.
2) Isolate area, treating all adjacent teeth.
3) Create ideal occlusion and morphology.
4) Create ideal interproximal contacts.
5) Remove all caries in an affected area.
6) Allow the lab to create ideal crowns with precision fit.
