25 Clinical tips for general practice



Author : Dr Ashish B Parmar






introduction
One of the best ways of becoming a better dentist is to learn from top dentists. I have been fortunate to be mentored by world-class dental educators. I recently did a webinar for Smile-On. This article is afollowup onthis webinar; I will share some tips and advice to allow you to offer a higher standard of dental care in your practice. I will be talking about a range of clijiical techniques and dental materials.
DISCLAIMER: I am not paid for promoting any dental ma­terials Iwillsimptyexplaintbeprefenedproductsfo^^ indailypractice.aswellasonmytrainingCourses.

TIP 1: Wearing Dental Loupes
I have been wearing dental loupes for many years. The magnification I useis2.5x. This gives meamplemagnifica-tion to do better general dentistry, as well as awider field of view when doing Smile Makoevers. I use the Orascoptic loupes, and can recommend you contact Chris Minall on 07740 922136 for an initial consultation to help and advise further. Also visit www.surgicalacuity.com to find out more about loupes in general. So, if you want to have better posture and protect your health long-term, have better vision when doing your dentistry, and want to offer your patients the best you can, then you cannot be withoutdental loupes!

TIP 2: Digital Photography
A modern private practice cannot be without a digital SLR camera. Dental photography is a powerful tool to communicate with your patients the condition of their mouth. Photography is also essential in cosmeticdentistry whether you are documenting teeth whitening results or doing a Smile Makeover. Digital photographs (before and after), as well as Makeovers at the end of treatment can be used for marketing. It is much better to 'show off your own work, with atestimonial fromthe patient, rather than usestock pictures from aphoto library.Thetwo most common makes of camera in dentistry are Nikon and Canon. You will need an SLR camera body, a macro lens, a ring flash, and some camera accessories. The investment should be about £1,500. An excellent comparison website for the latest camera equipment is www.dpreview.com. I bought my Nikon camera from an American company called Photomed (www.photomed.net).

TIP 3: The Comprehensive Dental Assessment
This is perhaps the most important tip I can give dentists. I have devised one of the most comprehensive dental assessments available in the UK. The advantage of doing a detailed initial examination for your patients is that it builds up trust and confidence. Also; by capturing allthe important diagnostic data before any treatment is done allows the dentist to make accurate diagnoses, treatment planbetter and therefore adviseand lookafterpatients in the ideal manner. It is also comforting to know that you have a "gold standard' of record keeping in casethereare any medico-legal issues in the future. I spend an entire day on my Hands-On Courseonthis importanttopidVlsit www.theacademybyash.co.uk tofindoutmore.





TIP 4: Excellent Periodontal Health (Figs 1 -3)
Having excellent periodontal health before restora­tive dentistry is an essential requirement for long-term success. Wehave a detailed i n it ial s cr een i n g p rot o col that includes six-point pocket charting, measuring percent­age scores of plaque and bleeding, analysing recession and mobility scores, etc. A relevant treatment plan with the hygienist and/or periodontist is then recommended so thatthe patient can be motivated and treated to achievehealthy gums and very good oral hygiene. Theuse of asoniccleaning brush (luseDiamond Clean by Philips), and daily and regular cleaning between teeth with floss and interdental brushes, as appropriate, is highly recom­mended. For many patients, Airfloss (by Philips) is also a great adjunct to their daily hygiene regime. Finally, I also recommend the Ultradex range of mouthwashes and products (from Periproducts). This mouthwash has chlorinedioxideand isthebestproduotinmyopinionfor fresh breath. I always encourage my patients tousethis when they are in the temporaries stage during a Smile Makeover case. I findthegum health to be excellent with no bleeding when I come to fitthe porcelain restorations upon removal ofthe temporaries. You can find out more by visiting the following websites: www.philips.co.uk/c/ electric-toothbrushes/139853/cat and also www.periproducts.co.uk.









TIP 5: Digital Calipers

A digital caliper is essential to measure teeth very accurately in cosmetic dentistry. You can take measure­ments very quickly and easily with accuracy to 0.01mm! This will definitely raisethe standard of your treatment as well as keep your technicians on their toes as to whatyou expectfrom themlThese can be easily bought for about £15fromAmazon oreBay.
TIP6: Pre Planning on Study Models
When doing a Smile Makeover, it is very useful to plan accurately on models regarding the preparation changes that are required. Areas where occlusal adjustments are to be made can be marked, as well as changes such as centre line shift, gingival height (zenith position) changes with lasers, finishing lines of porcelain veneers, etc. This, in conjunction with a trial preparation model, excellent wax ups and putty indices from an experienced laboratory technician will really helpthedentistalot.

TIP 7: Articulating Papers
Visit www.bauschdental.com to find out a lot more aboutthe different products and papers I usein my private practice. In particularthe bigtip I can givedentists isto use the two-phase articulation paper technique. This involves firstmarkingtheocclusal contacts withalOOmicronthick blue paper with transculase bonding agent in it. Then, you should use a 8-10 micron red articulation foilto mark the
exactareasthat will actually need adjustment. Youwillsee a bluewider diffuse mark, a halo, and a red dotinthemid-dle.ltisthisJbullseyeIthatyou havetoaim for-simple!
Another great tip is the use of Shimstock foil to record "Shimstock hold positions'. This means making a note of the teeth that are in tight contact and preventthe release of the Shimstock foil inter-occlusally when the teeth are in contact in centric occlusion. This can then be written on the laboratory docket. You can then expect accurate articulations, and restora­tions that are precise regarding occlusal anatomy and occlusal contact.This willsave a lot of time and hasslewhen fitting crown andbridgework!




TIP 8: TMJ Assessment
Before embarking upon a comprehensive course of dental treatment it is vital that the dentist knows how to do a clinical assessment of the temporo­mandibular joints (TMJ}; as well as the important facial and neck muscles. The dentist can detect if there are potential TMJ problems and whether referral to a TMJ specialist is required BEFORE dental treatment. I also strongly recommend Joint Vibration Analysis (or JVA), which is computerised equipment and software that is excellent at diagnosing the health of each TMJ. There are special sensors that measurethe vibrations of the TMJ on openingandclosing.Thedataisthenpresentedwithinthe computer software and within a few minutes, the dentist can use the Piper Classification of TMJ Health and reach a diagnosis (which supports the clinical findings). I also rec-ommend the use of T Scan, which I think is one of the best occlusion assessment computerised software available in the world. To find out more about JVA and T Scan, contact Mike Crooks (Ident Limited) on 07803 516737. There are also some great You Tube videos on occlusion topics that I have posted on my teaching website at www.theacad-emybyash.co.uk/Ash-s- G ems/occl usion.html.

TIP 9: Facebow Records
It is quick and easy to take a facebow record accurately when you know how to. I recommend the Denar system, as well as the Kois Facial Analyser. I take the Denar face­bow when I am planning bigger cases (e.g. wear cases that require a new vertical dimension), if I am doing two or more crown/bridge units, and also during a Smile Makeover case. I use the Kois Facial Analyser if I am doing a Mini Makeover, as well as when I am taking the centric relation bite record for making a Michigan/Tanner type of hard acrylicappliance. If adentist is thinking of buying an articulator or a facebow, I highly recommend the new Mark 320 Denar Articulator from Whip Mix Corporation. Call Peter Nutkins (on 07714 458215) from Prestige Dental (www.prestige-dental.co.uk) for more advice and a demonstration.
TIP 10: Taking an accurate Centric Relation Record(Figs4-9)

Many dentists lack the confidences do a !:full mouth case*. Once you understand how to do a comprehensive dental examination, diagnose accurately and verify that the vertical dimension has to be altered i.e. a REORGAN­ISED approach in restorative dentistry, then it becomes essential to carry out an accurate bite registration in centric relation. I teach practical methods in taking this important record using a variety of techniques. It is also important to learn howto make a deprogramming device using a product like the NTI appliance. Leaf gauges can be bought from Prestige Dental andthe NTI kit can bebought from S4SDental (www.s4sdental.co m).
The bite registration paste of choice that I use is Luxa-bite (DMG). This is a blue coloured material that sets very hard. This is the most accurate material that I am aware of, and requires precise and careful trimming in the dental laboratory. The other great bite registration paste that I use a lot is 0 Bite (DMG). This is orange in colour and not asrigidasLuxabite.














TIP 11: Accurate Silicone Impressions using Honigum(DMG)
Honigum (DMG) has been the material I have been using for all my crown/bridge work and Smile Makeovers, as well as open tray implant fixture head impressions, for many years. It is an accurate, easy to use material and the simple way I can validate its superiority is the quality of the impressions and the accuracy of the marginal fits I get. I use two techniques of impression. Thefirst isthe two stage putty and wash technique. My nurse mixes one scoop each of the rigid putty base and catalyst, ensuring non-latex gloves are used. The mixed putty isthen loaded in to the tray (I use Borderlock trays), and a thin layer of cling film is placed on top. I then seatthis down hard over the arch and wait about two minutes to ensure that the material is rigid. I removethetrayanddisposeofthecling film. My nurse then places some Honigum Light body material in to the set putty in the tray, as I injectsomeLight body material around the prepared teeth. I then seat the tray again fully and wait four-five minutes.
The alternative technique I use is the one-stage Honigum Heavy body material (dispensed from the Mixstar machine (DMG)) and the Honigum Light body material being simultaneously syringed around the teeth. Again, the tray is held in place for four-five minutes before being removed.
For managing the tissues, I use a soft tissue diode laser, Expasyl (Kerr) or retraction cords from the Tissue Management System (Optident).

TIP 12: CEJ-CEJ Measurements (Fig 10)
This is an important reference measurement that is taken with a digital caliper. It is an accurate measurement in mm taken between the cemento-enamel junction (CEJ) of two diametrically opposing teeth. In a wear case: a dentist can take a CEJ-CEJ measurement in centric oc­clusion (CO) to establish the vertical dimension. The bite can then be opened up to the desired amount in centric relation (CR). A kh CEJ-CEJ measurement can then be recorded, and an accurate inter-occlusal record (bite registration in CR) can be done. This can then be used to check at the temporaries stage, in the laboratory and also after the porcelain restorations have been fitted. In this way, a precise control can bemaintained throughout the treatmentstages.

TIP 13: Laser Gingival Contouring (Figs 11-14)
luseasofttissuediodelaserto carry out artistic, mini­mal gingival contouring changes. By placing the zenith positions of the upperteeth inthecorrectpositions allows morenaturalandattractivelookingsmiles.Thetheoryand techniques to do this can easily be learnt, and the prices of lasershave come downalot over theyears.
I also use a 'hard tissue laser' to correct gummy smiles by doing gingival contouring followed by the removal of bone subgingival^ by up to 2mm to recreate the biologic width. This allows faster healing times, no need for inci­sions and minimal or no post-operative discomfort. The key point is that laser energy has a sterilising effect and promotes faster and better healing.










 

TIP 14: Fibre-Reinforced Composite Dentistry
 (strongly advocate dentists to learn about fibres in dentistry. I use the everStick range of fibres fornumerous minimally invasiveprocedures including: -
• Periodontal splinting
• Fixed retainers afterorthodontictreatment
• Replacing a missing incisor premolar ormolar tooth
(studies show success rates of over 10 years)
• Extraction ofatoothjesectingtheapicalportionofthe
root and splinting ittothe adjacentteeth inthe mouth
• Making acustom fitting fibre post, which isthen usedto make a bonded composite core, before crown preparation
• Reinforcement of large composite direct restorations
Please have a look at my practice website at www. smiledesignbyash.co.uk/general-dentistry/fibreglass_ dentistry and alsothewebsite www.sticktech.co m.


TIP 15: Customised Composite ShadeTab
It is a good idea to purchase a blank shade tab that GC make, which canthenbeusedtomakeacustomisedshade tab with the different colours of composites you have in your composite kit. This will allow accurate shade match­ing abilitywh en doing moredemanding anteriorcompos-ite build-ups using the layering technique. My preferred composite products I use in practice are G-aenial for the anterior teeth and Kalore for the posterior teeth. Please have a look at www.gceurope.com to find out more about these composite products, as well as have a look at a very good App that GChave developed to help dentists in complex anteriorbuildupsusingthelayeringtechnique.


TIP 16: Use of Luxacore (DMG), Luxabond (DMG) and EverStick Posts (Sticktech)to do abonded Post/ Core build up.
I use everStick Posts (0.9mm and 1.2mm fibres) to anatomically adapt the flexible fibres in the prepared root canal after the root filling. Root canals are never circular in cross section, which is why this technique is superior than using pre-fabricated fibre posts, which are circular in cross section. I use Luxabond as the bonding system, and Luxacore to cement the post and build up the core simultaneously. The tooth can then be prepared minutes later. The whole clinical technique can be viewed on a video (part of a series) on my Academy website at www.theacademybyash.co.uk/Clinical-Cases-Videos/ porcelain-veneers-prep-videos.html.

TIP 17: Composite Veneers
I have done a lot of porcelain veneers over the years. However, increasingly I am using composite as a material of choice in a number of cases. Following simple ortho­dontic treatment using the Inman Aligner or six Month Smiles, teeth can be straightened quite well. Composite can then be used to make minor improvements (typically afterteeth whitening has been done).

TIP 18: The i:Spade" Instrument
The instrument which I call the 'spade' is a great instrument to help with easy and quick shaping of labial surfaces of teeth that require compositeveneers: as well as during addition of flowable composite material when making trial smiles using Luxatemp (DMG). It is a Hu-FriedyinstrumentandthereferencecodeisTNCCIB.


TIP 19: Learn to do the Inman Aligner and Six Month Smiles (Figs 15-22)
I have found the UK Courses to learn aboutthe Inman Aligner and the SixMonth Smiles braces to be excellent. I now use both these braces in clinical practice forthe ben­efit of my adult patients. Please visit www.inmanaligner. com andwww.6monthsmiles.com to findoutmore.








    


 

TIP20:Luxatemp(DMG)andLuxaglaze(DMG)for Temporaries
Luxatemp is a 5-star Reality rated productand rightly so! It is the number one choice formaking trial smiles by cosmetic dentists in USA and UK. I have been using it for many years, and B1 is my favourite colour. You can get Luxatemp Fluorescence or Luxatemp Star (stronger - if you require more durable transitional restorations to last longer in the mouth). The use of Luxaglaze light cured var- nish will significantly improve the appearance and stain resistanceofthetemporaries.

TIP 21: Use of a Speed Increasing (Red Ring) Hand­piece to perfect your Preparations
I highly recommend the use of a speed increasing handpiece in an electric motor. Friction grip burs under water spray can be used to get smooth, precisely prepared and finished tooth preparations.
I have been using NSK handpieces for many years in my practices and recommend the Ti-Max X95L hand­piece. You can contact Alex Breitenbach at NSK on 07900 245516 formore advice on NSK handpieces.

TIP 22: The Natural Die Material Shade Guide (Ivoclar)
This is an essential shade guideto have for doing Smile Makoevers properly. The prepared teeth can be matched carefully with reference to this shade guide. The ceramist technician can then ultimately produce model dies of the matched colour. This will help with precise colour match-ingastheporcelainbuild-upsaredone.Youneedtowrite downthe'Stump Shade' colour e.g.NDJ.

TIP 23: Using aTop Dental Laboratory
My private practice is in ChigwelL Essex. I use RobStorrar from Amdecc Dental laboratory (www.amdecc.com) based in Basildon for Smile Makeovers for my patients. For my Academy, I have a close working relationship with Castle Ceramics (www.castle-ceramics.com). It is a real pleasure to have technicians who are passionate, knowledgeable, skilled, artistic and who have a good understanding about occlusion.
TIP 24: Cementation with Vitique (DMG)
Vltique is my number one choice for cementation of multiple porcelain restorations when doing a Smile Makeover. I use the base and catalyst together (even if I am cementing porcelain veneers). My favourite colours are Transparent and B1 shades ofthe base, andlusethe low viscosity' catalyst. Thereis adequate working time with this cement to work in a stress free manner. I also use Vitique to cement in porcelain inlays, onlays and all porcelain crowns.

TIP 25: The Celebration
One of the best rewards for me in private practice is seeing the emotional reaction when a patient sees their new smile for the first time. We celebrate this important moment in the patient's life by presenting her with a nice bouquet of flowers, a signed card by the dental Team with the before and after photographs. We also celebrate with non-alcoholic champagne served in crystal glasses on a silver tray. Our patients are genuinely touched by the special effort we go to during this "Celebration". We also send the patient for a complimentary photo shoot with a professional photographer. The patients love the photos taken showing their increased confidence, because of their new smile. They get a complimentary photograph from the photographer, and we get the images that we want for our marketing use e.g. to go on the website as a case study. Please have a look at the Reveal for Dina, one of my patients who had a complex Smile Makeover, on my Academy website at www.theacademybyash.co.uk/Clini-cal-Cases-Videos/porcel ain-ven eers-th e-rev al.htm I.

Summary
So, I hope you found these 25 Clinical Tips useful. However clinical skills are only one of the important jigsaw pieces needed to create a successful and profitable dental practice.

4 comments:

Dentistwinnipeg said...

Excellent blog, good to see someone is posting quality information.
Invisalign Winnipeg is custom made, removable and comfortable in use and transparent.So get ready to make over your personality because invisalign is the only way out of all your worries. Take a deep breath, get yourself tidy and wear a sweet smile and get ready to have fun this is your lifestyle, why did you miss it?

Family Dental said...

Thank you for sharing best Tips. I am lucky reading you. It’s imperative blog.

Thank you,
Family and Cosmetic Dentist Kailua

Bill Stewart said...

This is very interesting. Would reading a book help me better understand cosmetic dentistry in Tacoma. I need to make a decision with what I am going to do.

Max Paganetti said...

Very good advice. Thank you for the great info


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