STANDARDS OF CARE  IN PERIODONTICS, ENDODONTICS, AND PROSTHODONTICS <ul><li>Paul Levy, DDS </li></ul><ul><li>Peter Velyvis...
Standard of Care <ul><li>Average, qualified dentist </li></ul><ul><ul><li>What a reasonable and prudent practitioner would...
Standard of Care <ul><ul><li>To a lesser extent, what is published in peer-reviewed journals </li></ul></ul><ul><ul><li>St...
Standard of Care <ul><li>Juries determine standards of care based on information presented during trials: </li></ul><ul><u...
Standard of Care <ul><li>Is there a separate standard of care for a specialist than for a general dentist doing specialty ...
<ul><li>Standards of Care </li></ul><ul><li>Periodontology </li></ul><ul><li>Paul Levy, DDS </li></ul>6
<ul><li>Failure to diagnose and treat periodontal disease falls below the standard of care. </li></ul>7
<ul><li>First, an accurate diagnosis is essential. Then an appropriate treatment plan including etiology and prognosis mus...
<ul><li>Clinical diagnosis, treatment planning, and procedures are decided, whenever possible, on evidence-based data and ...
<ul><li>Second, treatment is traditionally divided into 3 phases: </li></ul><ul><ul><li>Non-surgical Therapy </li></ul></u...
<ul><li>Periodontal surgery when not followed by good professional and personal care, will, in many cases, fail. </li></ul...
<ul><li>Patient compliance, even when optimal, must be reinforced by frequent maintenance and recall. </li></ul><ul><li>Th...
<ul><li>Dentistry is not a perfect science. Outcomes of treatment do not have to be ideal to conform to the standard of ca...
Essential Components  of Record Keeping <ul><li>Medical and dental history  </li></ul><ul><li>Chart notes and results of e...
Informed  Consent  <ul><li>Patient must understand the options of treatment. Several possibilities usually exist to treat ...
There are 5 Steps  to Consent: <ul><li>Their must be an understanding of the problem, the diagnosis. </li></ul><ul><li>The...
<ul><li>Consent may be verbal or written but it must be fully understood by the patient. I use different forms for each pr...
Beneficence <ul><li>This is a legal concept that refers to providing the best possible care. If the practitioner is unable...
Record Keeping <ul><li>All records must be contemporaneous and must be signed and dated. Legally, a professional written r...
<ul><li>Measuring and recording of pocket depths on six locations for each tooth provide the minimum foundation to documen...
OSHA <ul><li>Occupational Safety and Health Administration </li></ul><ul><ul><li>Universal precautions and bloodborne path...
HIPAA <ul><li>Health Insurance Portability and Accountabilty </li></ul><ul><ul><li>Electronic Transaction Standard </li></...
Continually  Upgrade Skills <ul><li>Use updated comprehensive text books, continuing education courses, current studies in...
<ul><li>Traditional periodontal treatment including both surgical and non surgical techniques have very high success rates...
<ul><li>Proper use of surgical regenerative procedures with a variety of grafts and membrane barriers have shown that bone...
Controversial  Comments <ul><li>Using ineffective therapies to avoid traditionally effective ones may result in progressio...
<ul><li>The Keyes technique, many time-released local antibiotics (chlorhexidine in a gelatin chip, tetracycline fibers, d...
<ul><li>New products such as tissue healing modulators, growth factors (BMP- 2) and even stem cells are promising addition...
Implants- Controversy <ul><li>Implant surfaces and designs make it difficult to find comparable long-term statistics for i...
<ul><li>In 1952, in the JADA, DeVan stated that ”Our objective should be the perpetual preservation of what remains  rathe...
When do we  place implants? <ul><li>When periodontal disease is present; how long should we wait to place the implant?  Ho...
<ul><li>In circumstances where extraction and implant placement is indicated, the patient should know the options, risks, ...
<ul><li>There can be complications in implant placement.  Pjetursson (2004) reported that 38.7 percent of patients had com...
<ul><li>This may dispel the belief that implants are a trouble- free panacea when compared to the retention of teeth that ...
Flossophy <ul><li>Do good work and carry as much insurance as possible. </li></ul><ul><li>We are fortunate to be in a prof...
<ul><li>Periodontal Plastic Surgery: </li></ul><ul><li>Framework for the  </li></ul><ul><li>Perfect Smile </li></ul>36
Esthetics 37
Achieving Optimal  Esthetic Results <ul><li>Treatment Options </li></ul><ul><li>Resective Therapy </li></ul><ul><li>Augmen...
Esthetics <ul><li>Crown Lengthening </li></ul>39
Anterior Crown  Lengthening <ul><ul><li>Pre-restorative  </li></ul></ul><ul><ul><li>For smile enhancement </li></ul></ul><...
Before After 41
42
Crown  Lengthening Before After 43
Crown  Lengthening Before Incisions 44
Crown  Lengthening Immediate Post-Suturing One-Month Healing 45
Crown  Lengthening Before Incision 46
Crown  Lengthening Before After 47
Crown  Lengthening Before One-Month Postsurgical 48
Crown  Lengthening Before Incisions 49
Crown  Lengthening Immediate Post-Op Surgical 50
Crown  Lengthening Before Incisions 51
Crown  Lengthening Before After 52
Augmentation  Therapy <ul><li>Hard and Soft Tissue Augmentation Procedures </li></ul>53
Augmentation  Therapy <ul><li>Clinical Indications  </li></ul><ul><ul><li>Recession </li></ul></ul><ul><ul><li>Deficiency ...
<ul><li>The presence or absence of papillae  can be anticipated by measuring the distance  from the proximal bone o the co...
Augmentation  Therapy <ul><li>Root Coverage  </li></ul><ul><li>Procedures </li></ul>56
Root  Coverage Before Immediate Post-Op 57
Root  Coverage Before After 58
Root  Coverage Before Prepared Root Surfaces 59
Root  Coverage 60
Root  Coverage Before After 61
Root  Coverage Before After 62
Root  Coverage Before After 63
Augmentation  Therapy <ul><li>Root Coverage  </li></ul><ul><li>for </li></ul><ul><li>Implants </li></ul>64
Root Coverage  for Implants After Before 65
Augmentation  Therapy <ul><li>Ridge Augmentation </li></ul>66
Root Coverage  for Implants After Before 67
Ridge  Augmentation Before After 68
Ridge  Augmentation Before Post-Suturing 69
Ridge  Augmentation Before After 70
Augmentation  Therapy <ul><li>Site Preservation </li></ul>71
Site  Preservation Before 72
Site Preservation/ Root Coverage Before One-Month Post-Extraction 73
Site  Preservation Before After 74
Site Preservation/ Ridge Augmentation 75
Site  Preservation 76
Site  Preservation Before After 77
Augmentation  Therapy <ul><li>Combination Procedures </li></ul>78
Combination  Procedures Before After 79
Combination  Procedures Before Suturing 80
Combination  Procedures Before After 81
Combination  Procedures Incisions Before 82
Combination  Procedures Before Immediate Post-Suturing 83
Combination  Procedures After Before 84
Combination  Procedures Before After 85
Esthetics with Implants 86
Site Preservation for Implants 87
Before Site Preservation/ Implants Immediate Post-Op 88
Site Preservation/ Implants 89
Site Preservation/ Implants 90
Implant  Placement 91
Implant  Placement 92
After After Site Preservation/ Implants 93
Site Preservation/ Implants 94
<ul><li>Augmentation </li></ul><ul><li>and </li></ul><ul><li>Implants </li></ul>95
Before Guided Bone Regeneration Implant Site  Development 96
Implant Placement Gingival Augmentation Augmentation/ Implants 97
Augmentation/ Implants 98
Augmentation/ Implants 99
Final Results Augmentation/ Implants 100
Before After Augmentation/ Implants 101
The Key that  Brings it Together: <ul><li>Communication </li></ul><ul><ul><li>Interoffice </li></ul></ul><ul><ul><li>Patie...
103
104
<ul><li>Standards of Care </li></ul><ul><li>in Endodontics </li></ul><ul><li>Peter Velyvis, DDS </li></ul><ul><li>Limited ...
Diagnosis <ul><li>Evaluation of pulpal and periradicular status must be performed for every tooth to be treated </li></ul>...
Pulp Testing <ul><li>Indicated tests include thermal, electrical, percussion, palpation and mobility </li></ul><ul><li>Occ...
Diagnosis <ul><li>Pulpal and periradicular diagnosis should be formulated for each tooth to be treated using endodontic te...
Pulpal  Diagnosis 109
Periradicular  Diagnosis  110
Treatment Plan <ul><li>Patient’s case difficulty as well as dentist’s abilities, experience and equipment should be evalua...
112
Radiographs <ul><li>Radiographs of diagnostic quality are required </li></ul><ul><ul><li>If periapical lesion is apparent,...
Emergencies <ul><li>Many emergencies can or even should be initially treated with medication </li></ul><ul><li>Pulpotomies...
Analgesics <ul><li>OTC drugs are usually sufficient to control much endodontic-related pain </li></ul><ul><ul><li>NSAIDs ,...
Antibiotics <ul><li>Primary infections tend to be a mixed flora of aerobic and anaerobic bacteria </li></ul><ul><ul><li>Pe...
Antibiotics 117
Narcotics <ul><li>Narcotics should be used to temporarily control breakthrough pain </li></ul><ul><ul><li>They do little t...
<ul><li>Endodontic Treatment </li></ul>119
Informed  Consent <ul><li>Consent should include the possibilities of post-op discomfort, swelling, need for medication, o...
Rubber Dam <ul><li>This is the only AAE dictated standard of care </li></ul>121
Anesthesia <ul><li>My advice, don’t skimp </li></ul>122
Magnification <ul><li>This could be considered a standard of care, as the AAE requires all endodontists to be trained in t...
Magnification <ul><li>Accreditation Standards for  Advanced Specialty Education Programs in Endodontics </li></ul><ul><li>...
Apex Locators <ul><li>Eliminate need for multiple working films </li></ul><ul><li>Canal lengths should be verified radiogr...
Cone Beam  CT Scans <ul><li>Interpretation </li></ul><ul><li>Clinicians ordering a CBCT are responsible for interpreting t...
Cone Bean  CT Scans <ul><li>CBCT should only be used when the question for which imaging is required cannot be answered ad...
Cone Bean  CT Scans 128
Cone Bean  CT Scans 129
Irrigation <ul><li>Most common intracanal irrigant is Sodium Hypochlorite (NaOCl) </li></ul><ul><ul><li>Dilution to 1% or ...
Irrigation <ul><li>Chlorhexidine 2%, EDTA  (ethylenediaminetetraacetic acid)  and saline are also commonly used during ins...
NiTi vs.  Stainless Steel <ul><li>Rotary Nickel-Titanium instrumentation is currently the most common method of cleaning a...
Filling  Materials <ul><li>Gutta Percha with eugenol-based sealer is still the most common root canal filling material </l...
Filling  Materials <ul><li>No more Silver Points </li></ul>134
Filling  Materials 135
Occlusal  Restorations <ul><li>The occlusal restoration of a root canalled tooth is as important at preventing infection a...
Occlusal  Restorations <ul><li>During the time between the onset of root canal treatment and placement of the definitive o...
Post-op  Radiographs <ul><li>This is essential to proper endodontic treatment </li></ul><ul><ul><li>Entire apex of tooth s...
<ul><li>Post Treatment </li></ul>139
Persistent  Discomfort <ul><li>Several days of discomfort post-treatment is not unusual. </li></ul><ul><li>Discomfort that...
<ul><li>Extraction/Implants </li></ul>141
<ul><li>Cracked Teeth </li></ul>142
  Cracked Teeth 143
  Cracked Teeth 144
  Cracked Teeth 145
<ul><li>Documentation </li></ul>146
<ul><li>Standards of Care </li></ul><ul><li>Prosthodontics </li></ul><ul><li>Robert J. Chapman DMD </li></ul>147
Standards? What do we mean? <ul><li>Procedural  </li></ul><ul><ul><li>Specific treatments: Example: Crown preparation = mi...
Reasons to Know &  Use Standards <ul><li>Better  possible  patient care outcome if followed </li></ul><ul><li>Benchmarking...
What Are the Problems  with Standards <ul><li>Not all are agreed upon: What is most important </li></ul><ul><li>No  Gold S...
Probably the Most  Important  Standard Is… <ul><li>…  the  Process of Treatment </li></ul><ul><ul><li>Findings </li></ul><...
Second Most  Important Standard <ul><li>Information and communication </li></ul><ul><ul><li>Ask What the patient  wants </...
What Determines  Success? <ul><li>Three things: </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment plann...
Radiographs and Study  Casts with Dx Wax-ups <ul><li>Follow ADA/AAOMR  </li></ul><ul><li>Radiographic Guidelines </li></ul...
Good preparations. Good margins Good maintenance plaque control electric brush flossing Patient over 65 so use risk-reduci...
(My) Guidelines  <ul><li>Use  some  guideline/standard that has been developed by some recognized group </li></ul><ul><ul>...
Diagnosis <ul><li>After your findings, determine if you wish to proceed </li></ul><ul><li>Diagnostic Codes will SOON be a ...
American College of  Prosthodontics <ul><li>Not procedural standards but  Prosthodontic Diagnostic Index Resources (PDI) <...
159
Good preparations. Good margins Good maintenance plaque control electric brush flossing Patient over 65 so use risk-reduci...
Comprehensive  Standards <ul><li>University of Kentucky </li></ul><ul><ul><ul><li>Very thorough and complete without being...
University of Kentucky  College of Dentistry - SOC <ul><li>FULL CROWN COVERAGE (All Porcelain )The Full Crown Coverage-(Al...
Focused  Standards <ul><li>Delta Dental </li></ul><ul><ul><li>Quality of Life (recently validated) </li></ul></ul><ul><ul>...
<ul><li>Standards would be impossible to achieve if too detailed and without exceptions. </li></ul><ul><li>Be careful whic...
What are minimal procedural standards  for prosthodontics  we could all feel comfortable with? <ul><li>Preparation </li></...
Biologic Health Potential (analysis of in vitro information) after crown preparation of  1.5 mm  depth <ul><li>Enamel & De...
If Pulp Exposure  Happens Anyway <ul><li>Tell patient  beforehand  of risks and what will happen if a pulp exposure result...
Probable Agreement for  Fixed and Removable  <ul><li>Occlusion: normal comfort ,function and bilateral simultaneous contac...
169
Continuing Education:  Always Good to Have Recorded <ul><li>Keep up with state CE requirements </li></ul><ul><li>Go to pro...
What’s in  the Future <ul><li>Implants </li></ul><ul><ul><li>With dentures: likely yes, but with limitations – bone, patie...
Council on Dental  Accreditation – CODA <ul><li>One of main Standards is to teach to evidence based care </li></ul><ul><ul...
Review at Leisure  But Do It!  <ul><li>http://jada.ada.org/cgi/content/full/135/10/1449 </li></ul><ul><ul><li>JOSEPH P. GR...
<ul><li>Questions </li></ul>174
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Risk management presentation

  1. 1. STANDARDS OF CARE IN PERIODONTICS, ENDODONTICS, AND PROSTHODONTICS <ul><li>Paul Levy, DDS </li></ul><ul><li>Peter Velyvis, DDS </li></ul><ul><li>Robert J. Chapman, DMD </li></ul><ul><li>Barry J. Regan, VP, Claims and Risk Mgmt, EDIC </li></ul>1
  2. 2. Standard of Care <ul><li>Average, qualified dentist </li></ul><ul><ul><li>What a reasonable and prudent practitioner would do in the same or similar circumstance </li></ul></ul><ul><li>Established by: </li></ul><ul><ul><li>What is taught in dental schools </li></ul></ul><ul><ul><li>What is promulgated by the specialty academies </li></ul></ul>2
  3. 3. Standard of Care <ul><ul><li>To a lesser extent, what is published in peer-reviewed journals </li></ul></ul><ul><ul><li>State licensing boards </li></ul></ul><ul><ul><li>And, unfortunately: </li></ul></ul><ul><ul><ul><li>By juries in malpractice actions </li></ul></ul></ul>3
  4. 4. Standard of Care <ul><li>Juries determine standards of care based on information presented during trials: </li></ul><ul><ul><li>Patient Records </li></ul></ul><ul><ul><li>Testimony of staff and other witnesses </li></ul></ul><ul><ul><li>Expert witness testimony </li></ul></ul>4
  5. 5. Standard of Care <ul><li>Is there a separate standard of care for a specialist than for a general dentist doing specialty work? </li></ul><ul><li>NO!!! </li></ul>5
  6. 6. <ul><li>Standards of Care </li></ul><ul><li>Periodontology </li></ul><ul><li>Paul Levy, DDS </li></ul>6
  7. 7. <ul><li>Failure to diagnose and treat periodontal disease falls below the standard of care. </li></ul>7
  8. 8. <ul><li>First, an accurate diagnosis is essential. Then an appropriate treatment plan including etiology and prognosis must be formulated. </li></ul>8
  9. 9. <ul><li>Clinical diagnosis, treatment planning, and procedures are decided, whenever possible, on evidence-based data and controlled clinical studies in peer-reviewed scientific literature. </li></ul><ul><li>This is somewhat of a controversial statement. </li></ul>9
  10. 10. <ul><li>Second, treatment is traditionally divided into 3 phases: </li></ul><ul><ul><li>Non-surgical Therapy </li></ul></ul><ul><ul><li>Surgical Therapy </li></ul></ul><ul><ul><li>Maintenance Phase </li></ul></ul>10
  11. 11. <ul><li>Periodontal surgery when not followed by good professional and personal care, will, in many cases, fail. </li></ul><ul><li>Nyman et al, J. Clin. Perio, 1977 </li></ul><ul><li>Becker et al, J. Perio, 1984 showed that when maintenance is provided, a surgical approach to treatment of moderate to advanced periodontitis is highly successful </li></ul>11
  12. 12. <ul><li>Patient compliance, even when optimal, must be reinforced by frequent maintenance and recall. </li></ul><ul><li>This requires a team effort by referring dentists, hygienists, and periodontists, which results in tooth retention and successful treatment in most cases. </li></ul><ul><li>Lindhe and Nyman, J. Clin. Perio, 1984 </li></ul>12
  13. 13. <ul><li>Dentistry is not a perfect science. Outcomes of treatment do not have to be ideal to conform to the standard of care. </li></ul><ul><li>Treating beneath the standard of care is considered negligence. </li></ul>13
  14. 14. Essential Components of Record Keeping <ul><li>Medical and dental history </li></ul><ul><li>Chart notes and results of examinations </li></ul><ul><li>Professional correspondence </li></ul><ul><li>Insurance Requests </li></ul><ul><li>Billing statements </li></ul><ul><li>Informed consent </li></ul><ul><li>HIPPA rules </li></ul><ul><li>Radiographs </li></ul><ul><li>Models, Photographs </li></ul>14
  15. 15. Informed Consent <ul><li>Patient must understand the options of treatment. Several possibilities usually exist to treat the periodontal problem. </li></ul><ul><li>The patient is an “active partner” to the clinician in their own care. </li></ul>15
  16. 16. There are 5 Steps to Consent: <ul><li>Their must be an understanding of the problem, the diagnosis. </li></ul><ul><li>The proposed treatment and alternative treatments must be fully explained. </li></ul><ul><li>No warranties or guarantees can be given. </li></ul><ul><li>Authorization must allow for change in plan if unforseen circumstances arise. </li></ul><ul><li>Discussion of all sequelae or side affects must be given. </li></ul>16
  17. 17. <ul><li>Consent may be verbal or written but it must be fully understood by the patient. I use different forms for each procedure. </li></ul>17
  18. 18. Beneficence <ul><li>This is a legal concept that refers to providing the best possible care. If the practitioner is unable to do this, the patient must be referred to a competent specialist for continuing or more advanced care. </li></ul><ul><li>Dentists and periodontists are treatment partners. </li></ul>18
  19. 19. Record Keeping <ul><li>All records must be contemporaneous and must be signed and dated. Legally, a professional written record carries more weight than plaintiff’s (patient’s) recollection. If something is documented in the chart, it is claimed to have occurred. Conversely, it is difficult to establish the event, if not documented. Radiographs are important records. The number and timing depends on the severity and activity of the case. The FDA issued guidelines for a full mouth survey every 5 years and bite-wing films approximately every 12-18 months to illustrate periodontal disease and its changes. </li></ul>19
  20. 20. <ul><li>Measuring and recording of pocket depths on six locations for each tooth provide the minimum foundation to document the legal responsibility for each patient. These pocket depth recordings are done at the initial exam, on completion of treatment, and once or twice a year during maintenance. </li></ul>20
  21. 21. OSHA <ul><li>Occupational Safety and Health Administration </li></ul><ul><ul><li>Universal precautions and bloodborne pathogens </li></ul></ul><ul><ul><li>Hazard communication </li></ul></ul><ul><ul><li>Waste management </li></ul></ul><ul><ul><li>Illness and injury prevention </li></ul></ul>21
  22. 22. HIPAA <ul><li>Health Insurance Portability and Accountabilty </li></ul><ul><ul><li>Electronic Transaction Standard </li></ul></ul><ul><ul><li>Privacy Standard </li></ul></ul><ul><ul><li>Security Standard </li></ul></ul><ul><li>HIPAA is enforced by the Office of Civil Rights </li></ul>22
  23. 23. Continually Upgrade Skills <ul><li>Use updated comprehensive text books, continuing education courses, current studies in the scientific literature. </li></ul>23
  24. 24. <ul><li>Traditional periodontal treatment including both surgical and non surgical techniques have very high success rates in saving teeth in a healthy, functional and esthetic state. This has been known for over 20-50 years. </li></ul><ul><li>Hirshfeld and Wasserman, J. Perio. 1978 </li></ul><ul><li>Oliver, J. West Soc. Perio. 1969 </li></ul><ul><li>Goldman, MJ et al, J Perio. 1986 </li></ul>24
  25. 25. <ul><li>Proper use of surgical regenerative procedures with a variety of grafts and membrane barriers have shown that bone and soft tissue that had been lost to periodontal disease can be regenerated and questionable teeth saved. </li></ul>25
  26. 26. Controversial Comments <ul><li>Using ineffective therapies to avoid traditionally effective ones may result in progression of disease around teeth that may ultimately be extracted. </li></ul><ul><li>Before using any new modality, any dentist should have histological, clinical and long-term proof that these procedures are effective. </li></ul><ul><li>Do we allow industry and companies with profit motive and little track record to establish the standard of care? </li></ul>26
  27. 27. <ul><li>The Keyes technique, many time-released local antibiotics (chlorhexidine in a gelatin chip, tetracycline fibers, docycyline hyclate in a polymer carrier or minocycline microspheres) and even lasers were tested scientifically and found to yield little, if any, improvement over traditional scaling and root planing (without surgical therapy). </li></ul>27
  28. 28. <ul><li>New products such as tissue healing modulators, growth factors (BMP- 2) and even stem cells are promising additions to currently proven materials and techniques which will require evidence-based research currently being performed. </li></ul>28
  29. 29. Implants- Controversy <ul><li>Implant surfaces and designs make it difficult to find comparable long-term statistics for implants currently being used. </li></ul><ul><li>Would you rather have a healthy functioning tooth or an implant? </li></ul>29
  30. 30. <ul><li>In 1952, in the JADA, DeVan stated that ”Our objective should be the perpetual preservation of what remains rather than the meticulous restoration of that which is missing.” </li></ul>30
  31. 31. When do we place implants? <ul><li>When periodontal disease is present; how long should we wait to place the implant? How much bone loss do we accept before deciding to place the implant? </li></ul><ul><li>There are shades of gray- answers are not always black and white. </li></ul><ul><li>Do we place implants when adjacent teeth are virgin teeth? </li></ul>31
  32. 32. <ul><li>In circumstances where extraction and implant placement is indicated, the patient should know the options, risks, benefits, anticipated results and potential complications before implant treatment is considered. </li></ul>32
  33. 33. <ul><li>There can be complications in implant placement. Pjetursson (2004) reported that 38.7 percent of patients had complications in the first 5 years after implantation </li></ul><ul><li>Lang(2004) reported that biological and technical complications with implant-supported restorations occurred in about 50 percent of cases after 10 years in function. </li></ul>33
  34. 34. <ul><li>This may dispel the belief that implants are a trouble- free panacea when compared to the retention of teeth that require periodontal treatment. </li></ul><ul><li>The standard of care takes into account all of our findings, clinical and radiographic, all our knowledge of diagnosis, prognosis and treatment considerations and alternatives. </li></ul>34
  35. 35. Flossophy <ul><li>Do good work and carry as much insurance as possible. </li></ul><ul><li>We are fortunate to be in a profession where we can earn a living and help people. </li></ul>35
  36. 36. <ul><li>Periodontal Plastic Surgery: </li></ul><ul><li>Framework for the </li></ul><ul><li>Perfect Smile </li></ul>36
  37. 37. Esthetics 37
  38. 38. Achieving Optimal Esthetic Results <ul><li>Treatment Options </li></ul><ul><li>Resective Therapy </li></ul><ul><li>Augmentation Therapy </li></ul><ul><ul><li>Root coverage procedures </li></ul></ul><ul><ul><li>Hard and soft tissue ridge </li></ul></ul><ul><ul><li>augmentation </li></ul></ul>38
  39. 39. Esthetics <ul><li>Crown Lengthening </li></ul>39
  40. 40. Anterior Crown Lengthening <ul><ul><li>Pre-restorative </li></ul></ul><ul><ul><li>For smile enhancement </li></ul></ul><ul><ul><li>Biologic width sensitive </li></ul></ul><ul><ul><li>Papillary retention </li></ul></ul><ul><ul><li>critical </li></ul></ul>40
  41. 41. Before After 41
  42. 42. 42
  43. 43. Crown Lengthening Before After 43
  44. 44. Crown Lengthening Before Incisions 44
  45. 45. Crown Lengthening Immediate Post-Suturing One-Month Healing 45
  46. 46. Crown Lengthening Before Incision 46
  47. 47. Crown Lengthening Before After 47
  48. 48. Crown Lengthening Before One-Month Postsurgical 48
  49. 49. Crown Lengthening Before Incisions 49
  50. 50. Crown Lengthening Immediate Post-Op Surgical 50
  51. 51. Crown Lengthening Before Incisions 51
  52. 52. Crown Lengthening Before After 52
  53. 53. Augmentation Therapy <ul><li>Hard and Soft Tissue Augmentation Procedures </li></ul>53
  54. 54. Augmentation Therapy <ul><li>Clinical Indications </li></ul><ul><ul><li>Recession </li></ul></ul><ul><ul><li>Deficiency in Gingival Form </li></ul></ul><ul><ul><ul><li>Ridge Collapse </li></ul></ul></ul><ul><ul><ul><li>Loss of Papilla </li></ul></ul></ul><ul><ul><li>Anterior Extractions </li></ul></ul>54
  55. 55. <ul><li>The presence or absence of papillae can be anticipated by measuring the distance from the proximal bone o the contact point. When the distance is less than 5mm (4.2mm), the chances of having a complete papilla is excellent. </li></ul>55
  56. 56. Augmentation Therapy <ul><li>Root Coverage </li></ul><ul><li>Procedures </li></ul>56
  57. 57. Root Coverage Before Immediate Post-Op 57
  58. 58. Root Coverage Before After 58
  59. 59. Root Coverage Before Prepared Root Surfaces 59
  60. 60. Root Coverage 60
  61. 61. Root Coverage Before After 61
  62. 62. Root Coverage Before After 62
  63. 63. Root Coverage Before After 63
  64. 64. Augmentation Therapy <ul><li>Root Coverage </li></ul><ul><li>for </li></ul><ul><li>Implants </li></ul>64
  65. 65. Root Coverage for Implants After Before 65
  66. 66. Augmentation Therapy <ul><li>Ridge Augmentation </li></ul>66
  67. 67. Root Coverage for Implants After Before 67
  68. 68. Ridge Augmentation Before After 68
  69. 69. Ridge Augmentation Before Post-Suturing 69
  70. 70. Ridge Augmentation Before After 70
  71. 71. Augmentation Therapy <ul><li>Site Preservation </li></ul>71
  72. 72. Site Preservation Before 72
  73. 73. Site Preservation/ Root Coverage Before One-Month Post-Extraction 73
  74. 74. Site Preservation Before After 74
  75. 75. Site Preservation/ Ridge Augmentation 75
  76. 76. Site Preservation 76
  77. 77. Site Preservation Before After 77
  78. 78. Augmentation Therapy <ul><li>Combination Procedures </li></ul>78
  79. 79. Combination Procedures Before After 79
  80. 80. Combination Procedures Before Suturing 80
  81. 81. Combination Procedures Before After 81
  82. 82. Combination Procedures Incisions Before 82
  83. 83. Combination Procedures Before Immediate Post-Suturing 83
  84. 84. Combination Procedures After Before 84
  85. 85. Combination Procedures Before After 85
  86. 86. Esthetics with Implants 86
  87. 87. Site Preservation for Implants 87
  88. 88. Before Site Preservation/ Implants Immediate Post-Op 88
  89. 89. Site Preservation/ Implants 89
  90. 90. Site Preservation/ Implants 90
  91. 91. Implant Placement 91
  92. 92. Implant Placement 92
  93. 93. After After Site Preservation/ Implants 93
  94. 94. Site Preservation/ Implants 94
  95. 95. <ul><li>Augmentation </li></ul><ul><li>and </li></ul><ul><li>Implants </li></ul>95
  96. 96. Before Guided Bone Regeneration Implant Site Development 96
  97. 97. Implant Placement Gingival Augmentation Augmentation/ Implants 97
  98. 98. Augmentation/ Implants 98
  99. 99. Augmentation/ Implants 99
  100. 100. Final Results Augmentation/ Implants 100
  101. 101. Before After Augmentation/ Implants 101
  102. 102. The Key that Brings it Together: <ul><li>Communication </li></ul><ul><ul><li>Interoffice </li></ul></ul><ul><ul><li>Patient </li></ul></ul>102
  103. 103. 103
  104. 104. 104
  105. 105. <ul><li>Standards of Care </li></ul><ul><li>in Endodontics </li></ul><ul><li>Peter Velyvis, DDS </li></ul><ul><li>Limited to Endodontics </li></ul>105
  106. 106. Diagnosis <ul><li>Evaluation of pulpal and periradicular status must be performed for every tooth to be treated </li></ul>106
  107. 107. Pulp Testing <ul><li>Indicated tests include thermal, electrical, percussion, palpation and mobility </li></ul><ul><li>Occlusal discrepancies should also be evaluated </li></ul><ul><li>Reproduction of patient’s symptoms “is desirable, if not mandatory” </li></ul>107
  108. 108. Diagnosis <ul><li>Pulpal and periradicular diagnosis should be formulated for each tooth to be treated using endodontic terms </li></ul>108
  109. 109. Pulpal Diagnosis 109
  110. 110. Periradicular Diagnosis 110
  111. 111. Treatment Plan <ul><li>Patient’s case difficulty as well as dentist’s abilities, experience and equipment should be evaluated before embarking on endodontic treatment </li></ul><ul><li>Case difficulty assessment checklist is available through the AAE </li></ul>111
  112. 112. 112
  113. 113. Radiographs <ul><li>Radiographs of diagnostic quality are required </li></ul><ul><ul><li>If periapical lesion is apparent, entire lesion should be visualized </li></ul></ul><ul><ul><ul><li>May require additional angles or types of films (bitewing, occlusal, panoramic) </li></ul></ul></ul>113
  114. 114. Emergencies <ul><li>Many emergencies can or even should be initially treated with medication </li></ul><ul><li>Pulpotomies are acceptable treatments for vital teeth </li></ul><ul><li>Pulpectomies are the indicated treatment for necrotic teeth, with or without periradicular disease </li></ul><ul><li>Incision and drainage can be used to relieve pressure buildup in a localized fluctuant swelling </li></ul>114
  115. 115. Analgesics <ul><li>OTC drugs are usually sufficient to control much endodontic-related pain </li></ul><ul><ul><li>NSAIDs , if tolerated, typically offer more relief than other analgesics </li></ul></ul><ul><ul><ul><li>NSAIDs help remove the source of a patient’s pain- a buildup of inflammation in the jawbone </li></ul></ul></ul><ul><ul><li>Acetaminophen is recommended if there is a contraindication to NSAIDs or in combination with NSAIDs for enhanced pain control </li></ul></ul>115
  116. 116. Antibiotics <ul><li>Primary infections tend to be a mixed flora of aerobic and anaerobic bacteria </li></ul><ul><ul><li>Penicillin is the first choice antibiotic </li></ul></ul><ul><li>Recurrent or long-standing infections are anaerobic </li></ul><ul><ul><li>Clindamycin, or penicillin with metronidazole is a good first choice </li></ul></ul>116
  117. 117. Antibiotics 117
  118. 118. Narcotics <ul><li>Narcotics should be used to temporarily control breakthrough pain </li></ul><ul><ul><li>They do little to relieve the source of the patient’s pain </li></ul></ul>118
  119. 119. <ul><li>Endodontic Treatment </li></ul>119
  120. 120. Informed Consent <ul><li>Consent should include the possibilities of post-op discomfort, swelling, need for medication, or complications </li></ul><ul><ul><li>Altered sensation, separated instruments, blocked or perforated canals, root fractures, damage to restorations </li></ul></ul><ul><li>Also included: the need for a subsequent restoration after RCT (filling, crown, etc.) </li></ul>120
  121. 121. Rubber Dam <ul><li>This is the only AAE dictated standard of care </li></ul>121
  122. 122. Anesthesia <ul><li>My advice, don’t skimp </li></ul>122
  123. 123. Magnification <ul><li>This could be considered a standard of care, as the AAE requires all endodontists to be trained in the use of magnification and illumination </li></ul>123
  124. 124. Magnification <ul><li>Accreditation Standards for Advanced Specialty Education Programs in Endodontics </li></ul><ul><li>Use of magnification technologies. Intent : The intent is to ensure that students/residents are trained in the use of instruments that provide magnification and illumination of the operative field beyond that of magnifying eyewear . In addition to the operating microscope, these instruments may include, but are not limited to, the endoscope , orascope or other developing magnification. </li></ul>124
  125. 125. Apex Locators <ul><li>Eliminate need for multiple working films </li></ul><ul><li>Canal lengths should be verified radiographically before root canal filling is bonded into place </li></ul><ul><li>Apex locators do not replace radiographs in confirming that all canals or tortuous canal space has been instrumented </li></ul>125
  126. 126. Cone Beam CT Scans <ul><li>Interpretation </li></ul><ul><li>Clinicians ordering a CBCT are responsible for interpreting the entire image volume, just as they are for any other radiographic image. Any radiograph may demonstrate findings that are significant to the health of the patient. There is no informed consent process that allows the clinician to interpret only a specific area of an image volume. Therefore, the clinician can be liable for a missed diagnosis, even if it is outside his/her area of practice. Any questions by the practitioner regarding image data interpretation should promptly be referred to a specialist in oral and maxillofacial radiology. </li></ul>126
  127. 127. Cone Bean CT Scans <ul><li>CBCT should only be used when the question for which imaging is required cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities. </li></ul><ul><li>Smaller scan volumes generally produce higher resolution images, and since endodontics relies on detecting disruptions in the periodontal ligament space measuring approximately 200μm, optimal resolution is necessary. </li></ul>127
  128. 128. Cone Bean CT Scans 128
  129. 129. Cone Bean CT Scans 129
  130. 130. Irrigation <ul><li>Most common intracanal irrigant is Sodium Hypochlorite (NaOCl) </li></ul><ul><ul><li>Dilution to 1% or 2.5% is generally considered a safer concentration in the prevention of “hypochlorite accidents” </li></ul></ul><ul><ul><li>Side-venting irrigating syringe should fit into the canals loosely, and never be expressed under pressure </li></ul></ul><ul><ul><li>NaOCl has both antibacterial and tissue dissolving properties </li></ul></ul>130
  131. 131. Irrigation <ul><li>Chlorhexidine 2%, EDTA (ethylenediaminetetraacetic acid) and saline are also commonly used during instrumentation </li></ul><ul><li>Calcium Hydroxide gel is the most often used inter-appointment medicament </li></ul>131
  132. 132. NiTi vs. Stainless Steel <ul><li>Rotary Nickel-Titanium instrumentation is currently the most common method of cleaning and shaping the root canals </li></ul><ul><ul><li>These do have a higher propensity of instrument separation than stainless steel hand files. </li></ul></ul><ul><ul><ul><li>Experience in handling these instruments is the only way to learn the limits of torque and pressure </li></ul></ul></ul>132
  133. 133. Filling Materials <ul><li>Gutta Percha with eugenol-based sealer is still the most common root canal filling material </li></ul><ul><li>Resin based, bonded root canal fillings are becoming more popular, as well </li></ul><ul><ul><li>There does not appear to be any conclusive advantage to either filling material at this time </li></ul></ul>133
  134. 134. Filling Materials <ul><li>No more Silver Points </li></ul>134
  135. 135. Filling Materials 135
  136. 136. Occlusal Restorations <ul><li>The occlusal restoration of a root canalled tooth is as important at preventing infection as the root canal, itself. </li></ul><ul><li>Cuspal coverage minimizes likelihood of root fracture </li></ul>136
  137. 137. Occlusal Restorations <ul><li>During the time between the onset of root canal treatment and placement of the definitive occlusal restoration, heavy occlusal and lateral forces should be eliminated. </li></ul>137
  138. 138. Post-op Radiographs <ul><li>This is essential to proper endodontic treatment </li></ul><ul><ul><li>Entire apex of tooth should be visible on radiograph to evaluate and confirm treatment of the entire canal system </li></ul></ul>138
  139. 139. <ul><li>Post Treatment </li></ul>139
  140. 140. Persistent Discomfort <ul><li>Several days of discomfort post-treatment is not unusual. </li></ul><ul><li>Discomfort that lasts weeks or months sometimes resolves on its own, but often indicates either uncleaned irritant in the canal system or other, more serious defects, i.e.cracked root. </li></ul>140
  141. 141. <ul><li>Extraction/Implants </li></ul>141
  142. 142. <ul><li>Cracked Teeth </li></ul>142
  143. 143. Cracked Teeth 143
  144. 144. Cracked Teeth 144
  145. 145. Cracked Teeth 145
  146. 146. <ul><li>Documentation </li></ul>146
  147. 147. <ul><li>Standards of Care </li></ul><ul><li>Prosthodontics </li></ul><ul><li>Robert J. Chapman DMD </li></ul>147
  148. 148. Standards? What do we mean? <ul><li>Procedural </li></ul><ul><ul><li>Specific treatments: Example: Crown preparation = minimal reduction for desired outcome? (esthetics = ?porcelain) </li></ul></ul><ul><li>Care </li></ul><ul><ul><li>Overall care: Treatments which in toto attempt to deal with all of patients needs or desires </li></ul></ul>148
  149. 149. Reasons to Know & Use Standards <ul><li>Better possible patient care outcome if followed </li></ul><ul><li>Benchmarking to an agreed upon and codified process and outcome </li></ul><ul><ul><li>Generally developed by some recognized dental organization </li></ul></ul><ul><ul><li>Often evaluated and modified over many years </li></ul></ul><ul><li>Guidelines to treatment planning </li></ul><ul><li>May offer some (not guaranteed) legal “shelter” especially in procedural outcomes </li></ul><ul><li>If not used can allow for challenge by expert or institutional (insurance, licensing, educational, peer) review </li></ul>149
  150. 150. What Are the Problems with Standards <ul><li>Not all are agreed upon: What is most important </li></ul><ul><li>No Gold Standard to compare to </li></ul><ul><li>Often address procedural rather than patient care processes or outcomes </li></ul>150
  151. 151. Probably the Most Important Standard Is… <ul><li>… the Process of Treatment </li></ul><ul><ul><li>Findings </li></ul></ul><ul><ul><ul><li>Histories, examinations (intraoral, radiographs, etc.) </li></ul></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment planning </li></ul></ul><ul><ul><ul><li>What do patients want? </li></ul></ul></ul><ul><ul><ul><li>Can it be achieved? </li></ul></ul></ul><ul><ul><ul><li>Informed consent </li></ul></ul></ul><ul><ul><ul><ul><li>Risks, benefits, potential outcomes </li></ul></ul></ul></ul>151
  152. 152. Second Most Important Standard <ul><li>Information and communication </li></ul><ul><ul><li>Ask What the patient wants </li></ul></ul><ul><ul><li>Let them know their needs </li></ul></ul><ul><ul><li>What are the risks associated with treatment of either needs or wants </li></ul></ul>152
  153. 153. What Determines Success? <ul><li>Three things: </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment planning </li></ul></ul><ul><ul><ul><li>OHRQOL - Patient Centered </li></ul></ul></ul><ul><ul><ul><li>Prognosis from Evidence Based Information </li></ul></ul></ul><ul><ul><li>Informed consent </li></ul></ul><ul><ul><ul><li>OHRQOL - Patient Centered </li></ul></ul></ul><ul><ul><ul><li>Prognosis from Evidence Based Information </li></ul></ul></ul>153
  154. 154. Radiographs and Study Casts with Dx Wax-ups <ul><li>Follow ADA/AAOMR </li></ul><ul><li>Radiographic Guidelines </li></ul>RC 9 154
  155. 155. Good preparations. Good margins Good maintenance plaque control electric brush flossing Patient over 65 so use risk-reducing high fluoride content toothpastes and varnishes All ceramic-1st premolar to 1st premolar PFM- premolars & 1st molars Gold - 2nd molars 155
  156. 156. (My) Guidelines <ul><li>Use some guideline/standard that has been developed by some recognized group </li></ul><ul><ul><li>American College of Prosthodontists, AAGD, Dental School (nearby/community/accredited, graduated from), state, other </li></ul></ul><ul><ul><li>Fairly recently developed or revised </li></ul></ul><ul><ul><li>In some way addresses patient concerns and your communication to them </li></ul></ul><ul><li>Treatment guide is evidence that is literature based whenever possible </li></ul><ul><ul><li>CorchoranCollborative reviews, </li></ul></ul><ul><ul><li>Research at some level above technique, case report, or bench study articles </li></ul></ul><ul><li>Communicate </li></ul><ul><ul><li>Write in record </li></ul></ul><ul><ul><li>Write letters </li></ul></ul>156
  157. 157. Diagnosis <ul><li>After your findings, determine if you wish to proceed </li></ul><ul><li>Diagnostic Codes will SOON be a reality </li></ul><ul><ul><li>Introduces new level of documentation </li></ul></ul><ul><ul><li>Electronic health records (Standard in 2014) well help </li></ul></ul><ul><li>Insurance companies and lawyers will be looking at Dx codes related to treatment plans </li></ul><ul><ul><li>Not lists of required tx’s but possibilities </li></ul></ul><ul><ul><ul><li>document tx reasons related to findings for paper or electronic record </li></ul></ul></ul>157
  158. 158. American College of Prosthodontics <ul><li>Not procedural standards but Prosthodontic Diagnostic Index Resources (PDI) </li></ul><ul><li>Class IV = refer to a prosthodontist </li></ul>158
  159. 159. 159
  160. 160. Good preparations. Good margins Good maintenance plaque control electric brush flossing Patient over 65 so use risk-reducing high fluoride content toothpastes and varnishes All ceramic-1st premolar to 1st premolar PFM- premolars & 1st molars Gold - 2nd molars 160
  161. 161. Comprehensive Standards <ul><li>University of Kentucky </li></ul><ul><ul><ul><li>Very thorough and complete without being overly detailed </li></ul></ul></ul><ul><ul><ul><li>Long but worth reviewing </li></ul></ul></ul>161
  162. 162. University of Kentucky College of Dentistry - SOC <ul><li>FULL CROWN COVERAGE (All Porcelain )The Full Crown Coverage-(All Porcelain) restoration is an indirect restorative procedure involving full replacement of the functional clinical crown. The crown is fabricated from different porcelains without a metal substructure. These restorations are usually limited to single unit crowns and are indicated when maximum esthetics is desired for a full coverage crown. Indications 1. For restoration of tooth defects from either dental caries, tooth fracture, developmental defects, or replacement of defective restorations.2.When full coverage is required and the esthetic demand is paramount. 3.Retainer for a fixed partial denture. 4.Retainer and rest seat for removable partial denture clasp. 5.Patient preference. Contraindications 1.Patient has a demonstrated allergy or medical intolerance to a component of the restorative material.2.Poor periodontal prognosis for tooth retention. 3.Presence of a direct pulp cap. 4.Patients with high and/or poorly controlled caries activity. 5.When there is insufficient sound tooth structure to support and retain the restoration. 6.Excessive or abrasive occlusal function. 7.Patient preference. 8.Patient economic resources. Outcomes Assessment1 . No evidence of caries beneath or adjacent to the Full Crown Coverage-(All Porcelain) restoration.2.Normal occlusal functions and tooth contours are maintained. 3.The restoration remains intact and continues to function acceptably. </li></ul>162
  163. 163. Focused Standards <ul><li>Delta Dental </li></ul><ul><ul><li>Quality of Life (recently validated) </li></ul></ul><ul><ul><ul><li>Published but not used </li></ul></ul></ul><ul><ul><ul><li>Not embraced by community </li></ul></ul></ul><ul><li>Dental schools, offices </li></ul><ul><ul><li>Process promises </li></ul></ul><ul><ul><ul><li>We promise to do our best </li></ul></ul></ul><ul><ul><ul><li>We will communicate </li></ul></ul></ul><ul><ul><ul><li>We’ll be nice </li></ul></ul></ul><ul><ul><ul><li>Etc. </li></ul></ul></ul>163
  164. 164. <ul><li>Standards would be impossible to achieve if too detailed and without exceptions. </li></ul><ul><li>Be careful which ones you choose. </li></ul>164
  165. 165. What are minimal procedural standards for prosthodontics we could all feel comfortable with? <ul><li>Preparation </li></ul><ul><ul><li>Know anatomy of tooth so as not to over-prepare </li></ul></ul><ul><ul><li>Look at recent literature, i.e. </li></ul></ul><ul><ul><ul><li>Full crown preparation removes approximately ~ 67 -75% of coronal tooth structure: Toothstructure removal associated with various preparation designs for posterior teeth.Edelhoff D, Sorensen JA.Int J Periodontics Restorative Dent. 2002 Jun;22(3):241-9. </li></ul></ul></ul>165
  166. 166. Biologic Health Potential (analysis of in vitro information) after crown preparation of 1.5 mm depth <ul><li>Enamel & Dentin Thickness (mm) * with 1.5 mm removed and numbers in parentheses what remains from prep to pulp </li></ul><ul><li>incisal thickness mid-crown 1 mm above CEJ </li></ul><ul><li>(tip of pulp to incisal edge) Labial Lingual Labial Lingual </li></ul><ul><li>Maxillary Central Incisor 4.2 - 1.5= (2.7) 2.4 (.9) 1.7 (.2) 2.7 (1.2) 3.2 (1.7) </li></ul><ul><li>Maxillary Canine 5.5 - 1.5 = (4.0) 2.8 (1.3) 2.7 (1.2) 2.9 (1.4) 3.1 (1.6) </li></ul><ul><li>Mandibular Incisor 4.6 - 1.5 = (3.1) 2.0 (.5) 1.5 (0) 2.4 (.9) 2.4 (.9) </li></ul><ul><li>Mandibular Canine 4.6 - 1.5 = (3.1) 2.8 (1.3) 2.3 (.8) 2.9 (1.4) 2.9 (1.4) </li></ul><ul><li>Prognosis: </li></ul><ul><li>Green = good; Blue = fair; Pink = marginal; Red = bad, </li></ul><ul><li>* Modified from: Shillingburg HT, Grace CS. Thickness of enamel and dentin. J South Calif Dent Assoc 1973;41:33. </li></ul>166
  167. 167. If Pulp Exposure Happens Anyway <ul><li>Tell patient beforehand of risks and what will happen if a pulp exposure results </li></ul><ul><ul><li>Endodontics, post, etc </li></ul></ul><ul><li>Do or refer endodontics and don’t charge </li></ul>167
  168. 168. Probable Agreement for Fixed and Removable <ul><li>Occlusion: normal comfort ,function and bilateral simultaneous contact Beyron, H, 1959 </li></ul><ul><li>Esthetics: Fits within the remaining tooth structure </li></ul><ul><li>Materials: those which are least likely to fail according to most recent literature </li></ul><ul><li>Communication with patient: </li></ul><ul><ul><li>Informed consent </li></ul></ul><ul><ul><li>At least discussion noted in record as to potential problems and longevity </li></ul></ul>168
  169. 169. 169
  170. 170. Continuing Education: Always Good to Have Recorded <ul><li>Keep up with state CE requirements </li></ul><ul><li>Go to programs that are relevant to patient care and keep copies </li></ul><ul><ul><li>Hands-on can be good </li></ul></ul><ul><ul><li>Jump-in with new procedures or products at peril unless research outcomes are well documented </li></ul></ul><ul><li>DON’T base a Standard , or any other treatment, on what some lecturer says! Won’t hold up in court no matter what the Speaker’s reputation. </li></ul>170
  171. 171. What’s in the Future <ul><li>Implants </li></ul><ul><ul><li>With dentures: likely yes, but with limitations – bone, patient health </li></ul></ul><ul><ul><li>Fixed prosthodontics: Soon but with limitations as above </li></ul></ul><ul><ul><li>Grafting – not many longitudinal studies but some </li></ul></ul><ul><li>CaMBRA </li></ul><ul><ul><li>Yes and very soon </li></ul></ul><ul><li>TMD? </li></ul><ul><ul><li>Unlikely although research data is getting better </li></ul></ul><ul><li>CAD/CAM? </li></ul><ul><ul><li>Too early to tell in popular literature </li></ul></ul><ul><li>Amalgam v. Composite </li></ul><ul><ul><li>No current research evidence but a lot of buzz in popular press </li></ul></ul>171
  172. 172. Council on Dental Accreditation – CODA <ul><li>One of main Standards is to teach to evidence based care </li></ul><ul><ul><li>Cochrane Collaborative= highest level of research reviews = http://www2.cochrane.org/reviews/ </li></ul></ul><ul><ul><li>National Library of Medicine website: pubmed.gov http://www.ncbi.nlm.nih.gov/pubmed/ </li></ul></ul><ul><li>CODA will de facto determine the standards of care for procedural outcomes within the next 10 years as this mandated dental school accreditation standard will go into affect 2013 </li></ul>172
  173. 173. Review at Leisure But Do It! <ul><li>http://jada.ada.org/cgi/content/full/135/10/1449 </li></ul><ul><ul><li>JOSEPH P. GRASKEMPER, D.D.S., J.D. 2004 ADA This article on standards is excellent. If recommendations followed can help avoid problems </li></ul></ul><ul><li>Review literature: pubmed.gov </li></ul>173
  174. 174. <ul><li>Questions </li></ul>174

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