Maximizing Case Acceptance: A Case Report

[Anonymous]

 CASE REPORT

Diagnosis and Treatment Planning With Preoperative Education 
A 44-year-old male visited our office for his recare exam. We took 4 bite-wing x-rays, and the radiographs showed decay at the distal margin of tooth No. 13 (Figure 1). An amalgam filling had been in service there for more than 20 years, and a fracture line was also developing on the tooth (Figure 2). The leakage under the restoration was sufficient enough and the original filling large enough that a full coverage crown was recommended to replace the restoration and to prevent the tooth from further breaking down. In cases such as this, patients sometimes request a new filling instead of a crown, but they are warned that any new filling has a slim chance of lasting long. In this case, once the patient saw the image we had taken with the intraoral camera, he readily accepted the need for a crown. 
     The patient had a traditional PFM crown placed before, so he understood the basic process that takes place, but I chose to show him a CAESY presentation for 2 reasons: First, I wanted him to have a better understanding of the procedure, and second, I planned to place a CEREC (Sirona) crown in this case, as opposed to the PFM with which he’d had experience. We explained to the patient that we had a new technology with which we could place the crown in one visit, and then had him view the “CAD/CAM Restorations” CAESY presentation (Figure 3). This particular presentation explains the procedure very well and illustrates the technology in an efficient and yet interesting way. The video also walks through the early steps of anesthetizing, placement of a rubber dam, and prepping the tooth with a handpiece. It then explains the unique steps of the in-office CAD/CAM procedure—powdering the teeth, taking images with a camera, and designing the restoration electronically. The presentation also explains the steps involved in milling and try-in, as well as final cementation and polishing. The presentation ends with a summary of the advantages offered by CAD/CAM crowns, including their high levels of accuracy, the minimal preparation required, and the dentist’s ability to place them in one visit. (I have found that this point, in particular, helps to raise patients’ interest and reassures them that we want to make the most of their time.) The CAD/ CAM Restorations presentation is important in helping patients understand why there are breaks in the crown placement appointment, as it demonstrates that the dentist must design and mill the crown while the patient waits. 
     After viewing the presentation, the patient was ready to commit to the procedure. An appointment was set, and the patient returned to the office approximately one month after his initial visit. At this time, we again showed him the CAESY presentation on CAD/CAM Restorations to refresh the points we’d covered at the past visit and to prompt any questions in advance of the procedure.

Restorative Procedures
Impressions (Quadrant dual-arch tray [Patterson Dental]) were taken for use in fabricating a backup provisional in the event that the CEREC restoration was unsuitable. At this point, I joined the procedure and anesthetized the patient. While waiting for the anesthetic to take effect, the patient’s bite was checked and the existing restoration was adjusted into proper occlusion for the initial CEREC image acquisition. An isolation device (Isolite) was placed to provide proper isolation and to prevent the camera from fogging up and thus distorting the image. A Powder Pro device (Advanced Dental Instruments) was used to cover the teeth to be imaged with a reflective coating for proper image acquisition (Figure 4). The images needed were captured within approximately 5 minutes, by which time the anesthetic had taken effect (Figure 5). The amalgam was removed along with the recurrent decay, and the tooth was prepped with a series of diamond burs (Premier Dental Products). A No. 1 retraction cord (Ultrapak [Ultradent Products]) soaked in Hemodent (contains no epinephrine) (Premier Dental Products) was placed around the prepped tooth, and the Powder Pro was again used to powder the teeth (Figure 6). A second series of images of the preparation and surrounding teeth was acquired.
     The area was thoroughly cleaned and the patient was instructed to rinse. The patient was then given a break from the procedure while I designed and milled the crown (Figures 7 and 8). Once the milling process was completed, I tried the crown in the mouth and completed some light adjustments, including the removal of the sprue. Giving the patient a second break, I cleaned the crown and completed the staining and glazing in my in-office porcelain oven (Programat CS [Ivoclar Vivadent]). After allowing the restoration to cool, the restoration was cemented with a resin cement (Anchor resin cement [Apex Dental Materials]). Any excess cement was then removed, the occlusion was checked, and final finishing/polishing steps were performed on the crown.

Postoperative Education and Instructions
At that time, I gave the patient a brief explanation of what to expect during the next stage, and the assistant then had the patient view an additional CAESY presentation, “Post-Op Instructions: Permanent Crowns.” This presentation is a quick overview of the typical instructions given to patients following placement of a crown. It advises them to avoid chewing anything until after the anesthesia wears off, to not chew ice or hard objects, and to brush and floss normally to care for the crown. The presentation also advises patients on what to do if they experience discomfort after the procedure, suggesting use of a desensitizing toothpaste for a few days if teeth are sensitive to heat, cold, or pressure following the procedure. Patients are also warned to take any antibiotics or medication only as prescribed, and instructed to rinse with warm salt water to reduce discomfort or swelling. The presentation explains that it is normal for gums to be sore for several days after the procedure. Finally, it emphasizes that patients should not hesitate to call the office if their bite feels uneven, if discomfort lasts beyond a few days, or if they have any questions. 
     After the patient completed viewing the presentation, he was again given an opportunity for questions. The patient was ultimately very pleased with the process and with the aesthetic look and comfortable feel of his new crown (Figures 9 and 10).

CLOSING COMMENTS
A procedure such as this one can be lengthy, and does necessitate several breaks during which the dentist has to leave the patient to fabricate and glaze the crown. Without a well-organized education program, patients in these cases can potentially become anxious after being left alone or might feel neglected because of the delay. However, making thorough use of CAESY presentations, our team is able to fully explain these procedures in advance, both helping patients prepare and giving them a better understanding of what the dental team is accomplishing. Furthermore, the thoroughness of the postoperatory instructions is very helpful, as these presentations cover a variety of issues that may come up once the patient reaches home. Knowing that each patient has been consistently briefed on some of the most common “What if?” questions is a significant help in minimizing postprocedure anxieties and calls to the office. 
     With every patient, our team aims to use the technology in the office to its fullest to educate and help patients take ownership of their situation. We have recently adopted a system in which I perform new patient examinations with the assistance of my treatment coordinators in my treatment rooms. This gives me an opportunity to welcome patients to the office right away, let them know what we’re about, show them images of their teeth taken with the intraoral camera, and then use CAESY patient education to better illustrate their individual condition. With these technological tools, we often hear feedback such as, “Wow, I didn’t know about that,” and, “I’ve never seen that before.” Impressing patients with these capabilities helps keep our word-of-mouth referrals coming and also helps us retain patients as we track their success with new images. I believe that every time a patient visits the office, we have an opportunity to educate. Utilizing tools such as the intraoral camera and CAESY system helps us accomplish our patient education goals consistently and effectively. These technologies help increase patient knowledge and acceptance of proposed treatment, and improve the chance for greater satisfaction once delivered.