How to Make Metal-Ceramic Technology Look Good and Why You Should Still Be Using It

Metal-ceramic restorations have long represented a reliable tooth-replacement option; however, they have begun to fall out of favor as all-ceramics systems have improved by leaps and bounds and patients continue to request tooth-colored restorative materials. As these changes have occurred within the industry, some clinicians are questioning the continued relevance of metal-ceramic technology and whether it is compatible with the current demand for esthetics. But according to prosthodontists W. Patrick Naylor and Charles J. Goodacre and master dental technician Satoshi Sakamoto, esthetics and metal-ceramic restorations can be a perfect fit.

Material Choice: A Generational Shift

Even as the dental industry’s overall preference shifts toward all-ceramic restorations, metal-ceramic restorations still occupy a significant niche within restorative dentistry: posterior restorations. According to a 2016 study on material selection for single-unit crowns, clinicians were almost equally likely to restore a first molar with an all-zirconia restoration as with a metal-ceramic restoration. This study also cautioned that “decisions for crown material may be influenced by factors unrelated to tooth and patient variables” and that clinicians should be cognizant of these factors. Perhaps most strikingly, one of the indirect factors significantly influencing material choice was how recently a clinician had graduated, with newer clinicians preferring all-ceramic over metal-ceramic.

Dr Naylor, author of the Introduction to Metal-Ceramic Technology (Quintessence, 2018), explains this shift: “Once these recent graduates get out of dental school, they get bombarded with literature and advertising promoting these inexpensive all-ceramic materials. Metal-ceramics are still a part of dental education but not the way they used to be. One of the biggest changes is that dental students and even graduate dentists in advanced training programs are receiving less and less technical training in the fabrication process for metal-ceramic restorations. More procedures are given to the laboratory to perform, whereas historically those procedures were taught to and performed by dentists. The theory now is that the clinician does the clinical work, and the laboratory technician does the laboratory work—but unless you’ve gone through the process of fabricating a metal-ceramic restoration, you really don’t have the same depth of knowledge and insight as someone who has. You haven’t seen how the technical work is affected when you underprepare a tooth or don’t provide two-plane reduction, or how the esthetic result is compromised when you only take off one millimeter of tooth structure on the occlusal surface and now can’t create secondary anatomy because there’s no depth. Because of the educational deficits, newer clinicians don’t have that experience in the laboratory that they can call upon in the clinic.”

“And that’s a handicap for them,” Dr Goodacre adds. “If you’ve never made something, you don’t know what someone else is going to need to make it.”

Mr Sakamoto, who works with Dr Goodacre at the Loma Linda University School of Dentistry, commiserates: “I work with many dentists who send me impressions, bite records, and shade and facial information. Almost none of them send perfect information. But Dr Goodacre actually knows how to make a crown, so he knows what I need in order to do my job well.”

(left) By any measure, the metal-ceramic restoration on the maxillary left central incisor was not treatment planned properly or executed well clinically. The dental laboratory outcome was also flawed in many respects: shade, length, outline form, surface texture, and level of glaze. Outcomes such as this warrant criticism of metal-ceramic restorations. Take a moment to critique this restoration, and note what changes should be made when replacing this crown. (right) Thanks to retreatment with proper treatment planning, improved execution of clinical procedures, and a high-quality laboratory outcome, the restoration on the maxillary left central incisor now blends well with the adjacent natural tooth. This is a metal-ceramic crown with a porcelain margin. (Courtesy of Dr Charles Goodacre and Mr Satoshi Sakamoto.)

“Most dentists today haven’t made many crowns,” Dr Goodacre emphasizes. “I’m from the old school where we made a lot of them, and I made hundreds for myself in the early years of practicing. Of course, I could never make them look as good as Satoshi does, but I did learn what was important in terms of tooth preparation and the records you need to make. I was shocked when I read a recent JADA article where they went to different laboratories and looked at 1,157 different impressions to determine whether they were adequate or not; 86% of those impressions had at least one detectable error, and 55% of those were critical errors related to the finish line. The impression is a really key portion of the fabrication process because you rely on the impression to get a good fit, and fit is a difficult thing to achieve.”

But with the changing landscape of education and material preference in dentistry, should newer generations even continue with metal-ceramics? Drs Naylor and Goodacre think they should.

“A lot of people have turned to all-ceramics because it’s simpler in some respects and it’s inexpensive compared with metal-ceramics,” Dr Naylor explains. “But if you talk to the people who are doing a lot of high-quality dentistry, they’re still using metal-ceramics.”

“In over 45 years of practice,” Dr Goodacre adds, “I have seen limited complications with metal-ceramic restorations. We have nowhere near that track record so far with all-ceramic systems—we don’t even have 20 years of data yet.”

“In metal-ceramics, we have a number of very high-quality alloys with very predictable behavior,” Dr Naylor says, “and technicians generally have a porcelain system they like to use for each metal alloy and have perfected the application process. And the restorations last for years if not decades. I’m not the only one doing this, and Dr Goodacre and Mr Sakamoto aren’t either. Dr Irena Sailer has some metal-ceramic restorations in Color in Dentistry (Quintessence, 2017). There are a lot of good clinicians doing metal-ceramics and doing them well.”

Drs Naylor and Goodacre stress that neither all-ceramic nor metal-ceramic is perfect for every situation. “The main disadvantage of a metal-ceramic crown is that light doesn’t pass all the way through it,” Dr Goodacre explains. “You have the metal substructure, which you have to block out with opaque porcelain. So all-ceramic has the advantage when you have a tooth that is very thin or translucent. If the color of the dentin is normal, then that color will pass through an all-ceramic crown and give you an optimal esthetic result. But that opaqueness can be an advantage in other situations. If the tooth is discolored, you’ll have a better result with a metal-ceramic crown than you would with all-ceramic because that dark discoloration will show through the all-ceramic.”

In Color in Dentistry, the authors describe a case involving the replacement of two crowns on both the patient’s maxillary central incisors where the left tooth was nonvital and discolored and the right was vital and nondiscolored. Complicating the treatment planning and material selection was the patient’s insistence on all-ceramic restorations rather than metal-ceramic—the two original 20- to 30-year-old metal-ceramic crowns were opaque and not natural-looking, not to mention unsuccessful at masking the cervical discoloration of the tooth root. However, even after placing opaque zirconia frameworks, the technician was not able to fully mask the discolored left central incisor. Luckily, the technician had also made a pair of metal-ceramic crowns that the team compared at try-in, and the patient ended up agreeing with the team that the metal-ceramic crowns were better after all. The metal-ceramic crowns allowed the technician to start with the same gray framework color on both teeth, while also allowing for a thinner framework with a stronger value of opacity and larger ceramic shoulders to better reflect the veneering ceramic. (Case rehabilitation performed in collaboration with Walter Gebhardt, DT.)

“Most clinicians will have a conversation with the patient and explain which material they think is best for each clinical situation,” Dr Naylor says. “The problem is that there are some clinicians who feel all-ceramic is appropriate for every situation. They’ve got the system in their office so they try to adjust their cases to use that material wherever possible. But a good clinician will choose the type of restoration for each patient based on what they feel is appropriate functionally and will also meet the esthetic expectations of the patient. Different patients have different priorities. Material choice is an individual decision that has to be achieved through a very enlightening conversation between the patient and the clinician, and good clinicians will have an armamentarium and select different types of restorations for different patients. It’s complex, and there are no simple answers.”

So how do we maintain this technology? To solve the education dilemma, we don’t necessarily have to turn back the clock on how education curricula have evolved. Expert knowledge of metal-ceramic fabrication still exists, and if clinicians want to reclaim that technical knowledge and make quality metal-ceramic restorations a treatment option for their patients, it’s only a phone call away—to the laboratory technician.

From the Clinic to the Lab: An Important Partnership

A good relationship between the clinician and the laboratory technician can have a profound effect on the esthetic success of a metal-ceramic restoration. Dr Naylor advises that clinicians hoping to elevate the esthetic quality of their metal-ceramic restorations, especially newer clinicians, should forge a collaborative working relationship with laboratory technicians.

“Spend some time with the dental laboratory you use,” he says. “Some clinicians have to mail their work out to laboratories far from their practice if they’re in a rural setting, but there are still tools you can use to facilitate open communication in that situation. Develop a relationship with your dental laboratory. Go there, look at their work, talk to the laboratory technician, and ask what they need from you as far as records and tooth preparation go. The conversation will flow. When you’re doing fixed prosthodontics or making prostheses, you have to realize that you are partnering with someone in the laboratory. That person is your colleague—your partner. Once you know the challenges they face and how those challenges can be addressed clinically, you can be the client they want to do great work for because you don’t send them work with the limitations that other clients do. We have to team up with our dental technician colleagues and work together, and it’s an educational process. The benefits of this kind of partnership will roll over to the patient and improve the quality of care you are able to provide.”

Dr Goodacre and Mr Sakamoto have a distinct camaraderie. When discussing specific cases, each man tries to defer full credit for a successful result to the other. In truth, their work is an equal partnership—one that was built with purpose by two professionals who recognize that a successful result relies on careful collaboration.

The mandibular left first molar was restored using a metal-ceramic crown with a porcelain margin. Both the overall form and appearance are remarkably like a natural tooth but recreated with dental porcelain veneering a metal substructure. Note how Mr Sakamoto has harmonized the appearance with the adjacent natural tooth (mandibular left second premolar). When viewing the intaglio surface, the form of the porcelain margin is visible. The ceramic margin was positioned well past the mesial proximal contact area to hide the metal substructure from view. (Courtesy of Dr Charles Goodacre and Mr Satoshi Sakamoto.)

“I’ll have Satoshi come up and we’ll look at the patient together,” Dr Goodacre says. “Satoshi will take some pictures and study them to determine, based on his experiences, which material will provide the most esthetic result based on each individual tooth.” Dr Goodacre admits that their geographic proximity facilitates a closer partnership than a traditional situation would. “When he was working at Ultimate Styles in Irvine, California and couldn’t come in personally, we communicated using a lot of photos and written information and that worked well. It’s perfectly appropriate to have a patient go to a dental laboratory for a consultation, but if that’s not available you can work it out through a lot of photos and personal contact, back and forth. The key to having a good relationship between the technician and the clinician is two-way communication. I also always send Satoshi photos of the completed treatment so he can see the results of his work, and that’s something a lot of dentists don’t take the time to do. It’s a team effort, and you need to take the time to show your technician when they’ve done a nice job.”

This positive feedback can be seen as sharing credit where credit is due, but Dr Goodacre also emphasizes how important contact at the end of treatment can be if the result is less than optimal. “If something isn’t quite right and you have to do it again,” he says, “you want documentation that you can evaluate and learn from for the next one. We’ve had a few of those over the years—the first restoration doesn’t work out, so you do another one and get a better result with that one.”

“Actually,” Mr Sakamoto interjects, “I have done many metal-ceramic crowns for Dr Goodacre but hardly any redos, because the records Dr Goodacre sends are correct. If I can start with good information, I can do my best work. That is why we can get such good results in most cases.”

“Colleagues I know,” Dr Naylor adds, “they have a rapport with their lab. Clinicians should pick up the phone and talk to their laboratory technician and collaborate, so the laboratory can feel like they can converse with the clinician without fear of losing the client if they say something critical. You have to be able to accept criticism from anybody, and that person needs to be able to tell you things like, ‘Well, Doc, to be honest the impression wasn’t that great, and we couldn’t read the margins,’ or ‘We tried our best, but you didn’t have enough occlusal reduction, so that’s the best we could do for the occlusal anatomy.’ And the dentist should say, ‘Well gosh, next time call me if you see a problem, and then I’ll decide based on the patient whether I can re-prepare the tooth or if we need to change the design of the restoration.’ We have to rely on our colleagues in the field of dental technology because this is their area of expertise, so let’s facilitate that kind of dialogue. This communication is especially important in metal-ceramic cases because so many clinicians just don’t have that technical experience anymore.”

Examples of Success

One of the most complicated yet esthetically rewarding types of metal-ceramic restorations is the porcelain-margin restoration, which can satisfy the esthetic requirements needed to restore teeth in the anterior region. Mr Sakamoto describes the technical considerations involved in making these highly esthetic restorations.

Direct and mirrored views of the intaglio and occlusal surfaces of a metal-ceramic restoration with a 360-degree porcelain margin created for a maxillary right first premolar. The restoration presents with lifelike dental morphology and no externally visible metal. (Courtesy of Dr Charles J. Goodacre and Mr Satoshi Sakamoto.)

“These restorations have a 360-degree porcelain margin,” he explains, “and the porcelain margin needs to be perfect. I bake the porcelain margin four or five times to eliminate all shrinkage. Timewise, I can spend up to 2 hours just baking the porcelain margin. Then I can start on the opacious body, the regular body, and the incisal body. The weak point for metal-ceramic restorations is the opaqueness, so the most important part of making these restorations esthetic is the gradation from that opaque layer using opaque modifier. It’s kind of like how you see a drawing or picture that looks like it’s three-dimensional, when in reality it is a two-dimensional image—that’s the same thing as what I do with the opaque layer. The body of the tooth should be warmer, while the incisal layer should be bluish or grayish. Then I create the internal structure and use an internal stain to characterize the tooth. The final porcelain stage is a clear porcelain over the incisal structure to mimic natural tooth enamel. After this bakes and I finish grinding and adjustment, I polish, glaze, and polish again—it is important to polish after the glaze so you can achieve a natural luster that matches with the adjacent teeth, otherwise the result will not be esthetic.”

Here are a few more examples that represent the high level of esthetics that can be achieved using porcelain-margin restorations:

(left) Facial view of a defective metal-ceramic crown on the maxillary right central incisor. Note the high value of the ceramic, absence of surface texture and incisal translucency, facial overlap, gingival recession, and the display of metal at the cervical margin. (right) The defective restoration was replaced with a metal-ceramic porcelain-margin restoration. Note the corrections made to the outline form (no overlap needed), color, surface texture, incisal translucency, and the gingival margin placement. The soft tissue responded positively to the highly glazed porcelain. (Courtesy of Dr Charles J. Goodacre and Mr Satoshi Sakamoto.)

The mandibular right first molar was restored with a metal-ceramic porcelain-margin restoration next to an all-ceramic crown on the second premolar. Note the positive soft tissue response to both restorations and the harmony of the esthetic outcomes. The metal coping was designed to extend the porcelain margin lingual to the proximal contacts for maximum esthetics. Courtesy of Dr Charles J. Goodacre and Mr Satoshi Sakamoto.)

(left) Facial view of a metal-ceramic restoration for a maxillary premolar. (right) Direct and mirror view of the occlusal surface with its excellent characterization and esthetic occlusal morphology. (Courtesy of Dr Charles Goodacre and Mr Satoshi Sakamoto.)

The Future of Metal-Ceramic Technology

So with new all-ceramic systems cropping up every year and education programs that are unlikely to revert back to old ways, what does the future have in store for metal-ceramic technology?

“I don’t have a crystal ball,” Dr Naylor says, “however, I do see that while the trend in some commercial laboratories is an increase in all-ceramic technology and a decrease in metal-ceramic technology, we have to bear in mind that the patient population is ever increasing—even though the percentage and proportion may decrease, if you look at the number of individual patients there is still a huge demand for metal-ceramics. And I think we’ll see continued demand because the parameters of the mouth are not going to change: there will always be short crowns, there will always be bruxers, there will always be patients who may not be the best candidates for all-ceramic systems. We need to have both all-ceramic and metal-ceramic in our armamentarium. A master ceramist like Mr Sakamoto can layer a metal-ceramic restoration internally to develop a very lifelike restoration, whereas with all-ceramic you have a core, you have a veneer, you have to worry about compatibility between the core and the veneer, and then you have to color it externally. Will that be just as attractive and have the longevity of a metal-ceramic restoration? We’ll find out in time. With metal-ceramic technology, we already have a good thing—we just have to maintain it. With all-ceramic systems, we’re learning as we go how to improve them, identifying their weaknesses so we can try to overcome them, and improving their predictability. That’s what we have to look forward to.

Whatever you’re using, just use it well,” Dr Naylor concludes. “Make sure it’s appropriate for the environment in which it’s being placed. One of the main things we’re hoping to achieve with this edition of the Introduction to Metal-Ceramic Technology is to show people that metal-ceramic technology has an esthetic range that is greater than they realize, but neither metal-ceramics or all-ceramics is absolute or good for every situation. I believe in relying on the good professional judgment of the clinician to identify which material has the greatest likelihood of providing the outcome that the patient is expecting and that the clinician hopes to achieve. You have to judge each clinical case on its merits and limitations, then prescribe the most appropriate treatment. We just want to show that if you plan properly and take these clinical steps, and if your laboratory has a talented ceramist following some very exacting procedures, you can achieve an esthetic outcome with metal-ceramics—probably one that you didn’t think was possible outside of all-ceramic systems. You don’t have to settle for a material that will look good but won’t perform properly, nor do you have to settle for a material that will work well but won’t look good. With the instructions in this book, you can make the material that works look great.”

The Introduction to Metal-Ceramic Technology, Third Edition, which includes several stunning cases contributed by Dr Goodacre and Mr Sakamoto, puts technical concerns into a clinical perspective and can be used to create valuable common ground between clinicians in the dental practice and technicians in the dental lab. Whether you’re a clinician looking to expand your material options by improving the esthetic quality of your metal-ceramic restorations or a technician hoping to master both the science and art of metal-ceramic technology, Dr Naylor’s book provides the detailed instructions and expert tips necessary to succeed. The rest is up to you.


Introduction to Metal-Ceramic Technology, Third Edition

W. Patrick Naylor

For 25 years, the Introduction to Metal-Ceramic Technology has been an essential textbook, and this revised edition underscores its import to the discipline. The author expertly outlines the history and theory behind metal-ceramic restorations and then guides readers through each step of the fabrication process. Although many students do not realize the esthetic possibilities of metal-ceramic technology, this book illustrates how to achieve esthetic results to rival those of all-ceramic materials through treatment planning, clinical procedures, and dental laboratory steps executed at their highest levels. New to this edition are an expanded illustrated glossary, a simplified four-step buttonless technique, fresh analysis of bonding mechanisms, and a full chapter on the esthetic porcelain-margin restoration. Whether you are providing patients with esthetic fixed prosthodontics or are responsible for fabricating lifelike restorations in the dental laboratory, this book can serve as a valuable resource.

Also, for those we who wish to use the buttonless casting technique as described in the textbook, check out the Wax Pattern Alloy Converter App. This easy to use, well-designed app is available through Apple.

240 pp; 617 illus; ©2018; ISBN 978-0-86715-752-9 (B7529); US $98

 

W. Patrick Naylor, DDS, MPH, MS, is Adjunct Professor of Restorative Dentistry and former Associate Dean for Advanced Dental Education at the Loma Linda University School of Dentistry in Loma Linda, California. He completed advanced education programs in prosthodontics, dental public health, and dental materials. In 2000, Dr Naylor retired from the United States Air Force, having served as a prosthodontist (1981 to 2000) and linguist (1968 to 1972). Dr Naylor has written several books, book chapters, and scientific articles, including the Introduction to Metal-Ceramic Technology (Quintessence, 2018). He maintains membership in numerous dental organizations and societies and lectures on topics pertaining to prosthodontics, dental technology, and practice management.

Charles J. Goodacre, DDS, MSD, is Distinguished Professor of Restorative Dentistry at the Loma Londa University School of Dentistry. He received his DDS from the Loma Linda University School of Dentistry in 1971 and his MSD in prosthodontics and dental materials from Indiana University School of Dentistry in 1974. He served as Chairman of the Department of Prosthodontics at Indiana University, and as Dean of the Loma Linda University School of Dentistry from 1994 to 2013. He has received numerous awards throughout his career, including the Distinguished Service Award from the Academy of Prosthodontics and the Dan Gordon Lifetime Achievement Award from the American College of Prosthodontics in 2014. He has authored over 200 publications, textbooks, and textbook chapters, and contributed numerous cases to the Introduction to Metal-Ceramic Technology, Third Edition (Quintessence, 2018). Dr Goodacre maintains a part-time private practice limited to prosthodontics and has given more than 500 invited presentations.

Satoshi Sakamoto, MDT, studied dental technology at the Osaka Dental University School of Dental Technology in Japan. He started his career as the technical manager at the Sakamoto Dental Technology Training Center in Japan before moving to the United States in 2002, where he served as the technical manager at Ultimate Styles Dental Laboratory in Irvine, California, from 2002 to 2010. In 2010, he joined the Loma Linda University School of Dentistry as Master Dental Technician. Mr Sakamoto contributed numerous cases to the Introduction to Metal-Ceramic Technology, Third Edition (Quintessence, 2018) and lectures on topics pertaining to dental technology.

 

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Quintessence Roundup: November

Quintessence 2017 Catalog

Monthly Special


Evidence-Based Clinical Orthodontics

Edited by Peter G. Miles, Daniel J. Rinchuse, and Donald J. Rinchuse

Despite the ever-expanding array of orthodontic journals and textbooks available today, too many clinical decisions are based on either anecdotal evidence or the treatment philosophy of the current luminary of the lecture circuit. The authors of this book take an unbiased approach to orthodontics by systematically reviewing the relevant clinical literature and analyzing the scientific evidence to help practitioners select the most effective and efficient modes of treatment. Each chapter addresses a specific topic by summarizing the literature, critically reviewing the evidence, and offering impartial recommendations that can be adopted by clinical practitioners.

220 pp; 590 illus; ©2012; ISBN 978-0-86715-564-8 (B5648); Special Price! US $39

 

New Titles in Books


Esthetic and Restorative Dentistry: Material Selection and Technique, Third Edition

Douglas A. Terry and Willi Geller

Restorative dentistry has seen dramatic advances in recent years, especially with the use of digital technologies, and this book provides the most up-to-date information on enhanced developments, materials, and techniques that have emerged since the publication of the second edition, offering the reader a completely updated, revised, and newly illustrated overview of modern esthetic and restorative dentistry complete with tutorial videos. New topics include web-based communication with the laboratory, indirect composite chairside CAD/CAM restorations, a comparison of digital and conventional techniques, the resin composite injection technique, as well as updated information on composites and ceramic systems, including esthetic zirconia. New cases illustrate the maintenance of esthetic restorative materials, esthetic contouring, immediate dentin sealing, and novel surgical techniques such as lip repositioning, connective tissue grafting, and ridge preservation with collagen membranes. Dr Terry expanded his team of editorial reviewers to include the best minds in research and clinical practice, and the final product is a testament to his dedication to patient satisfaction and treatment success. The techniques demonstrated in this book will no doubt elevate your practice to the next level.

792 pp; approx. 2600 illus; ©2018; ISBN 978-0-86715-763-5 (B7635); Available February 2018. Reserve your copy today at our special preorder price! $278

 

Introduction to Metal-Ceramic Technology, Third Edition

W. Patrick Naylor

For 25 years, the Introduction to Metal-Ceramic Technology has been an essential textbook, and this revised edition underscores its import to the discipline. The author expertly outlines the history and theory behind metal-ceramic restorations and then guides readers through each step of the fabrication process. Although many students do not realize the esthetic possibilities of metal-ceramic technology, this book illustrates how to achieve esthetic results to rival those of all-ceramic materials through treatment planning, clinical procedures, and dental laboratory steps executed at their highest levels. New to this edition are an expanded illustrated glossary, a simplified four-step buttonless technique, fresh analysis of bonding mechanisms, and a full chapter on the esthetic porcelain-margin restoration. Written specifically for dental technology students, dental students, and residents in advanced technical courses.

240 pp; 617 illus;  ISBN 978-0-86715-752-9 (B7529); Now available! US $98

 

RBFDPs: Resin-Bonded Fixed Dental Prostheses

Matthias Kern

Nowadays single-retainer metal-ceramic and all-ceramic resin-bonded fixed dental prostheses (RBFDPs) often present a minimally invasive alternative to single-tooth implants or other conventional prosthetic methods. With a growing body of evidence showing that implants placed in the esthetic zone of younger patients present a high risk of esthetic problems in later years, RBFDPs made from zirconia ceramics are experiencing a great renaissance. This book details the protocols necessary to achieve success when replacing incisors with single-retainer RBFDPs. Although the method is technically sensitive, it is simple and extremely reliable when the correct procedures are implemented. The principles outlined in the text can also be used to replace canines and premolars. Numerous high-quality figures detail the procedures for metal-ceramic and all-ceramic RBFDPs, and case presentations—some with 20 years and more of follow-up—document the development of the success model for RBFDPs. This comprehensive text will benefit practitioners who want to expand their minimally invasive treatment options for esthetic single-tooth replacement.

264 pp; 888 illus; ISBN 978-1-78698-020-5 (B9102); Now available! US $148

 

Anesthesia Considerations for the Oral and Maxillofacial Surgeon

Edited by Matthew Mizukawa, Samuel J. McKenna, and Luis G. Vega

Although office-based anesthesia administration has been essential in the evolution of outpatient surgery, it is becoming more complex as people live longer and with more comorbid diseases. The purpose of this book is to strengthen the margin of safety of office-based anesthesia administration by helping practitioners determine whether the patients they treat are good candidates for office-based anesthesia. This book is organized into three sections. The first section provides a review of the principles of anesthesia, including the pharmacology of anesthetic agents, local anesthesia, patient monitoring, preoperative evaluation, the airway, and management of emergencies and complications. The major organ systems of the body are reviewed in section two, and the most common comorbid conditions that affect these systems are described in terms of their pathophysiology, diagnosis, management, and anesthesia-related considerations. Section three reviews patient groups that warrant special consideration in the administration of office-based anesthesia, such as geriatric, pediatric, pregnant, and obese patients. Spiral-bound and featuring tabs for quick and easy reference, this important book belongs on the shelf of every clinician who provides anesthesia in the office setting.

482 pp; 101 illus; ISBN 978-0- 86715-713- 0 (B7130); Now available! $168

Read more about Anesthesia Considerations for the Oral and Maxillofacial Surgeon here!

Anesthesiology in OMS: Past, Present, and Future

 

Oral Pathology in Clinical Dental Practice

Robert E. Marx

While most dentists do not perform their own histologic testing, all dentists must be able to recognize conditions that may require biopsy or further treatment outside the dentist office. This book does not pretend to be an exhaustive resource on oral pathology; instead, it seeks to provide the practicing clinician with enough information to help identify or at least narrow down the differential for every common lesion or oral manifestation of disease seen in daily practice as well as what to do about them. Organized by type of lesion, mass, or disease, each pathologic entity presented includes the nature of the disease; its predilections, clinical features, radiographic presentation, differential diagnosis, and microscopic features; and the suggested course of action for the dental practitioner as well as the standard treatment regimen. In keeping with the concise nature of the text, all but the rarest disease entities include at least one photograph to illustrate the clinical condition. This book distills the comprehensive information from Dr Marx and Dr Diane Stern’s award-winning pathology reference text (Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment, ed 2 [Quintessence, 2012]) into practical guidelines for restorative and general dentists everywhere.

376 pp; 425 illus; ISBN 978-0-86715-764-2 (B7642); Now available! $98

Read more about Oral Pathology in Clinical Dental Practice here!

Why Clinical Pathology Should Matter in Your Clinic

 

New Issues in Journals


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Featured article: Reconstruction of Atrophied Posterior Mandible with an Inlay Technique and Allograft Block: Technical Description and Histologic Case Reports
Vittorio Checchi, Annalisa Mazzoni, Giovanni Zucchelli, Lorenzo Breschi, and Pietro Felice

The Management of Peri-implant Mucosa Deficiencies in Esthetic Sites: Case Report of a Combined Surgical-Prosthetic Approach
Karolina Jurczyk, Urs C. Belser, and Anton Sculean

Socket Shield Technique for Implant Placement in the Esthetic Zone: A Case Report
Matthias Petsch, Benedikt Spies, and Ralf-Joachim Kohal

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Comparison of Fixed Dental Prostheses with Zirconia and Metal Frameworks: Five-Year Results of a Randomized Controlled Clinical Trial
Irena Sailer, Marc Balmer, Jürg Hüsler, Christoph Hans Franz Hämmerle, Sarah Känel, and Daniel Stefan Thoma

Post-and-Core Restoration of Severely Damaged Permanent Posterior Teeth in Young Adolescents
Nili Tickotsky, Roy Petel, Yael Haim, Maysa Ghrayeb, and Moti Moskovitz

Additive Manufacturing Techniques in Prosthodontics: Where Do We Currently Stand? A Critical Review
Nawal Alharbi, Daniel Wismeijer, and Reham B. Osman

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Featured article: Accuracy of Cone Beam Computed Tomography Grayscale Density in Determining Bone Architecture in the Posterior Mandible: An In Vivo Study with Microcomputed Tomography Validation
Feng Wang, Wei Huang, Yiqun Wu, Jesus Montanero-Fernandez, Rachel A. Sheridan, Hom-Lay Wang, and Alberto Monje

Thematic Abstract Review: Implants and the Spectrum of Aging
David Chvartszaid

Stability of Grafted Implant Placement Sites After Sinus Floor Elevation Using a Layering Technique: 10-Year Clinical and Radiographic Results
Fouad Khoury, Pierre Keller, and Philip L. Keeve

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Interaction Between Awake and Sleep Bruxism Is Associated with Increased Presence of Painful Temporomandibular Disorder
Daniel R. Reissmann, Mike T. John, Annette Aigner, Gerhard Schön, Ira Sierwald, and Eric L. Schiffman

Subjective Sleep Quality in Temporomandibular Disorder Patients and Association with Disease Characteristics and Oral Health–Related Quality of Life
Rafael Benoliel, Avraham Zini, Avraham Zakuto, Hulio Slutzky, Yaron Haviv, Yair Sharav, and Galit Almoznino

Systematic Mapping of Pressure Pain Thresholds of the Masseter and Temporalis Muscles and Assessment of Their Diversity Through the Novel Application of Entropy
Ana M. Álvarez-Méndez, Fernando G. Exposto, Eduardo E. Castrillon, and Peter Svensson

Dental Meetings Quintessence Will Attend in November


ACP 2017 Annual Session: Booth #407
hosted by the American College of Prosthodontists, November 1–4 in San Francisco, California

Pikos Symposium 2017
hosted by the Pikos Institute, November 2–4 in Orlando, Florida

Expo AMIC Dental: Booth #1701
hosted by the Agrupación Mexicana de la Industria y el Comercio Dental, November 16–17 in México City, México

Greater New York Dental Meeting 2017: Booth #3003
hosted by the New York County Dental Society and the Second District Dental Society of New York, November 27–30 in New York, New York

AAOMS Dental Implant Conference: Booth #202
hosted by the American Association of Oral and Maxillofacial Surgeons, November 30–December 1 in Chicago, Illinois

 

Posted in Books, Dental Technology, Endodontics, Esthetic Dentistry, Implant Dentistry, Journal of Oral & Facial Pain and Headache, Journals, Misc, Multidisciplinary, Occlusion & TMD, Oral and Maxillofacial Surgery, Orthodontics, Periodontics, Promotions, Prosthodontics, Research, Restorative Dentistry, Roundup, Special Offer, The International Journal of Oral & Maxillofacial Implants, The International Journal of Periodontics & Restorative Dentistry, The International Journal of Prosthodontics, What's New | Tagged , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Anesthesiology in OMS: Past, Present, and Future

In recent decades, office-based surgery has become more and more common as the medical landscape changes to accommodate a cultural shift toward preventive care and an increase in elective medical procedures. While medical specialties like plastic surgery and gastroenterology have only recently begun providing office-based surgery, dentistry—specifically oral and maxillofacial surgery (OMS)—has been providing the service for over 150 years. In that time OMS has developed industry-leading safety protocols for office-based anesthesia administration and an anesthesia-related safety record that is second to none. But how did it all start?

The Discovery of Anesthesia and Its Effect on Dentistry

An illustration of Horace Wells’s first nitrous oxide experiment, wherein he allowed his partner, John Riggs, to extract one of his own teeth after Gardner Quincy Colton administered nitrous oxide. (Source)

Pain is often the reason patients seek dental care, but the fear of pain is also one of the reasons why many patients avoid dental care. It was this close relationship between dentistry and pain that motivated Horace Wells (1815–1848), an American dentist, in his discovery of anesthesia. As the famous story goes, Dr Wells attended a nitrous oxide demonstration in Hartford, Connecticut, where he witnessed a participant bang his legs into a bench accidentally but without experiencing any pain. The next day, Dr Wells tested the effects on himself—he asked a colleague to remove one of his teeth while he was under the influence of nitrous oxide. A few weeks later, he demonstrated his anesthetic method at Massachusetts General Hospital by administering nitrous oxide to a medical student prior to extracting the student’s third molar. His use of nitrous oxide earned him the credit for discovering anesthesia.

Dr Wells’s discovery sparked an era of innovation as other dentists rushed to offer anesthesia for their patients and discover new methods for anesthesia administration, including local anesthesia. Before the 1930s, when dentists began using local anesthesia on a larger scale, patients in need of extractions or similar procedures migrated to practices that had access to general anesthesia. A distinctive divide developed between dentists who provided general anesthesia for their patients and those who did not; the cohort of dentists who did provide general anesthesia, mainly exodontists, eventually developed into the OMS specialty. This divide culminated with the formation of the American Society of Exodontists in 1918; today, this organization is known as the American Association of Oral and Maxillofacial Surgeons (AAOMS).

Anesthesiology Spreads to Medicine

While dentistry grappled with its own identity crisis with regard to anesthesiology, the broader field of medicine also began questioning the role anesthesiology should play in the practice of medicine. Daniel L. Orr II, an oral and maxillofacial surgeon based in Las Vegas, Nevada, explains: “After safe, reproducible anesthesia was discovered by dentistry in 1844, dentists were the primary operator/administrators and providers of the service for others, including physicians in hospitals, for most of the 19th century. It wasn’t until the 20th century that medicine also began to embrace anesthesia, beginning with the precursor of the American Society of Anesthesiologists (ASA) in 1905.”

When the ASA started, it was a small organization of just nine physicians based in Long Island, New York. It would still take a few more decades before physicians across the country caught on. In an article published in 2013 by the Oral and Maxillofacial Surgery Clinics of North America, Dr Orr identifies the catalyst that elevated anesthesiology into the broader spectrum of medicine:

[The 1940s were] significant in that anesthesiology changed from what was often deemed an insignificant afterthought. . . to an area that began to be embraced as essential by dentistry, medicine, veterinary medicine, and nursing.
The remarkable growth of anesthesiology in the 1940s was brought on by 2 major factors. First, it was the decade that recognized the 100th anniversary of the discovery of anesthesia. . .
The second factor influencing the remarkable recognition of anesthesia was World War II itself. In fact, wars did much to promote the art during the previous century. [William Taggart Green] Morton provided 3,000 anesthetics during the Civil War.7 The American Association of Nurse Anesthetists traces its founding to the same conflict. However, World War II was the first time that the military formally planned for the provision of anesthesia during surgery. . .

After World War II, anesthesiology took off as a designated field of medicine. But, despite dentistry’s contributions to both the discovery and the development of anesthesiology, contention developed between the two fields over dentistry’s use of anesthesia.

Surgeons and an anesthesiologist performing surgery during World War II in a makeshift surgical bunker. (Source)

Dentistry Versus Medicine, Office-Based Anesthesia Versus Hospital-Based Anesthesia

The original Baltimore College of Dental Surgery, the first dental college in the world and the birthplace of the DDS degree. The dental college was incorporated into the University of Maryland in 1923. (Source)

For a detailed history of how dentistry developed separate from medicine, take a look at The Long Climb: From Barber-Surgeons to Doctors of Dental Surgery by Philias Roy Garant (Quintessence, 2013). For a quick and simplified explanation, we can trace the root to 1837 when two dentists named Horace Hayden and Chaplin Harris proposed that the medical faculty of the University of Maryland add dentistry to their medical program; the faculty responded that “the subject of dentistry was of little consequence and thus justified their unfavorable action.” So the two dentists opened their own dental school, the Baltimore College of Dental Surgery, and formal dental education has remained separate from medical school ever since. This separation would later lead to the parallel development of two fields of anesthesia: office-based (dentistry) and hospital-based (medicine).

“Perhaps the most important development that can be attributed to dentistry,” Dr Orr explains, “is office-based, out-of-hospital, outpatient surgery and anesthesia. Because dentists worked from private offices, they couldn’t admit patients the night before surgery, operate the next day, and release them on the third day. Dental procedures done using general anesthesia were completed in a matter of a few hours, portal to portal—a concept unheard of at the time in medicine.”

Meanwhile, medical surgeons did have access to those resources. They had admitting privileges at hospitals with anesthesiologists and nurses. Moreover, their procedures were often covered by their patients’ health insurance, so the cost of those resources was not antithetical to the existence of their practice.

“Anesthesiology has been controversial in dentistry and medicine since it was first discovered,” Dr Orr laments. “But there are situations unique to dentistry that are interesting. Until 1950 dentists were able to be unrestricted members of the ASA.” (Now, membership for dentists, veterinarians, and other non-physician administrators of anesthesia is restricted to educational membership.) “The ASA even had dental officers and at least one dental president, Charles Teeter. The International Anesthesia Research Society (IARS) still accepts dentists as full members. The American Dental Society of Anesthesiology (ADSA) was founded in order to provide a platform for dentist anesthesiologists, including OMS, after the ASA option was lost.”

In his 2013 article, Dr Orr recounts a moment from his residency at the University of Utah Medical Center Department of Anesthesiology that exemplifies the tension between medicine and dentistry on the subject of anesthesiology:

In early 1976 the opening of Utah’s first outpatient surgical center was announced to university anesthesia residents at rounds. It was explained that this was a facility where patients could be admitted in the morning, receive an anesthetic for a surgical procedure, and return home on the same day! The anesthesia faculty discussed in an animated fashion whether this new model was safe and questioned if it would even survive. One of the dental residents then commented that dentistry had been doing the same thing for 100 years (actually since December 1844), out of private dental offices in fact, causing consternation for the physician anesthesiologists in the room.

Just as education was the first step toward the professionalization of dentistry, education also forms the foundation of anesthesiology in OMS, and it is only through organized effort that the OMS community has been able to protect this foothold. Later in the article, Dr Orr describes this event from 1990:

Historically, there were more than 150 anesthesia residencies that had allowed dentist residents through the decades. In June 1990 the ASA was advised about the numbers of dentist anesthesiologists that had been trained in medical residencies through the years. The ASA then contacted the Accreditation Council for Graduate Medical Education (ACGME) and opined that residencies that deigned to train dentists should not be accredited. The ACGME then contacted all accredited anesthesiology residencies and iterated that if dentists continued to be rostered, programs might lose accreditation. Almost overnight, all but a handful of medical residencies determined to no longer admit dentists for training. The AAOMS, however, was able to negotiate continued rotations on anesthesiology services for OMS residents.

Even while hospitals and medical specialties were implementing treatment protocols designed by OMS (outpatient anesthesia and surgery, office-based anesthesia and surgery), the medical community still seemed to reject OMS’s place within their community. We can only imagine how different history would be had the University of Maryland accepted Drs Hayden and Harris’s proposal: How quickly would anesthesia have been implemented by the entire medical community, and how early would outpatient surgery have become an option for patients outside of the dental clinic?

The Safety of Anesthesia in OMS

The legacy of and reasoning behind continuing anesthesiology in OMS isn’t just based on the discoveries and innovations of prior centuries, despite the noteworthiness of the office-based surgery model. OMS has also developed a team approach to anesthesia that has contributed to an anesthesia-related safety record that even beats that of hospitals for comparable procedures. There are many possible reasons for this: the lengthy history of anesthesiology in OMS, the team-based approach of OMS versus the individual approach of hospital-based surgery, and the overall emphasis by the industry on safety. Because OMS faced increased scrutiny and discrimination by the medical community from the beginning, the industry has developed safety protocols to protect their patients and, consequently, the industry’s legacy.

No one expects to die at the dentist’s office, making it all the more shocking when an adverse outcome is made public. However, statistics show that anesthesia in an OMS clinic is quite safe. Studies by the Southern California Society of OMS in the 1960s showed that while hospital mortality for tonsillectomy and adenoidectomy was 1 in 12,000, removal of third molars under general anesthesia in dental offices was less than 1 in 400,000. According to the Oral and Maxillofacial Surgery National Insurance Company (OMSNIC), between 2000 and 2014 oral surgeons covered by the OMSNIC administered office-based anesthesia 42,792,419 times, which is about 666 administrations per oral surgeon per year. Out of the total number of administrations, 415 anesthesia-related claims for complications were reported to the OMSNIC and included 121 deaths. This equals 1 death for every 353,657 administrations.

How to Protect a Legacy

As patients live longer and with more comorbid diseases, the field of anesthesiology as a whole, whether hospital-based or office-based, must adapt their models to include thorough assessments of each individual patient. This challenge is what motivated Matthew Mizukawa to develop his new book for clinicians, Anesthesia Considerations for the Oral and Maxillofacial Surgeon (Quintessence, 2017).

“In residency, you are constantly encountering complex patients who are difficult from an anesthesia standpoint,” Dr Mizukawa explains. “You become accustomed to managing those patients, all while under the supervision of a faculty surgeon—someone who will always be there to back you up or get you out of a bind. In private practice, you don’t have that safety net. The buck stops with you. On top of that, over time you start to forget some of the principles of managing comorbid diseases when you see them less frequently. You begin to lose the information you need to answer the questions of: Is it safe to perform office-based anesthesia on this patient? Why, or why not? What additional information do I need to make this decision?

“The complexity of each anesthetic case,” he continues, “is dictated by the patient’s age, medical history and current medications, past anesthetic experiences, airway anatomy, and degree of procedural anxiety. Each patient must be evaluated thoroughly, and the provider personalizes the anesthetic plan based on those careful assessments. This book guides the anesthesia provider along their decision tree and ultimately gives insight to the question of whether office-based anesthesia can be safely provided for each patient.”

The contents of the book are divided into three sections: Section 1 covers the principles of anesthesia, Section 2 provides a review of each major organ system and related diseases/disorders, and Section 3 addresses anesthetic considerations for special patient populations. Dr Mizukawa gives an example of a patient he treated and explains how the book can assist clinicians in similar cases:

A 78-year-old man presented for consultation prior to having his remaining teeth extracted. His medical portfolio included coronary artery disease, atrial fibrillation, asthma, type 2 diabetes, hypertension, hyperlipidemia, chronic kidney disease, and morbid obesity with associated obstructive sleep apnea. He was taking myriad medications to manage these conditions. In addition, poor experiences receiving dental treatment in the past had made him extremely anxious around the dental and surgery setting in general. “This scenario may have been an outlier a few decades ago,” Dr Mizukawa says. “However, with the rate of current advances in medicine, patients like these come in every day.”

So, is it safe to perform an office-based anesthetic for this patient? Dr Mizukawa explains how the book can be used to answer that question: “To tackle the coronary artery disease first, the clinician can review the section on ischemic heart disease in the cardiovascular system chapter. Here, the book provides refresher information on the pathophysiology of coronary artery disease to help the clinician determine the severity of the patient’s disease, a general review of how coronary artery disease is medically managed to help evaluate how well the patient’s disease is currently controlled, and information on how coronary artery disease is worked up to help the clinician communicate with the patient’s cardiologist. The chapter then discusses anesthetic considerations for coronary artery disease. The renal chapter provides the same information regarding the patient’s chronic kidney disease, with an additional section on recommended changes in anesthetic drug dosage based on kidney function. This process can be repeated for each of the patient’s comorbidities with the goal of determining how to most effectively and safely manage this patient’s needs, whether that be through office-based anesthesia or moving the procedure to a hospital environment.

“Once all of the disease processes have been reviewed and assessed for severity and control, additional resources are available to help guide the provider. The chapter on IV anesthetic agents helps the clinician determine which agents to use and which to avoid, as well as whether to modify dosing in light of comorbid disease. The chapter on obstructive sleep apnea (OSA) advises the clinician on how OSA will affect the monitors, particularly the end-tidal carbon dioxide monitor, while the chapter on airway emergencies covers management of the airway in the presence of OSA. The medical emergencies chapter covers myocardial ischemia and infarction, which must be considered in light of the history of coronary artery disease. In the special patient population section of the book, the clinician finds special anesthetic considerations that must be appreciated regarding geriatric patients and patients with morbid obesity and obstructive sleep apnea.

The STOP-BANG questionnaire as it appears in the book.

Sample pages from the chapter on geriatric patients and anesthesia considerations for their safe treatment.

“And finally: Patients with multiple comorbidities will likely have a very long medication list,” Dr Mizukawa concludes. “All medications modulate the normal physiological processes of the human body to some degree. For some medications, these changes are insignificant, while some medications have serious effects on anesthesia. Appendix A of the book provides a comprehensive list of commonly prescribed medications, their mechanism of action, indications for use, and their effects on anesthesia. While not a complete index of every drug that exists, it is a list of drugs commonly encountered while evaluating patients.”

A sample from Appendix A in the book.

As for the patient above: Dr Mizukawa was able to safely anesthetize him in office. After consulting with the patient’s primary care provider and specialists and reviewing the information he would later include in the book, Dr Mizukawa developed an anesthetic plan personalized to address the patient’s individual needs. The book takes initially overwhelming cases like this one and provides a simplified, structured guide for the clinician in creating an anesthetic plan.

The Future of Anesthesiology in OMS

“My hopes for the future of anesthesiology in OMS are threefold,” Dr Mizukawa explains. “I hope that we are able to not just maintain, but strengthen the margin of safety of office-based anesthesia by reducing the number of complications and deaths—despite the rising number of total anesthetics provided each year, and despite the increasing complexity of patients encountered. I hope that we continue to be leaders and innovators in anesthesia progress and develop evolving techniques and devices that make office-based anesthesia more safe and efficient. There are some who feel that the OMS model, where the surgeon also functions as the anesthesia provider, is not safe. My last hope is that OMS, by strengthening our margin of safety and innovating office-based anesthesia, will prove that our model is both safe and efficient.

“The biggest obstacle we face regarding our continued use of anesthesia is distinguishing OMS from other dental anesthesia providers,” he says. “The anesthesia training that we receive is sound. I feel that, though they are not an ADA-recognized specialty, dental anesthesiologists also receive sound training. But there are other specialties and general dentists who receive minimal training—sometimes only a 1- or 2-week course—who are then able to provide anesthesia to their patients. There is a growing concern in the public that dentists who perform anesthesia are dangerous. Even though I know there is no comparison between the anesthesia background and training in OMS and these other groups, the public at large cannot distinguish us from them. Our ability to distinguish ourselves from these groups is critical in preserving our ability to practice the surgeon/anesthetist model. This underscores my motivation behind this book.”

The unique organizational structure of Dr Mizukawa’s book makes it an invaluable and practical supplement to the clinician’s personal knowledge and expertise. It aims to quickly and effectively provide pertinent information to the anesthesia provider and assist in making decisions regarding anesthesia care and, in doing so, help preserve and strengthen the exceptional margin of safety of office-based anesthesia in OMS. The hope is that any group providing office-based anesthesia—whether oral and maxillofacial surgeons, periodontists, dental anesthesiologists, certified nurse anesthesiologists, gastroenterologists, or myriad others—can use this book to safely and efficiently provide anesthesia to their patients. The goal of anesthesia has always been to safely manage patient pain, and Dr Mizukawa’s book furthers this goal in a nonpartisan way for anyone willing to use it.


Anesthesia Considerations for the Oral and Maxillofacial Surgeon

Edited by Matthew Mizukawa, Samuel J. McKenna, and Luis G. Vega

Although office-based anesthesia administration has been essential in the evolution of outpatient surgery, it is becoming more complex as people live longer and with more comorbid diseases. The purpose of this book is to strengthen the margin of safety of office-based anesthesia administration by helping practitioners determine whether the patients they treat are good candidates for office-based anesthesia. This book is organized into three sections. The first section provides a review of the principles of anesthesia, including the pharmacology of anesthetic agents, local anesthesia, patient monitoring, preoperative evaluation, the airway, and management of emergencies and complications. The major organ systems of the body are reviewed in section two, and the most common comorbid conditions that affect these systems are described in terms of their pathophysiology, diagnosis, management, and anesthesia-related considerations. Section three reviews patient groups that warrant special consideration in the administration of office-based anesthesia, such as geriatric, pediatric, pregnant, and obese patients. Spiral-bound and featuring tabs for quick and easy reference, this important book belongs on the shelf of every clinician who provides anesthesia in the office setting.

482 pp; 101 illus; ©2017; ISBN 978-0-86715-713-0 (B7130); US $168

 

Matthew Mizukawa, DMD, is Assistant Clinical Professor in the Department of Oral and Maxillofacial Surgery at the Vanderbilt University Medical Center in Nashville, Tennessee. He obtained his dental degree from the University of Nevada at Las Vegas and completed his oral and maxillofacial surgery residency at the Vanderbilt University Medical Center, where he was awarded Best Consultant from the Department of Emergency Medicine. Dr Mizukawa is board certified by the American Board of Oral and Maxillofacial Surgeons and is a member of the American Association of the Oral and Maxillofacial Surgeons, the American Dental Association, the Utah Dental Association, and the Southern Utah Dental Association. He is co-editor of the book Anesthesia Considerations for the Oral and Maxillofacial Surgeon (Quintessence, 2017) and maintains a private practice limited to oral and maxillofacial surgery in St George, Utah.

 

Samuel J. McKenna, DDS, MD, currently serves as Professor and Chair
of the Department of Oral and Maxillofacial Surgery residency at the Vanderbilt University Medical Center in Nashville, Tennessee. He received his dental degree from the University of California, Los Angeles School of Dentistry and completed his medical degree at the Vanderbilt University Medical Center, where he served as director of the oral surgery residency program. His research includes temporomandibular joint surgery, oral manifestation of systemic disease, and virtual surgical planning in the management of skeletal facial deformities. He is co-editor of the book Anesthesia Considerations for the Oral and Maxillofacial Surgeon (Quintessence, 2017). Dr McKenna lectures within both the dental and medical communities and is a member of the American Medical Association, the American Dental Association, the American Association of Oral and Maxillofacial Surgeons, and the Cumberland Pediatric Foundation.

 

Luis G. Vega, DDS,
 is Associate Professor and Residency Program Director in the Department of Oral and Maxillofacial Surgery at the Vanderbilt University Medical Center in Nashville, Tennessee. He received his dental degree from the University of Costa Rica and his certificate in oral and maxillofacial surgery from the University of Alabama at Birmingham. Dr Vega’s clinical practice covers the full scope of oral and maxillofacial surgery. He is co-editor of the book Anesthesia Considerations for the Oral and Maxillofacial Surgeon (Quintessence, 2017) and lectures locally, nationally, and internationally on the topics of temporomandibular joint reconstruction, orthognathic surgery, obstructive sleep apnea surgery, complex maxillofacial reconstruction utilizing zygomatic implants, and endoscopy in oral and maxillofacial surgery.

 

Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD, is Professor and Director of Oral and Maxillofacial Surgery at the University of Nevada, Las Vegas School of Dental Medicine. He received his dental degree from the University of South California School of Dentistry and completing both a residency and master of science in anesthesiology at the University of Utah School of Medicine. He is a member of the American Dental Association, the American Association of Oral and Maxillofacial Surgeons, and the American Dental Society of Anesthesiology, among others. In 2011, Dr Orr received the Daniel M. Laskin Award for Outstanding Predoctoral Educator from the American Association of Oral and Maxillofacial Surgeons. He is board certified in oral and maxillofacial surgery, anesthesiology, and legal medicine and contributed a book chapter to Anesthesia Considerations for the Oral and Maxillofacial Surgeon (Quintessence, 2017).

 

Posted in Books, Feature, Implant Dentistry, Multidisciplinary, Oral and Maxillofacial Surgery, Practice Management, What's New | Tagged , , , , , , , , , , , , , , , | 1 Comment

Quintessence Roundup: October

Quintessence 2017 Catalog

Monthly Special


At the Forefront: Illustrated Topics in Dental Research and Clinical Practice

Edited by Hiromasa Yoshie

This volume brings together articles on the topics of bioscience and clinical science, punctuated with striking illustrations. The first half addresses scientific topics such as diagnosis of periodontal disease, tooth regeneration, tissue-engineered bone, correlation of periodontal disease with other conditions, and genetic diagnosis of drug-induced gingival overgrowth. In the second half, the focus is on clinical issues, including dentinal remineralization, whitening procedures, caries detectors, nerve injury, morphologic changes following tooth loss, and identification of vessels and nerves prior to implant placement. A visually stunning and instructively enlightening compilation of reports on the cutting edge of dental scientific and clinical research.

108 pp; 188 illus; ©2012; ISBN 978-0-86715-515-0 (B5150); Special price! US $39

 

New Titles in Books


Introduction to Metal-Ceramic Technology, Third Edition

W. Patrick Naylor

For 25 years, the Introduction to Metal-Ceramic Technology has been an essential textbook, and this revised edition underscores its import to the discipline. The author expertly outlines the history and theory behind metal-ceramic restorations and then guides readers through each step of the fabrication process. Although many students do not realize the esthetic possibilities of metal-ceramic technology, this book illustrates how to achieve esthetic results to rival those of all-ceramic materials through treatment planning, clinical procedures, and dental laboratory steps executed at their highest levels. New to this edition are an expanded illustrated glossary, a simplified four-step buttonless technique, fresh analysis of bonding mechanisms, and a full chapter on the esthetic porcelain-margin restoration. Written specifically for dental technology students, dental students, and residents in advanced technical courses.

240 pp; 617 illus;  ISBN 978-0-86715-752-9 (B7529); Special preorder price! US $78

 

Oral Pathology in Clinical Dental Practice

Robert E. Marx

While most dentists do not perform their own histologic testing, all dentists must be able to recognize conditions that may require biopsy or further treatment outside the dentist office. This book does not pretend to be an exhaustive resource on oral pathology; instead, it seeks to provide the practicing clinician with enough information to help identify or at least narrow down the differential for every common lesion or oral manifestation of disease seen in daily practice as well as what to do about them. Organized by type of lesion, mass, or disease, each pathologic entity presented includes the nature of the disease; its predilections, clinical features, radiographic presentation, differential diagnosis, and microscopic features; and the suggested course of action for the dental practitioner as well as the standard treatment regimen. In keeping with the concise nature of the text, all but the rarest disease entities include at least one photograph to illustrate the clinical condition. This book distills the comprehensive information from Dr Marx and Dr Diane Stern’s award-winning pathology reference text (Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment, ed 2 [Quintessence, 2012]) into practical guidelines for restorative and general dentists everywhere.

376 pp; 425 illus; ISBN 978-0-86715-764-2 (B7642); Now available! $98

Read more about Oral Pathology in Clinical Dental Practice here!

Why Clinical Pathology Should Matter in Your Clinic

 

Anesthesia Considerations for the Oral and Maxillofacial Surgeon

Edited by Matthew Mizukawa, Samuel J. McKenna, and Luis G. Vega

Although office-based anesthesia administration has been essential in the evolution of outpatient surgery, it is becoming more complex as people live longer and with more comorbid diseases. The purpose of this book is to strengthen the margin of safety of office-based anesthesia administration by helping practitioners determine whether the patients they treat are good candidates for office-based anesthesia. This book is organized into three sections. The first section provides a review of the principles of anesthesia, including the pharmacology of anesthetic agents, local anesthesia, patient monitoring, preoperative evaluation, the airway, and management of emergencies and complications. The major organ systems of the body are reviewed in section two, and the most common comorbid conditions that affect these systems are described in terms of their pathophysiology, diagnosis, management, and anesthesia-related considerations. Section three reviews patient groups that warrant special consideration in the administration of office-based anesthesia, such as geriatric, pediatric, pregnant, and obese patients. Spiral-bound and featuring tabs for quick and easy reference, this important book belongs on the shelf of every clinician who provides anesthesia in the office setting.

482 pp; 101 illus; ISBN 978-0- 86715-713- 0 (B7130); Now available! $168

 

New Issues in Journals


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Featured article: Prognosis of Dental Implants Immediately Placed in Sockets Affected by Peri-implantitis: A Retrospective Pilot Study
Eduardo Anitua, Laura Piņas, Leire Begoņa, and Mohammad Hamdan Alkhraisat

Principles for Vertical Ridge Augmentation in the Atrophic Posterior Mandible: A Technical Review
István A. Urbán, Alberto Monje, Jaime Lozada, and Hom-Lay Wang

Ten-Year Nonsurgical Periodontal Treatment Protocol with Adjunctive Use of Diode Laser Monitoring Clinical Outcomes in ≥ 6 mm Pockets: A Retrospective Controlled Case Series
Marisa Roncati, Annalisa Gariffo, Cinzia Barbieri, and Paolo Vescovi

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Comparison of Fixed Dental Prostheses with Zirconia and Metal Frameworks: Five-Year Results of a Randomized Controlled Clinical Trial
Irena Sailer, Marc Balmer, Jürg Hüsler, Christoph Hans Franz Hämmerle, Sarah Känel, and Daniel Stefan Thoma

Post-and-Core Restoration of Severely Damaged Permanent Posterior Teeth in Young Adolescents
Nili Tickotsky, Roy Petel, Yael Haim, Maysa Ghrayeb, and Moti Moskovitz

Additive Manufacturing Techniques in Prosthodontics: Where Do We Currently Stand? A Critical Review
Nawal Alharbi, Daniel Wismeijer, and Reham B. Osman

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Featured article: Accuracy of Cone Beam Computed Tomography Grayscale Density in Determining Bone Architecture in the Posterior Mandible: An In Vivo Study with Microcomputed Tomography Validation
Feng Wang, Wei Huang, Yiqun Wu, Jesus Montanero-Fernandez, Rachel A. Sheridan, Hom-Lay Wang, and Alberto Monje

Thematic Abstract Review: Implants and the Spectrum of Aging
David Chvartszaid

Stability of Grafted Implant Placement Sites After Sinus Floor Elevation Using a Layering Technique: 10-Year Clinical and Radiographic Results
Fouad Khoury, Pierre Keller, and Philip L. Keeve

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Psychosocial Profiles of Temporomandibular Disorder Pain Patients: Proposal of a New Approach to Present Complex Data
Simple Futarmal Kothari, Lene Baad-Hansen, and Peter Svensson

Psychosocial and Behavioral Aspects of Pain and Perception of Oral Health
Miriane Lucindo Zucoloto, João Maroco, and Juliana Alvares Duarte Bonini Campos

Prevalence, Course, and Associated Factors of Pain in the Temporomandibular Joint in Early Rheumatoid Arthritis: Results of a Longitudinal Cohort Study
Jessica P.S. Chin Jen Sem, Marike van der Leeden, Corine M. Visscher, Karin Britsemmer, Samina A. Turk, Joost Dekker, Dirkjan van Schaardenburg, and Frank Lobbezoo

Dental Meetings Quintessence Will Attend in October


AAID 66th Annual Conference: Booth #206
hosted by the American Academy of Implant Dentistry, October 11–14 in San Diego, California

AAOMS 99th Annual Meeting: Booth #1202
hosted by the American Association of Oral and Maxillofacial Surgeons, October 12–14 in San Francisco, California

ADA 2017: Booth #1027
hosted by the American Dental Association, October 19–21 in Atlanta, Georgia

4th Joint Meeting of ISMR-AAMP
hosted by the International Society for Maxillofacial Rehabilitation and the American Academy of Maxillofacial Prosthetics, October 27–31 in San Francisco, California

Posted in Books, Dental Technology, Endodontics, Esthetic Dentistry, Feature, Implant Dentistry, Journal of Oral & Facial Pain and Headache, Journals, Misc, Multidisciplinary, Occlusion & TMD, Oral and Maxillofacial Surgery, Pediatric Dentistry, Periodontics, Promotions, Prosthodontics, Research, Restorative Dentistry, Roundup, Special Offer, The International Journal of Oral & Maxillofacial Implants, The International Journal of Periodontics & Restorative Dentistry, The International Journal of Prosthodontics, What's New | Tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Why Clinical Pathology Should Matter in Your Clinic

When patients notice something strange in their mouths, they will probably schedule an appointment with their general dentist. Even for potentially serious symptoms, most dental or health insurers require referrals before approving specialist visits. General dentists are and will always be the gatekeepers of patient access to oral health care—and that position carries with it a significant burden.

When Robert E. Marx decided to write a book on oral pathology for general dentists, the need was clear. “One of the obstacles preventing dentists from recognizing oral diseases in their patients is the de-emphasis of clinical pathology in many dental schools today. Pathology courses may not even require or use a textbook for more than ‘suggested supplemental reading.’ This de-emphasis creates dentists who are not trained on how to refer a patient to a specialist for treatment—or even which specialist is best for any particular finding.”

Sometimes the best education comes from hands-on experience. But when it comes to clinical pathology, the stakes can be high. Dr Marx describes some successes and failures of referring dentists.

Successful Diagnoses

A 5-year-old girl presented to a restorative dentist with a mass at the base of her tongue. The mass was difficult to see and required a thorough examination. A radioactive iodine scan confirmed the suspicion that the mass was a persistent lingual thyroid; further, it was the only thyroid the patient had. Had her doctors preemptively biopsied/excised the mass, the patient would have been sentenced to a permanent hypothyroid condition at a critical point in her growth and development.

Persistent lingual thyroid as the entire thyroid gland with no presence in the neck.

In another case, a pediatric dentist noted redness and puffiness of the gingiva on the lingual side of a first molar in an 11-year-old girl. During exploration of the lesion, the dentist provoked a small but pulsatile bleeding that required 5 minutes of pressure to stop. When Dr Marx and his team evaluated the lesion, angiograms identified a large arteriovenous hemangioma where, in his words, “the gingiva represented the crown of a volcano of a potential exsanguinating bleed.” The early identification allowed Dr Marx to embolize the lesion and remove it before it grew any larger; had the lesion gone unnoticed and untreated, the hemangioma could have ruptured and resulted in massive bleeding, as illustrated below in a similar case.

Angiogram of an arteriovenous hemangioma showing large vascular networks.

Young girl in hypovolemic shock from an arteriovenous hemangioma bleed.

 

Squamous cell carcinoma of the lateral border of the tongue.

Dental hygienists are also capable of making these critical finds. One hygienist noticed an area of redness and firmness while performing a dental prophylaxis on the left lateral border of the tongue in a 61-year-old woman. Both the hygienist and dentist were suspicious enough of the lesion to refer the patient to Dr Marx, despite the fact that two physicians had previously identified it as a hypertrophied lingual tonsil. When Dr Marx biopsied the lesion, the results identified a squamous cell carcinoma. With a depth of invasion of 9 mm, the cancer required excision of the lesion as well as selective neck dissection. Thanks in part to the vigilance of the dental hygienist, the now–79-year-old patient is alive and well and continues to enjoy normal speech and eating.

Missed Diagnoses

But if every story had a happy ending, we wouldn’t need to be concerned about the status quo. Sometimes the find doesn’t come soon enough—other times, it comes far, far too late.

In one particularly frustrating case, a 45-year-old restorative dentist on the faculty of a major dental school presented with persistent redness of the anterior maxillary gingiva and frenulum. Despite impeccable plaque control—remember, the patient herself was a dentist—and her request for a biopsy, this squamous cell carcinoma was ignored and local periodontal care and topical antibiotic therapy continued for 2 years. When she was finally referred to Dr Marx, his biopsy identified the cancer that had by then invaded bone. An anterior maxillectomy was required.

Squamous cell carcinoma that was incorrectly diagnosed and treated as gum disease for 2 years, giving the cancer time to invade the bone.

A pyogenic granuloma—or could it be a cancer?

In a similar case, though one in which the patient did not have the advantage of a dental degree, a 42-year-old woman was diagnosed with a pregnancy tumor when a small, red, friable lesion emerged between her maxillary lateral and central incisors. After it was confirmed that the patient was in fact not pregnant, the working diagnosis was changed to a pyogenic granuloma. Over the course of treatment, the so-called pyogenic granuloma was removed twice but not sent for biopsy. By 20 months after her first presentation, the lesion had grown to the size of a tennis ball, and the patient had bilateral lymphadenopathy from squamous cell carcinoma. The required treatment included an anterior maxillectomy and bilateral neck dissections followed by chemotherapy and radiation therapy. The patient remains disease-free a decade later but has undergone five reconstructive surgeries so far.

A final case demonstrates the many levels of care at which patients are vulnerable to misdiagnosis. An 18-year-old girl with a hard mass at the left angle of the mandible was diagnosed by her primary care physician as having mumps, even though the mass was attached to the angle of the mandible, not the parotid gland, and the patient had no fever, malaise, or anything else that would suggest mumps. After 9 months, the physician referred her to a dentist with the complaint of “numb lip.” The numb lip was incorrectly attributed to impacted third molars, and another 6 months transpired before a referral was made to an oral and maxillofacial surgeon. The surgeon recognized the irregular bony mass as a probable osteosarcoma, which Dr Marx’s biopsy later confirmed. Despite surgery and chemotherapy, the patient died from diffuse metastasis shortly before her 21st birthday.

Osteosarcoma of the mandible as seen on a panoramic radiograph.

How to Move Forward

No one can go back in time and change a mistake that was made. What we can do is arm ourselves with the knowledge and tools necessary to do better the next time around. Dr Marx had the stories above in mind when he wrote his book Oral Pathology in Clinical Dental Practice. His goal in writing this book was not to produce a 700-page textbook for oral pathologists or maxillofacial surgeons on every possible finding, with detailed protocols for their management (that has already been done). Instead, his intent was to put potentially life-saving information into a format that would be accessible for the dental hygienist performing a routine cleaning who is in an ideal position to track changes in a patient’s oral health over time; for the general dentist whose gut instinct may be saying that a patient’s lesion doesn’t quite fit the textbook definition for a common condition and warrants a second opinion for ease of mind; and for the specialist who receives a referral for a prosthodontic rehabilitation that has already been cleared by the general dentist, but notices a potential issue that had not been previously managed and is now responsible for addressing it. This book empowers dental professionals across the spectrum of disciplines by giving them the information they need to recognize when something is wrong and to know what to do next.

“Dentists and their dental hygiene team historically have been the great identifiers of oral diseases,” Dr Marx emphasizes. “This book is dedicated to those practitioners who have picked up on diseases and conditions early, thus saving their patients from disease progression, deformity, and at times, even death. But it is also dedicated to those dentists who may have missed the early signs or obvious diseases while focusing exclusively on the dentition. It is hoped that this book will provide examples and guidance as well as the encouragement to be a diagnostician before being a treatment provider.”

Dr Marx’s aim is for his book to help each dentist, dental hygienist, and specialist become a more complete oral health care professional and, in doing so, maybe save a life or two.


Robert E. Marx, DDS, is Professor of Surgery and Chief of the Division of Oral and Maxillofacial Surgery at the University of Miami Miller School of Medicine. He is a well-known educator, researcher, and innovative surgeon who has pioneered new concepts and treatments for pathologies of the oral and maxillofacial area as well as new techniques in reconstructive surgery. The first edition of his textbook Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment (Quintessence, 2012) won the American Medical Writers Associations Prestigious Book of the Year award, and two of his other textbooks, Oral and Intravenous Bisphosphonate–Induced Osteonecrosis of the Jaws: History, Etiology, Prevention, and Treatment, Second Edition (Quintessence, 2011) and Atlas of Oral and Extraoral Bone Harvesting (Quintessence, 2009), have both been bestsellers. His many prestigious awards, including the Harry S. Archer Award, the William J. Giles Award, the Paul Bert Award, the Donald B. Osbon Award, and the Daniel Laskin Award, attest to his dedication and commitment to the field of oral and maxillofacial surgery.

 

Oral Pathology in Clinical Dental Practice

Robert E. Marx

While most dentists do not perform their own histologic testing, all dentists must be able to recognize conditions that may require biopsy or further treatment outside the dentist office. This book does not pretend to be an exhaustive resource on oral pathology; instead, it seeks to provide the practicing clinician with enough information to help identify or at least narrow down the differential for every common lesion or oral manifestation of disease seen in daily practice as well as what to do about them. Organized by type of lesion, mass, or disease, each pathologic entity presented includes the nature of the disease; its predilections, clinical features, radiographic presentation, differential diagnosis, and microscopic features; and the suggested course of action for the dental practitioner as well as the standard treatment regimen. In keeping with the concise nature of the text, all but the rarest disease entities include at least one photograph to illustrate the clinical condition. This book distills the comprehensive information from Dr Marx and Dr Diane Stern’s award-winning pathology reference text (Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment, Second Edition [Quintessence, 2012]) into practical guidelines for restorative and general dentists everywhere.

376 pp; 425 illus; ©2017; ISBN 978-0-86715-764-2 (B7642); US $98

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