Fixed Prosthodontics

Course

• RS 631 and RS 641

Course Director

• Celeste V. Kong DMD, CAGS, Associate Professor and Director of Restorative Dentistry, Clinical Course Director for Fixed Prosthodontics, Room G 614 , Phone 617/638-5209. ckong@bu.edu
  

Faculty

• Shola Abatti DMD
• Nily Abramovitz DMD
• Lina Al-Aswad DMD
• Myra Brennan DMD
• Jacqueline Argandona DMD
• Thomas A. Armstrong DDS
• Louis Brown DMD
• Gennaro Cataldo DMD
• Casey Cook DMD
• Ted Engle DDS
• Aristides Exarchos DMD
• Karl Flanzer DMD
• Mark Ferriero DDS
• David M. Gabelman DDS
• Deedee Gurin DMD
• Frederick Hains,DMD
• Francis Harrington DMD
• Marianne Jurassic DMD
• Shiro Kamachi DMD
• George Keleher DDS
• John C. McManama DDS
• Alfred Mcmanama DMD
• Steven Mollica DMD
• Emrey Moskowitz DDS
• Negar Nasseripour DMD
• Mayumi Onoe-Miyamoto
• Deborah Hong Pan DMD
• Janet Peters DMD
• Douglas Riis DMD
• Edward Riley DMD
• Richard Rosen, DMD
• Parviz Sadooghi DMD
• Gregory Stoute DMD
• Franson Tom DMD
• Ira Weinberg DMD

Volunteers

• Mike Davies DMD
• Nick Kanelos DMD
• Marmar Mesgarzadeh DMD
• Joseph Sawan DMD
• Teresa Venedikian DMD

Laboratory Technicians

• John Alexander, CDT
• Gerard Dorato, BS

Purpose

There are two basic purposes to the clinical program in Restorative Dentistry

1. Patients must be provided with high quality comprehensive care, which includes fixed prosthodontics and operative dentistry within the context of a well-organized and sequenced comprehensive treatment plan.
2. In providing care for patients, students will achieve the competencies as stated by the school especially in the restoration of teeth to form and function, the replacement of missing teeth and occlusal analysis and adjustment.

Entry Level Skills and Prerequisites for Entering the Clinic

1. The First year and Second year preclinical technique courses are prerequisites for the Patient-Care phase of Restorative Dentistry
2. Certification by the Second Year Promotions Committee of eligibility to treat patients in the clinic
   

Daily Feedback and Evaluations

Students are regularly advised of their clinical performance in this discipline. There are three mechanisms by which students are apprised of daily their clinical performance.

1. Each treatment appointment is evaluated by clinical faculty during the clinic session and this is documented in the “Clinic Journal” which is kept by the student.
2. Summative Evaluation forms for the different skills tests are filled out by faculty members and are viewable by the students. They are also posted on The Student Performance System on the internet so that students and their mentors can track their progress towards competency.
3. Last, individual meetings with students are scheduled at the student or faculty’s request. Students who are not performing to expected levels will be advised of such status by their Mentor.

Clinical Protocol Regarding Diagnosis and Treatment Planning:

Rationale: The diagnostic phase of patient care is critical to the patient’s proper treatment and to the student’s understanding of the complex exercise called diagnosis and treatment planning. Each student should bear in mind that a well-developed treatment plan is a goal unto itself, not “paperwork” to be skimmed over to “get to treatment”. In the process of collecting all pertinent diagnostic information and the subsequent development of a comprehensive treatment plan, the student will be making progress towards the achievement of Competencies I and II

1. The student shall have received medical and dental histories, performed head and neck exams, intra-oral exams and surveyed available radiographs. Chief complaint will be noted.
2. In order to write a comprehensive treatment plan, consults form different departments are important and will be performed as needed on the clinic floor. Consults may be needed for Oral Surgery and Implantology and these will be done at a different location and time.
3. The student is responsible for performing a through restorative examination. Any chief complaint or subjective symptoms must be noted in the chart. In the operative consult sheet, all previous restorations are marked in blue, all problems marked in red, and the diagnosis section is completed in ink.
4. Often, the faculty member will request that the first appointment also be used to obtain additional information, such as, study casts; Face-bow and Centric relation registration so that an occlusal analysis may be conducted; additional radiographs or specific consultation from other dental departments such as periodontology, and implantology.
5. If the patient requires treatment that would include a fixed partial denture of great than 3 units, or 5 or more single unit crowns this case must be presented to one of the senior faculty for case discussion and approval. The senior faculty members who can discuss and approve the large cases include: Dr. Brown, Dr. Hains, Dr. Kong, Dr. Riis and Dr. Sadooghi. Large cases are great formative learning experiences but many are not suitable for the pre-doctoral clinic. Many of these cases may need to be referred to the Post-graduate Prosthodontic Dept.
6. After all the information has been gathered, a treatment plan is developed with the help of a mentor or faculty member. This treatment plan must be approved, sequenced and signed by a mentor or a restorative dentistry faculty member before treatment can be started. The patient must also sign the informed consent.
7. Additions to the treatment plan sheet, in the back of the form, can be made ONLY for single tooth restorations. i.e. fixed partial dentures cannot be added to the treatment plan without rewriting the treatment plan and all that this entails.
8. Any work performed on a patient 1) without a signed treatment sequence or 2) out of proper sequence will be, if not specifically approved in writing by a faculty member, considered a serious breach of conduct and may result in disciplinary action leading to suspension or dismissal from clinic.

Treatment Planning Combined Fixed/Removable Prosthodontic Cases

Both the prosthetic directors must be consulted during the final treatment planning of such cases. This meeting is usually scheduled without the patient present, but with the patient’s record, radiographs, mounted study casts and all relative departmental consultations, including initial prosthetic consultations completed with clinical faculty.



Clinical Protocol Regarding Delivery of Treatment

Dental students are not independently licensed by the Commonwealth of Massachusetts to render dental treatment. A faculty member must specifically supervise all clinical work performed in this school. This includes all treatment, including such seemingly innocent steps as exams, radiographs, and re-cementations. Students must treat only in approved clinical areas, and during normal clinic hours with the express consent of the faculty member who will supervise the work.

Compliance of students to infection control procedures will be documented on the daily feedback reports. This will also cover OSHA regulations that are integral to the way the clinics operate.

Students must review the medical status of the patient and determine the depth of anesthesia necessary for each procedure. The instructor and the student will select the appropriate drug and needle size and type of injection to be used. A green requisition slip must be filled out and signed for each carpule to be dispensed by the supply window. If an adequate level of anesthesia is not reached after the first injection, the student MUST seek the advice of a faculty member.

If emergency treatment is necessary before completion of the consultations and sequenced treatment plan, the student must discuss this problem with a mentor and get signed authorization to treat the patient. There is a fee for the emergency visit. Making provisional restorations for fixed prosthodontics is not usually considered an emergency and will require that the patient pay for the temporary restoration.

Account Receipt (Contracts)

All fixed prosthetic work performed by DMD students, with two exceptions, must be contracted. The first exception is the re-cementation of existing restorations. The second exception is in the case of emergency treatment that has been approved by a mentor or Oral Diagnosis. In this case there will be a charge to the patient for an emergency appointment or provisional.
Contracts must also be made for Ryan White patients or patients who are receiving “remakes” at no charge. Documentation of this “contract” is given with a print out from the front desk of the Account Receipt. The receipt will have the “amount paid” and the “procedure” being paid for.

Continuity of Care

Students bear the ultimate responsibility to provide regular and ongoing care to patients within the guidelines of the signed comprehensive diagnosis and treatment plan form. The student should seek assistance from their Mentor, consulted prior to scheduled rotations, to assist in providing coverage or transfer of patients. In addition, team Mentors should be consulted if problems in executing a treatment plan develops. Problems with patient management should be reviewed with the Division of Patient Services.

Before a patient can be transferred, the student must get approval from Dr. Kong and the mentor. Only in extenuating circumstances will a fixed prosthodontic case be transferred after final impression stage. All cases that are to be transferred must have a written case summary in the chart and approval from the mentor or Dr. Robinson.

The Mentors will do random record reviews to ensure compliance with treatment planning schedules. The timing and sequence of procedures are to be determined by the final sequenced treatment plan. Gross violations of these regulations will result in serious sanctions.

Before any restorative procedure is started, the following must be properly completed:

1. Authorization to start: An instructor MUST examine the patient and give a written authorization to start the procedure.
2. A local anesthetic requisition slip must be filled out and signed. This slip authorizes the procurement of one carpule of anesthetic and one needle from the supply window. Instructors will have these slips.
3. The Sequenced Treatment Plan sheet at the front of the chart must be checked, initialed and dated by a Restorative Dentistry faculty member. This is done next to the listed procedure. This is the formal authorization to start the procedure.
4. The student journal will be filled out by the faculty during or at the end of the session
5. Daily progress notes MUST be signed by the faculty member at the end of each appointment session. Each meeting with the patient in the clinic must be noted in the chart and signed by both the student and the faculty. Canceled appointments must be similarly recorded. Telephone discussions must also be documented.
6. The flow sheet for fixed prosthodontics must be used in order to keep track of the progress of each clinical case. These are the documents which fixed prosthodontics will use to determine eligibility for summatives.

When an appointment is completed, there are several things that must be done:

1. The patient should be told of any post-op instructions and prevention techniques (floss threading etc.).
2. Any financial obligations must be addressed. Payment is always expected on the date of service. Patients will not be able to continue to book appointments if they have unpaid balances.
3. The student must make certain that the patient is not dismissed until the instructor has checked all necessary steps. The patient should never leave the school with any restoration (permanent or temporary) that has not been checked by an instructor.
4. All necessary paperwork must be completed at this time. Do not wait until the end of the day. The Chronological Record of all Treatment/Visits must be completed properly and signed by both student and faculty member. It is very important that this part of the record be properly completed, dated and signed. The Chronological record should include all interactions with patients (even canceled appointments), the dates, tooth numbers, description of procedures, amounts of all drugs administered and prescribed, bases, liners, cements etc.
5. The visit sheet and the patient’s chart must be brought to the reception desk with the patient so that payment can be made and the next appointment can be scheduled. The Front desk receptionist will give the patient his/her appointment. Please note that all appointments must be made through the Front desk and every patient must be brought to the reception desk after each appointment.

Basic Fixed Prosthodontic Treatment Permitted in the Clinic

All work must be treatment planned and contracted.

1. Cast gold restorations
2. Porcelain-fused-to-metal crowns
3. Cast post and cores
4. Fixed partial dentures

Our students must be competent in the replacement of a single missing tooth and therefore it is strongly suggested that students seek patients requiring such treatment. All efforts from the Division of Patient Services to arrange these assignments will be made. In addition, the school provides access to “Dental Simulators” that allow students the experience of preparing teeth and fabricating provisional fixed partial dentures in simulated clinical settings. Simulation is also an important aspect of preparation for Licensure Examinations.

In order to properly meet patients’ needs, a variety of additional procedures may be rendered under the direction of the Division of Restorative dentistry for credit:

• All ceramic restorations (inlays, onlays, crowns)
• Porcelain laminates
• Resin retained bonded fixed partial dentures
• Abutment or copings for removable prosthodontics
  

Specific Fixed Prosthodontic Clinic Policies

If pre-fabricated post & cores are part of a treatment plan that includes a crown for the same tooth, it must be treatment planned and contracted. Prefabricated posts & full amalgam build-ups that are not currently treatment planned for crowns will be credited towards the grade in Operative Dentistry. Pin-Amalgam build-ups, whether preparatory to an ultimate crown or not, must also be contracted and treatment planned.

Fixed Partial Dentures of more than three units are occasionally permitted to be delivered by DMD students. All such bridges must have a co-signature by the director of the division of restorative dentistry, in addition to the clinical faculty member’s signature on the General Dentistry Consultation form.

If more than five single units of indirect restorations are treatment planned for one patient, a co-signature of the director of the division of restorative dentistry is also required.

The director can also delegate other senior faculty members to approve these, more complicated treatment plans. At this time the other faculty who have been delegated this responsibility are: Drs. L. Brown, F. Hains, D. Riis, and P. Sadooghi. In order to discuss one of these extensive treatment plans, all consults must have been documented in the chart. Study casts mounted in CR with another set of diagnostic wax-ups of the proposed restorations would aid the student in determining the extent and the goals of treatment and therefore this is strongly encouraged.

Provisionals

Several different types of provisional restorations may be provided:

• For a single posterior tooth: a block temporary crown; custom prepared shell; a matrix made from a vacuform or silicone putty
• For Multiple posterior teeth: a processed provisional fabricated with the help of one of the lab technicians.
• For single anterior teeth: prefabricated polycarbonate shell crowns are available from one of the lab technicians or a custom pre-fabricated shell
• For any provisional of more than three splinted units, it is recommended that a heat processed custom shell be fabricated.

Cosmetic Dentistry

Whenever there is a need for a restoration to specifically deal with a cosmetic or esthetic problem, the student should discuss the case with Dr. Cataldo or a Restorative Dentistry faculty member. These procedures include direct and indirect veneers, bleaching, diastema closure, etc. These procedures may be options that are presented to a patient when discussing the comprehensive treatment plan.

Impression Materials and Techniques

The technique of choice for soft tissue management prior to impressions is displacement cord without epinephrine. Electrosurgery may be used with the guidance and demonstration of a faculty member when appropriate.
A tray-syringe technique using either polyether or poly-vinyl siloxane is the technique of choice. Trays and impression materials are available at the supply window but there will be instances when a custom tray will be required.

Laboratory Work

All wax-patterns must be evaluated by Mr. John Alexander or Mr. Gerry Dorato before gold will be issued. There are NO exceptions to this important rule. All work associated with preparation of die models will also be evaluated by the laboratory technicians.

Clinical Grade for Fixed Prosthodontics

Please see handouts for qualifiers and summative exercises given out by Dr. Kong in the clinical syllabus.

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[Draft: 6-04]

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