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Maximizing Case Acceptance: A Case Report

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Figure 1. Explaining the radiograph showing decay on tooth No. 13.

Figure 2. An intraoral photo was taken to share with our patient. The existing amalgam filling was more than 20 years old, and a fracture line was developing.

Figure 3. The patient views the CAESY presentation (CAESY Systems) with our treatment coordinator.

Figure 4. The area was powdered prior to the initial image acquisition.

Figure 5. The CEREC camera (Sirona) was used to capture a digital impression for creation of the crown.

Figure 6. The completed preparation with retraction cord placed.

Figure 7. The crown was digitally designed with the CEREC system (Sirona).

Figure 8. The crown was milled in the CEREC MC XL (Sirona).

Figure 9. Occlusal view of the completed restoration.

Figure 10. Buccal view of the completed restoration

As dentists, we’ve gone through years of schooling to develop the knowledge to diagnose and treat patients. However, in the rush of a busy day it can sometimes be easy to forget that it isn’t as simple for patients to understand our recommendations for their oral health. It can also be time consuming and monotonous to accurately and consistently explain procedures and treatments. The downside of this reality is that some patients will delay or reject needed treatment because the dental team hasn’t been able to help them fully understand the scope of their problem.
     The frequency with which this situation occurs can be startling, especially at times when patients don’t feel they are financially able to take the steps we recommend. However, over the past year, I have experienced the dramatic difference that a well-organized patient education program can make for patients’ dental knowledge, concern for their oral health, and ultimately—case acceptance.
     When I purchased my practice 3 years ago, the retiring dentist had been using a pegboard system for accounting and a paper flipbook-style schedule. While this had been effective for him, one of the first purchases I made was a computer for scheduling and accounting purposes. It worked great for a while, but we started to learn more about the things we weren’t doing with the software we already had. After doing some research, we decided to expand the computer system to the operatories. In April 2008, we began using EagleSoft practice management software, Schick digital radiographs, and CAESY Patient Education (CAESY Systems). Since that time, we’ve been able to see the benefits that one integrated system offers.

As a young practitioner, developing an effective method to train our office team members was a challenge. The varying levels of experience found among the hygienists who I employed also complicated the situation; while one hygienist had been practicing for 15 years, others were new in their careers. I did not want my practice team to feel as though there was a script they had to recite at every appointment, but I did want a sense of continuity. It was important to know that every patient was fully informed about his or her particular situation and treatment options. I have found that CAESY helps us meet that objective with its variety of clinical presentations. For almost any patient condition or treatment, we have a presentation that can simply, accurately, and consistently explain what the patient should expect.
     CAESY offers presentations on both large and small procedures in the dental office, from a simple hygiene visit to placement of dental implants. The software includes more than 270 presentations, with options of English or Spanish. Its organization makes it easy for office staff to navigate between chapters and subchapters, and its comprehensive topic selection allows the office to deliver patient education for multiple aspects of a procedure or condition. The system also offers “playlists” of often related conditions, playing these presentations in a logical order for patients. For example, one playlist offers the “Brush Abrasion,” “Brushing,” and “Electric Toothbrush” presentations in order, helping patients to see the associations among these topics.
     Thanks to the consistency we gain with these presentations, when I spend time with patients, I know that their basic clinical situation has been already outlined. My team and I are then able to supplement that information in person with our own practice philosophy, as well as answer any questions that the patient might have. It provides us with a wonderful jumping off point to have a more informed discussion.

Our patient education system has been just one element of technology that we use in the office to enhance our patient education and help patients fully understand their conditions. We recently began transitioning to a completely paperless office. We also rely heavily on the use of intraoral cameras to help us show patients what they can’t see at home. The cameras integrate easily with our practice management software, which allows us to simply take the images and display them on the screen in a very user-friendly way. This process makes it simple to look back at older images in a patient’s file and compare them with the new ones. Having all of our patient information, images, and patient education in the same place helps us to keep the office running smoothly and in a very organized way.
     We began to see the benefits of using the intraoral camera after practicing for the first year without one. During that time, I would often try to explain to a patient what I was seeing in his or her mouth; however, without being able to actually show them, I found it more difficult to bring patients to an understanding of their real problem. Now, however, we use the intraoral camera to show the patient exactly what we are seeing in full detail. We strive to take at least one intraoral photo on each patient, even if it is to point out an area of improvement since the last visit. Patients are impressed with the technology and enjoy the positive feedback if they have been working hard to improve a particular problem. Additionally, in many cases, we follow this up with a CAESY presentation on their specific condition. Seeing the issue illustrated first in a photo of the mouth, and then again in the patient education program, helps patients recognize the problem, own it, and then to accept the recommended treatment.
     We now use the intraoral cameras and CAESY presentations in every new patient exam in order to establish a baseline to monitor patients over the course of their visits. When we are able to actually show a patient’s calculus buildup and inflammation, for example, instead of simply telling them they need to floss, it can help them take responsibility and address the problem. After showing patients their intraoral images and a CAESY presentation, we often see them return for their next visit to tell us they have been using an electric toothbrush. They then ask us to retake the photo to see if their situation has improved. Seeing patients adopt these changes because we have helped illustrate a problem for them is very rewarding as a practitioner.
     CAESY presentations are heavily used in recare exams, where hygienists have found them very useful to illustrate to patients the importance of proper home care and regular office visits. A variety of presentations on periodontal disease helps give patients a more complete picture of just how much of a difference 2 or 3 millimeters can make in periodontal probings. Presentations on the systemic effects of periodontal disease cover topics including cardiovascular health, diabetes, pregnancy, low birthweight, and respiratory infections. These videos play an important role in helping hygienists drive home the systemic importance of proper periodontal care. For patients who require hygiene procedures such as local antibiotic therapy, we also incorporate a CAESY presentation to demonstrate how they should care for the mouth once they get home. In the end, these patients receive information from the hygienist, CAESY, and in written materials we send home with them, and each of these methods helps reinforce our instructions.
For lengthy procedures, or for those that require multiple visits, patient education can also function to reassure patients and to explain to them the value of the process. The following case illustrates a situation in which multiple CAESY presentations were used in a CAD/CAM crown procedure.

Diagnosis and Treatment Planning With Preoperative Education

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

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

Diagnosis Photography

Tom M. Limoli, Jr
This includes photographic images, including those obtained by intra- and extraoral cameras, excluding radiographic images. These photographic images should be a part of the patient’s clinical record.
This code is not to identify the photographic duplication of radiographs.
     This procedure is frequently overlooked, yet it is a necessary key to third-party reimbursement. The clinical team sees the patient’s current condition face-to-face, and the patient can see the condition in both the hand mirror and monitor. But can the third party participating in the cost of care see the patient’s condition?
     Diagnostic photography should be used to provide and confirm that what x-rays fail to show. Send the radio­graphs that do not show the clinical condition and supplement them with the photograph and a short narrative.
     Ever since the caveman began drawing on walls, it has been widely acknowledged that, “A picture is worth a thousand words.” Nowhere is this more true than in dentistry. Diagnostic photographs can be invaluable in circumstances such as failed restorations (Figures 1 and 2), soft-tissue anomalies and fractured or missing cusps. In other words, when simple radiographs do not confirm and/or support the clinical observations of the patient’s condition, document the situation with a photographic image.
     When diagnostic photographs are submitted, the attached narrative need simply state: “The enclosed photograph shows the ___ that is not seen in the radiograph.”

Table. Oral/Facial Photographic Images
Code Description Lower Low Medium High Higher National
D0350 Oral/facial photographic images $24 $28 $35 $41 $55 $37 1.07

CDT-2009/2010. Copyright American Dental Association. All rights reserved. Fee Data. Copyright Limoli and Associates/Atlanta Dental Consultants. This data represents 100% of the 90th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office is available for a charge from Limoli and Associates/Atlanta Dental Consultants at (800) 344-2633 or visit Web site limoli.com.

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

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

Dr. Lewis received her dental degree from Southern Illinois University School of Dental Medicine in 2004 and practices in Decatur, Ill. She is active in the state and local dental societies, currently serving as president of the Decatur District Dental Society. She can be reached at (217) 877-1742 or via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..


Disclosure: Dr. Lewis reports no conflicts of interest.

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