INTRODUCTION
There are days I love what I do; there are also days I can’t wait to go home. For me, it’s not all that exciting to do a crown prep or 4-surface composite anymore, and, despite trying hard to please everyone, things don’t always go as planned. As it’s often said, attitude is everything. This is certainly true for us in the dental profession! We must always keep in mind the importance we play in the overall health and happiness of those patients we serve. While we can let procedures become mundane, we must always keep in mind that the clinical treatment that we provide can go well past just saving a tooth, reducing sensitivity, or removing decay. It can be life-altering—maybe even life-saving!
Can You Help Me?
“Saving a life” is not meant to be overly dramatic but to emphasize the role we can have in the overall effect on a patient’s health and outlook on life. This does not refer to your ACLS and/or BLS training or an EpiPen. It instead involves seeing oral disease, investigating the cause, and having a plan to deal with it. When we see rampant decay, restorations that fail, or an oral environment that does not fit in with the norm, we must try to discover (diagnose) the underlying causes of the clinical problem if we want to propose a solution (treatment plan) to our patient that will be a long-lasting success.
Of course, patients come to us asking, “Can you help me?” It is important that the staff also ask for help from the patient: “Can you help us…?” The questions we ask can make all the difference. “Can you help us figure out why you are getting so much decay?” “Can you help us determine why your fillings keep breaking?” “Can you help us find out why your teeth are so worn?” Simple, yet effective, questioning can make the difference between just restoring teeth and restoring the person.
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| Figure 1. Obvious decay and a compromised smile. | Figure 2. At the consultation appointment for aesthetic treatment, photos are taken to review with the patient. |
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| Figure 3. Photos help create a “shared understanding” of what can be done within biologic limitations. | Figure 4. More important than seeing rampant decay is finding out its cause. Poor hygiene, diet, and dental care are the usual suspects, but what about substance abuse? |
When the doctor examines a patient, questions are usually asked about pain, past dental experiences, and any goals the patient may have as they relate to his or her smile. Color, shape, and positioning are all very important, but these considerations are not above treating the cause. When we see rampant decay, we obviously consider normal etiology such as poor diet, hygiene, and habits. In our differential diagnosis in these times, we must always rule out the potential for substance abuse.
Substance Abuse
One cause of the deterioration of oral health, often overlooked, is substance abuse. In our office, we would love to help a patient improve his or her smile, but we fineed to understand and treat the underlying cause first if we want long-lasting restorations. With the rise in use of crystal methamphetamine (meth), heroin, and other life-destroying drugs, we are now seeing more and more dentitions in a very poor state of health. It is easy to typecast the “user” into specific groups, but we must be cautioned that abuse is not limited to any race, sex, or socioeconomic group. It’s become almost as big of a problem with, say, executives as with construction workers. These days, abuse must be included in the differential diagnosis when determining the cause of rampant decay, prematurely failing restorations, or oral damage that is beyond “the norm.”
Drugs like meth have many chemical and psychological effects on the body. Users suffer oral damage because of very poor diet and little, if any, home hygiene care. An increased predisposition to teeth grinding/clenching has also been shown to be associated with drug abuse. When smoking certain drugs, chemicals often damage hard and soft tissues, leading to red, irritated gingiva and teeth that demineralize and decay rapidly. Salivary flow can also be disrupted, contributing to an increase in the presence of caries.
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| Figure 5. Chemicals often create an environment that fosters aggressive decay that weakens the platform for any restorative work. | Figure 6. A caries indicator can increase operator efficiency in areas of large decay. |
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| Figure 7. A caries indicator is very important as a tool for missed decay and as an aid in knowing when to stop caries excavation. | Figure 8. Without etching, a universal bonding agent (ALL-BOND UNIVERSAL [BISCO Dental Products]) was massaged onto the tooth and then air-thinned. |
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| Figure 9. A regenerative build-up material (ACTIVA BioACTIVE [Pulpdent]) was used for its ion release and strength. | Figure 10. Depth cuts were made using a 330 Carbide Bur (Microcopy), which has a head length of 2.0 mm. |
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| Figure 11. Basic preparations were made with a course, tapered diamond. | Figure 12. The preps were smoothed and the corners rounded with a finishing diamond. |
Help Without Condemnation
After first meeting the patient and reviewing his or her concerns, the chairside dental team should begin by asking the patient for his or her help in determining the causes of the damage. It is recommended that there is a time in the evaluation and planning process that the doctor and the chairside team each spend some time alone with the patient. It’s amazing how often the patient will say, “I’ve had issues with abuse in the past” to the doctor or a team member when in a more private setting.
We do not judge, condemn, or criticize. As a healthcare provider (and team), we need to ask our patients questions with a sincere interest in their overall well-being. There is no reason to have a beautifully restored smile if the patient’s inner being is not healthy. One must also keep in mind that we may be the first healthcare provider the patient has opened up to about his or her issues and must not minimize our influence on life-saving treatment.
What do you do if a patient says, “I’ve had some issues with medications?” In a caring manner, we simply say, “Thank you for sharing the information with us. Here’s the card of someone we work with to make sure our restorations last as long as possible.” We recommend that each office has business cards or referral slips forsomeone in the area who is a therapist, counselor, or group that deals with substance abuse. In this way, we are providing an avenue for further help and assistance.
Suspicion serves no purpose if we don’t follow up on it. The staff must be careful not to be condemning, judgmental, or critical in any way but instead have the attitude that we are sympathetic and understanding. Our office policy is that a person be clean and sober one year before elective work can be started; that is the approximate time frame when there is the greatest chance of relapse. We can get rid of infection, eliminate pain, and other palliative measures before the restorative process is started.
CASE REPORT
Diagnosis and Treatment Planning
The following case is an example of treatment that we provide one year after substance therapy has concluded. These cases come to our office 4 to 5 times per year, and, once per year, we get answers that lead us to offer help.
An adult male came to our office with obvious decay (Figure 1). The consult was for cosmetic treatment, and several photos were taken by the staff and put on a large operatory monitor (Figure 2). We listened to the patient about his desires and asked that he point out areas he doesn’t like while looking at his own images on a 35” monitor. Notes are taken as we try to reach a common understanding of how treatment goals are affected by biologic limitations (Figure 3).
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| Figure 13. Impressions and needed records were taken and sent to the dental lab team. | Figure 14. At the insertion appointment, the lithium disilicate crowns (IPS e.max [Ivoclar Vivadent]) were tried in, then cemented into place (BeautiCem [Shofu Dental]) per manufacturer directions. |
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| Figure 15. Mandibular teeth were restored with regenerative/bioactive filling materials (ACTIVA BioACTIVE [Pulpdent]), and a long-term plan was made for indirect restorations. | Figure 16. A healthy response resulted from proper diagnosis, personal treatment, and providing an environment where tissues can heal. |
Effects of long-term chemical use often include red, inflamed gingiva; tooth wear; and decay (Figure 4). Periodontal therapy was completed, and then decay was removed with a No. 4 slow-speed round bur and a spoon (Figure 5). Particularly in these cases, thorough decay removal is desired and evaluated with a caries indicator (Sable Seek [Ultradent Products]) (Figure 6). Despite our best attempts, we often leave decay in areas that we did not evaluate well enough that could lead to prematurely failed restorations (Figure 7).
The treatment plan for this patient was for lithium disilicate crowns from teeth Nos. 5 to 12, with regenerative fillings in all other teeth until definitive restorations could be placed.
Maximizing Longevity
A universal dentin bonding agent (ALL-BOND UNIVERSAL [BISCO Dental Products]) was massaged onto the teeth, air thinned, and cured (Figure 8). A bioactive/regenerative restorative material (ACTIVA BioACTIVE [Pulpdent]) was then used for the build-ups because of its overall strength, ion release, and the potential to remineralize and stimulate secondary dentin formation (Figure 9). These types of materials have the potential to reduce secondary decay by their ion release, rechargeability, and re-release.
The preparations for lithium disilicate were begun with depth cuts using a 330 carbide bur (Microcopy) to ensure adequate reduction and postoperative strength (Figure 10). A tapered diamond bur was used to do the preparations, leaving a chamfer (Figure 11). To decrease internal porcelain stresses, the preps were smoothed and the corners rounded using a finishing diamond (Figure 12).
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| Figure 17. The patient was given a bleach-type tray with medication to recharge the cement and regenerative filling materials and instructed to wear it 2 nights per week. | Figure 18. Controlling habits and regenerative therapy are the keys to long-term success. |
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| Figure 19. Dental professionals must not underestimate the potential that we have to alter and, perhaps, even save a life! |
Impressions, alignment guides, preparation shades, and a full series of photos were taken, and all were sent to our dental laboratory team, along with the patient’s stated treatment goals (Figure 13). Temporaries were made, and the patient was given a fluoride containing remineralization paste (ReminPro [VOCO]) to brush with twice per day. The patient was scheduled for delivery of the maxillary lithium disilicate crowns and to do the mandibular restorations in 3 weeks.
Insertion Appointment and Postoperative Care
The temporaries were removed, the teeth cleaned, and the layered lithium disilicate (IPS e.max [Ivoclar Vivadent]) restorations tried in (Figure 14). Cementation was done with a high-fluoride-releasing, dual-cure, giomer resin cement (BeautiCem [Shofu Dental]). Then, after completion of all the cementation steps, the occlusion was adjusted (Figure 15).
Next, an impression was taken and a bleach-type tray extending 2.0 mm onto the gingival tissue was made. The patient was instructed to place the same remineralization-fluoride paste into the tray (using an amount that is similar to when bleaching the teeth) and to sleep with the tray inserted in the mouth 2 times per week. The purpose of this protocol is to recharge the giomer cement. In addition, the patient was also asked to continue brushing his teeth with the material at least once per day.
After 6 days, the patient returned for a postoperative visit, and the obvious improvement in hard and soft tissue was observed (Figures 16 to 18). The patient was reassured and given praise for the commitment to his overall health and encouraged to continue with our re-care program. In our office, the importance of diet and hygiene is also reinforced with the recovered patients in a very positive way.
CLOSING COMMENTS
Not only will correcting a defective smile make a patient look good (Figure 19), but the improved self-worth may give a patient the confidence to improve his or her life in other areas. This may be the self-assurance needed by the patient to restore and maintain himself or herself and other relationships in his or her life. The power of a rehabilitated smile and addressing the destructive causes is immense.
We must not undervalue the potential effect we may have on a patient’s life. Realize that you and your team are important healthcare providers, and that with the right questions and treatment, you may change a life. You and your team can be much more important in the overall well-being of a patient’s life than for just the teeth.
Acknowledgment
The author thanks the the Pacific Aesthetic Continuum (thepac.org) for the principles used in this case and the Pacific Aesthetic Dental Studio in California for their excellent case planning and restorations.
Dr. Griffin earned his DMD from Southern Illinois University (1987) and completed a general practice residency at the University of Louisville, Ky (1988). He has Diplomate status with the American Board of Aesthetic Dentistry, accreditation with the American Academy of Cosmetic Dentistry, and a Mastership in the AGD. He has been involved in product improvements with dental companies and has reviewed products for Reality Esthetics, THE DENTAL ADVISOR, the Catapult Group, and others. He is currently one of the clinical directors for the Pacific Aesthetic Continuum and serves the community with a St. Louis County, Mo, practice emphasizing cosmetics and all phases of general dentistry. He can be reached at (636) 625-3380, via the website mysmilecenter.com, or via the email address jgriffinjrdmd@gmail.com.
Disclosure: Dr. Griffin reports no disclosures.
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