Switching from Analog to Digital Workflow

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The process of fabricating dental prosthetics has changed rapidly over the last decade with the most impactful change being our decision to switch to digital workflows. That is helping us ensure a better product that continues to improve as new technology emerges.

Traditionally, a dental team took analog impressions that were hand waxed and hand cast before a hand-applied porcelain or acrylic technique was utilized to fabricate the final restoration. The process was time consuming and dependent upon the skill of the lab technician and accuracy of the analog models.

Larger laboratories evolved into digital workflows like other manufacturing industries, allowing for more accuracy and precision along with the ability to perform quality control and consistency.

With the ability to control a variety of parameters through a digital workflow, we can now design, control and standardize occlusion, interproximal contacts, marginal fit and emergence profile. Additionally, if a remake of a fractured prosthesis is required, the digital workflow allows for the prosthetic to be remade by simply remilling from the stored scan data.

The ideal way to initiate a digital workflow is to perform an intraoral scan. While most large dental laboratories have adopted digital capabilities, intraoral scanners are still underutilized in dental offices. Currently, in many dental offices, an analog impression is taken and sent to the dental laboratory, where it has to be scanned before a digital workflow is carried out.

The analog impression is the least accurate and least reproducible part of the process and introduces a source of error perpetuated in the fabrication of the prosthesis. To avoid that risk, we have been utilizing an intraoral scanner to fabricate study models and allow for digital planning of implant placement. The improvement is distinct.

While the quality of alginate study models that we receive and that we produce ourselves is variable, the digital workflow ensures greater consistency and accuracy. Now that we have had the intraoral scanner for almost a year, we are slowly moving away from requesting analog study models because of accuracy issues.

If you would like to take advantage of a digital workflow for your implant restorations, please let me know and we can put that process into effect. The only situation where an intraoral scan for final restoration might be problematic is if there is need to perform “guide planes” for interproximal contact or if occlusal equilibration is required prior to restoration.

While we have aligned our office with Jamestown Dental Lab, a subsidiary of ROE Dental Laboratory, it is your choice where you send your restorations. ROE allows the full spectrum of digital workflows to be utilized.

Another way to best utilize a digital workflow is to incorporate digital photography for shade, esthetics, lip line and smile design. This “extra step” has a very low additional cost and can be performed by staff. There are a number of digital platforms available that allow you to design restorations you can show your patient and perform a “digital wax up”.

We would welcome the opportunity to discuss digital workflows or answer any questions you may have.
 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

Dental Implants: Building a Timeline to Restore Your Patient’s Smile

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Dental implants are a great treatment option for qualified candidates. With an initial success rate of 98 percent, implants will prevent further bone loss and actually stimulate bone growth. They also restore a patient’s smile and give them back their self-confidence.

Determining the appropriate treatment plan for patients who may need dental implants requires a highly-coordinated approach between the referring dentist and oral surgeon. The first step is building a timeline discussed between the oral surgeon, referring dentist and the patient. It is important to design a plan that a patient is comfortable with and ensures the best possible outcome.

1. Referral
Making a referral when the patient is considering replacement options (implants, fixed bridges, partial dentures or possibly no replacement of the tooth) allows the oral surgeon to help the patient make the most informed decision.

Once an implant consult has been carried out, a treatment plan is generated. For more complicated cases, a second consult may be required at our office or at the general dental office to make sure the treatment steps are understood by the patient.

Insurance and financing is also discussed at this consult since many insurance plans will often not cover implant dentistry.

2. Exam
An initial exam allows the oral surgeon to consider key factors that influence treatment.

  • Are there minimally restored teeth adjacent to the site? If so, an implant is most often the treatment of choice.
  • Have the adjacent teeth had endodontic treatment? If so, implants are also the best choice since endodontically-treated teeth fail at a high rate as bridge abutments.
  • What is the status of bone? Implants ideally require healthy bone. Rebuilding the bone can be costly and require substantial healing time.
  • Other key factors include the periodontal status of the patient and rate of decay.

When referring for an implant consult, it is most helpful to fabricate study models prior to the consult and discuss with the patient what type of temporary is recommended during the healing period.

3. Surgery: Restoring Your Patient’s Smile
While the majority of implants we perform are placed at the time of extraction, it is not always the case. How long it takes before a patient’s smile is restored depends on the treatment plan and the condition of the bone.

  • If implants have excellent primary stability, which usually means abundant healthy bone, immediate temporization is carried out and a patient never loses their smile. The temporary is worn for 3-4 months before a final restoration is made.
  • If implants have less than excellent primary stability, then 6-8 weeks of healing is required prior to temporization.
  • A popular treatment performed today for patients who have a terminal dentition or have lost all their teeth is the fixed hybrid prosthesis. Implants are placed and a temporary denture is converted to an immediate temporary. The patient gets their smile back immediately, while a final prosthesis is made after three months of healing.

4. Following Up: A Team Approach
After time for the area to heal, usually a period of 8-16 weeks, the patient is referred back to the general dentist for fabrication of the impression. The timeline is dependent upon the site. If an implant is placed in a healed site with minimal need for graft repair, the eight-week time frame is utilized. For implants where substantial graft repair is required, a 16-week time frame or slightly longer, is utilized.

Dental implants is a significant decision for many patients. Having a general dentist and oral surgeon working together makes that decision easier.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

Five Steps to Limit the Extent of Opioid Prescriptions

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The opioid crisis has had a well-documented impact across the country, and our neighborhoods in Chautauqua County have not been spared. According to New York State Department of Health’s 2017 Opioid Annual report, the county rates for opioid overdoses and deaths rank considerably higher than state averages.

We have seen friends, families and colleagues affected. One young man who performed electrical work for me during construction of both my office and home died of a narcotic overdose several years ago. It has left a lasting impression.

People can and have become addicted to opioids after receiving a medically prescribed prescription for pain medication. We, as dentists, can minimize our contribution to the problem by changing our prescribing practices.

The American Dental Association recently announced a new policy supporting mandates on prescription limits and continuing education in prescribing opioids and other controlled substances.

One of the ADA policies, supporting dentists registering and utilizing a Prescription Drug Monitoring Program, is already in effect in New York State. This has allowed us to see what other prescribers have given to a patient.

Here are five other ways that we can limit the amount of opioids we prescribe.

  1. Be Proactive and Pre-empt Pain.
    We use pre-emptive pain control where possible. A loading dose of a nonsteroidal pain medication prior to a procedure can be helpful in limiting post-surgical pain. A 600 mg dose of ibuprofen one hour pre-operatively can establish pain control and limit inflammatory mediators prior to the procedure.Keeping the 600 mg dose on a post-op 6-hour clock schedule will prevent the blood levels of the medication from falling and maintain efficacy, reducing the need for narcotic pain medication. Additionally, alternating acetaminophen and ibuprofen allows for different mechanisms of action to achieve more complete pain control. We also break treatment into stages to allow for smaller steps at a single time, minimizing pain response.
  1. Be Clear: This is Not Pain Free.
    We communicate with patients that we want them to be comfortable, but avoid using the words “pain free.” Most patients can tolerate some discomfort and it is safer to have some discomfort rather than be “pain free” as was advocated in the past.
  1. Ice is Still Effective!
    Using ice packs when swelling is anticipated also helps with discomfort.
  1. Lower Dosages = Less Problems.
    Prescribe narcotics in smaller numbers. A refill can always be emailed to a patient’s pharmacy if more pain medication is needed. Using lower strength narcotic prescription medications when possible will help minimize the potential for addiction. We use Exparel, a long-acting depot form of bupivacaine for procedures where incisional pain and surgical site pain can be significant. We use this routinely for third molar sites since this form of pain control lasts for three days and usually allows patients to get past the acute phase of recovery.
  1. Know the Patient’s History.
    Being aware of a patient’s current medication usage and history is vitally important.If there is a history of narcotic abuse and treatment, utilizing the primary care physician as a resource or an addiction specialist for advice is very helpful. Deferring pain management to them is a good strategy and, in some cases, is even restricted to them.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

Oral Surgery beyond Wisdom Teeth and Implants

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The healthcare of patients and the treatments they receive from oral surgeons go beyond dental implants and evaluating and extracting wisdom teeth.

Having a medical degree and a dental degree allows an oral surgeon more insight into the connection between systemic disease and oral disease. Referring dentists can feel secure that the oral surgeons they refer can fully diagnosis and manage their patents’ difficult oral conditions.

Our additional training in the diagnosis and management of oral conditions allows us to see patients with a variety of traumatic, auto-immune, infectious, medication related and congenital conditions that manifest as pathology in the oral cavity.

These are some of the ways we can help you find the best treatment for your patients.

Biopsies. We routinely perform incisional and excisional biopsies for diagnosis and management of lesions.  These biopsies allow for H&E and Immunofluorescent studies to be performed.  While all dentists perform oral cancer screening, my team and I work with the referring dentist to confirm a diagnosis.  We diagnose about a dozen squamous cell carcinomas annually.

Treatment of Infections.  Fortunately, most oral infections are managed in a straightforward way with empiric antibiotic treatment. Sometimes, when the infection does not respond in a typical manner or the patient is immune compromised, further treatment is required.  Oral surgeons are able to perform intraoral and extraoral incision and drainage, as well as order IV antibiotic treatment.

Soft Tissue Grafting.  We offer a variety of soft tissue grafts for root coverage, providing additional attached tissue, preprosthetic surgery or esthetic indications.  While most of our soft tissue procedures are related to implant treatment, the same techniques are utilized for teeth.

Imaging.  We have a CBCT which can be very useful for evaluation of oral pathology, failed or symptomatic endodontically treated teeth and evaluation of MRONJ. We will work with referring dentists to use this technology on their patients for imaging only (with no exam).

Anesthesia.  We offer IV sedation and general anesthesia for procedures.  While we are happy to provide anesthesia to address the fear and anxiety of patients who need a surgical procedure, not all patients are appropriate candidates for office-based anesthesia services.  Patients need to be relatively healthy, not morbidly obese, have good exercise tolerance and have a good airway.

Crown Lengthening.  We are often asked to help evaluate a tooth to see if it should be removed and replaced with an implant, or salvaged with caries removal, crown lengthening, endo and crown fabrication. An implant is usually the preferred choice, if the endo has already been performed and been successful, a patient will choose salvaging the tooth.

Dentoalveolar trauma.  While major trauma is not treated in the office, many cases of dentoalveolar trauma are. We offer a range of services, including reduction and stabilization of traumatized teeth, as well as the repair of soft tissue lacerations.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

The Danger of Partially Erupted Teeth

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Waiting for the inevitable when dealing with partially erupted teeth can sometimes mean waiting too long.

Partially erupted teeth can be a threat to adjacent teeth, present a risk for development of periodontal disease and contribute to the risk for other diseases. Here’s why you shouldn’t wait to see an oral surgeon for a consult.

Risk to adjacent teeth.  Partially erupted teeth do not meet the adjacent teeth in the normal position and are often a food trap. The food trap often leads to decay of both teeth. Decay that develops on the root of an adjacent tooth can be very difficult to treat.

Additionally, partially erupted teeth can cause resorption of the adjacent tooth. Resorption causes loss of tooth structure by a pressure related inflammatory process and can also be difficult to treat.

Risk of periodontal disease.  We know from long-term studies on individual patients that periodontal disease often originates from partially erupted teeth, especially wisdom teeth.

Partially erupted teeth have a shiny smooth enamel surface that is trapped below the gum line.  The space between this shiny smooth surface and the adjacent gum tissue traps microscopic food debris and bacteria and is an environment that is more anaerobic than the surface of the mouth.

Once established, the bacteria are very difficult to eliminate from the mouth, causing inflammation which leads to bone loss around the teeth and can cause an acute infection in the mouth as well. An acute infection around the crown of an impacted tooth is termed pericoronitis.

Risk for other disease. The same inflammatory process that occurs in the mouth releases inflammatory mediators into the blood stream that can potentially contribute to heart disease and stroke.

Patients with periodontal disease may have an increased risk of stroke and heart disease compared to those patients who do not have periodontal disease. We also know that patients who have diabetes have a more difficult time controlling their blood sugar when they have periodontal disease and inflammation in their mouth.

Lastly, patients with inflammation in their mouth have an increased risk of cancer through mechanisms we do not understand well.

Partially erupted teeth should be evaluated in a timely manner to determine what treatment options, such as orthodontically repositioning the teeth or removal, are best to prevent complications. Waiting too long will not only narrow your options, but lead to more complications.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

Our Process: The Importance of Obtaining an Accurate Medical History

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An accurate medical and dental history is vital when assessing and diagnosing a patient because it allows for the necessary modifications in our approach to treatment.

For young and healthy patients, a review of medical history is a relatively easy process that may simply consist of evaluating pertinent findings on the history questionnaire. The process is usually more involved with older patients.

Step One: Obtain Thorough History

Obtaining a medical history for older patients is more complex and time consuming as their medical complexity increases. One definition of medical complexity is a when a patient is taking 5 or more medications.

Older patients may not remember the medications they are taking or have recently taken and, in some cases, patients will list “untoward” reactions such as nausea, vomiting or headaches to medications as allergies when they are not allergic reactions. Sometimes, older patients cannot tell us their medical diagnoses.

All of this information, however, is critical since modification of treatment is more likely. So, to make sure we have the necessary information to determine the right treatments for a patient, we go through a medical history review checklist that includes:

  • Patient history questionnaire
  • Notes from referring dentist
  • The most recent assessment from a patient’s primary care physician if the patient is medically complex or if they are a poor medical historian

Sometimes, one can infer a patient’s medical diagnoses and their severity from the medications they are taking. In addition to their medical history, we also ask patients about their exercise tolerance since it is a good indication of a patient’s ability to tolerate stress.

Step Two: Review and Assess

The next step is to review the pertinent information gathered to understand the implications that the information will have on our management and approach to treatment. When dealing with patients who have a variety of medical problems, we need to assess how well those problems are being controlled.

If a disease’s process is not ideally managed or optimized, then referral back to their primary care physician is indicated prior to treatment. Common examples included poorly controlled hypertension, poorly controlled diabetes, asthma and heart disease.

We also assess conditions which may impact healing such as chemotherapy, radiation treatment, diabetes, medications that modify a patient’s immune status, smoking or bisphosphonate use.

Step Three: Modify Treatment

Smoking is the most common modifiable risk factor for poor wound healing and we try to educate patients about their use of cigarettes. We also note which medications a patient may need to refrain from taking the day of the procedure. Among the more common medications are:

  • Oral anticoagulants
  • Diabetes medications

Medications such as coumadin, Pradaxa, Eliquis and Xarelto often need modification. As a general rule, most other medications should be taken on schedule, although older patients will often not take their medications on the day of the appointment because they do not understand or remember our instructions.

Lastly, there are a few indications for perioperative antibiotics that should be noted. Additionally, when we prescribe new medications, we want to ensure that there are no drug to drug interactions and that the patient understands how to take the new medication.

Oral surgery is not always an easy process for patients, especially older ones. A way to make sure that process is as easy as possible for them is to have a full grasp of their medical history to reduce the likelihood of unexpected complications.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

No Smoking, Please

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As part of an initial consultation, we make patients aware that elements of their medical history may reduce the predictability of a surgical oral surgery procedure and affect how a wound heals. The post-surgery consequences are sometimes unavoidable and must be endured by the patient, and best treated by the provider.

Patients, however, can avoid unwanted consequences in some circumstances. The most notable being the avoidance of smoking.

The smoke inhaled from cigarettes, cigars or pipes will contaminate the wound, while the nicotine contained in the tobacco will cause blood vessels delivering oxygen, wound healing cells and nutrients to the wound to become narrow and inhibit delivery.

Smokers demonstrate a slower rate of wound healing and higher chance of infection compared to non-smokers. Smokers will also tend to experience more pain than nonsmokers and have a higher chance of “dry socket” after extraction. Consequences become increasingly severe for more frequent smokers. There is also the chance of bleeding as a result of suction applied to the mouth when inhaling a cigarette.

Three specific oral surgery procedures affected by smoking are:

  • Bone grafting. Bone is a slow healing tissue that matures over time and builds up in stages. Smokers have demonstrated less bone volume generation, leading to a higher risk of the wound rupturing.
  • Gum grafting. Gum grafting requires a healthy blood supply and that supply is obstructed by smoking.
  • Implant therapy. The long-term success of implant therapy for smokers is three to four percent lower than non-smokers.

Smokers can also experience complications when receiving office-based anesthesia for more complex oral surgery procedures or procedures of longer duration.

We understand that quitting or reducing smoking habits can be difficult. There are numerous options for people looking for help, including medical prescriptions that will gradually reduce and ultimately eliminate the urge to smoke, peer and family support, as well as other resources available through online research.

We want all of our patients to receive treatment that is successful and free of complications. Reducing or avoiding smoking is a modifiable risk factor that can really help optimize healing after oral surgery.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

“Am I a Candidate for Dental Implants?”

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Dental implant surgery has been hailed as one of the major breakthroughs in dentistry of the last 50 years. For good reason.

Implants have proven to successfully replace single missing teeth and missing bridges. They stabilize dentures and will replace an entire arch of teeth. The success of implants offers patients with treatment options not widely available until recently.

Are you a candidate for dental implants? Here are five criteria we consider when assessing a patient’s candidacy:

1. Desire for treatment

2. Medical history

3. Condition of mouth and commitment to dental hygiene

4. Results of an X-ray exam

5. Budget

When patients present for treatment, one of the critical questions to resolve during the patient interview is to make sure we understand their desire for treatment.

Once the goal of treatment is understood, a treatment plan with necessary procedures and sequence of treatment can be established. Sometimes the process is simple, such as replacing one lost tooth. In other situations, planning for treatment involves several different consultation appointments with facial photographs, creating dental study models and treatment planning “wax ups” of proposed tooth positions.

As part of the initial interview, a review of a patient’s medical history is carried out.

Although implants have a very high success rate, there are times when the treatment is not the right fit for a patient. Patients who have uncontrolled diabetes, are undergoing chemotherapy, are heavy smokers (a pack per day or higher) or have compromised healing potential for any reason, are not good candidates for dental implants.

The condition of the mouth and commitment to dental hygiene is also very important.

Patients must have good oral hygiene and be free of periodontal disease. The condition of the other teeth is important in planning care. If there are many teeth which are heavily repaired or compromised, it is generally not appropriate to place single implants as the other teeth may fail in a relatively short period time. Treatment of other dental disease needs to be carried out prior to implant therapy. Assessment of oral hygiene is very important and sometimes patient education and training is required to improve oral hygiene prior to implant placement.

X-rays (radiographs) are carried out to determine the relationship of the implant sites to the adjacent teeth and volume of bone present at the site. Thanks to the advancement of implant techniques, extractions are performed and often implants can be placed immediately. However, with some patients, bone repair (bone grafting) must be carried out prior to implant placement.

Lastly, dental implant treatment can be expensive and the creation of a budget is important.

Many dental insurance companies do not cover implant treatment as a benefit. However, our office can work with you to provide options that will allow you to receive care within your budget.

Dental implant treatment is an excellent way to replace missing teeth and has been very successful. Like all medical and dental treatments, a proper evaluation is needed to determine who is an appropriate candidate for care. If you are interested in dental implants, we welcome you to schedule a consultation with our office.

 

Dr. David W. Todd, DMD, MD, Oral SurgeonDr. David W. Todd, DMD, MD, has been active in his profession. He has authored 18 articles in various publications and made numerous presentations at state, regional, and national meetings. For Dr. Todd’s full bio click here.

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Location

Oral and Maxillofacial Surgery in Lakewood

120 Southwestern Drive
Lakewood, New York 14750

Office Hours

Monday: 8AM-5PM
Tuesday: 8AM-5PM
Wednesday: 8AM-5PM
Thursday: 8AM-3PM
Friday: 7:30AM-4PM

Lakewood Dental News

Lakewood Oral and Maxillofacial Surgery