Crowns and fixed prostheses compose a significant portion of the activity in general practice, and a major amount of a general dentist’s income comes from this area of practice. A growing number of prosthodontic specialists, with their extra education, experience and expertise, augment the fixed prosthodontic services provided by general dentists. As a result, for years, the American public has been afforded relatively high-quality fixed-prosthodontic treatment at a moderate cost, and most Americans can afford to retain teeth that have been broken down and require crowns.
Admittedly, the level of fixed prosthodontic quality could be improved in some practices, and, in my opinion, the highest quality level of fixed prosthodontic treatment in some other highly developed countries is competitive with or superior to that of the care available in the United States. However, American general dentists, prosthodontists and the laboratory technicians supporting their teams provide Americans with prosthodontics of an admirable level of quality and at a fraction of the cost reported in some other developed countries.
It is important to dentists that practicing dentistry be both enjoyable and profitable. Can fixed prosthodontic procedures be accomplished at a higher level of quality and faster speed, yet still at a moderate cost? I contend that both goals can be accomplished. This article expresses my opinions, developed during many years of practice as a prosthodontist, about how to improve the quality and speed of providing fixed prosthodontic services.
Fixed prosthodontic procedures can be accomplished at a higher level of quality and faster speed, yet still at a moderate cost.
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LEGAL DELEGATION OF RESPONSIBILITIES TO STAFF MEMBERS
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There are many different laws, beliefs and cultural differences among states, provinces and countries relative to acceptable use of staff members in any clinical area of dentistry. Since fixed prosthodontics is a major area of clinical activity, it seems appropriate to evaluate the steps in fixed prosthodontic treatment and indicate those that can be accomplished by qualified staff members.
Before doing that evaluation, I will raise three pertinent questions:
- In some areas of fixed prosthodontics, can nondentist staff members provide care equal in quality to a dentist’s care?
- Should nondentist staff members be allowed to accomplish these procedures?
- How does the accomplishment of clinical procedures in fixed prosthodontics by nondentist staff members affect practice activity?1,2
Here are my answers to the questions, based on my many years of using staff members in expanded functions.
- With adequate education, nondentist staff members can provide care not only equal in quality to, but better than that of dentists providing the same services. This quality level is achieved because of the staff members’ continued repetition of the delegated clinical tasks.
- I feel that well-paid nondentist staff members who are allowed to accomplish clinical procedures in fixed prosthodontics become valued members of the team who are loyal to the practice and its patients and who want to stay in the profession.
- It has been my experience that involvement of nondentist staff members in accomplishing clinical procedures reduces the cost of fixed prosthodontic procedures, frees the dentist to accomplish procedures that only the dentist can accomplish legally and increases the quantity of services rendered by the practice.
What are the logical procedures to be delegated? Every practitioner must evaluate her or his own opinions on the subject and make personal decisions based on the local laws and personal preferences. Check with your licensing organization if you have any questions about what is legal and what is not legal in your area.
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DELEGATION OF FIXED PROSTHODONTIC TASKS TO STAFF MEMBERS
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The following steps in the fixed prosthodontic procedure are discussed in relation to the potential for all or some of the steps, where legal, to be delegated to responsible, educated and qualified staff members.
Diagnostic appointment.
In every geographic area, diagnosis and treatment planning is the dentist’s legal responsibility. However, collection of all of the data for an excellent diagnosis and treatment plan can be delegated to staff, including making diagnostic casts, taking radiographs, accomplishing patient education, charting, charting periodontal pocket depth and performing pulp testing, among other tasks.3
Anesthetic delivery.
In some geographic locations, delivery of local anesthetic by nondentist staff members is legal. If such is not the case in your area, at least the staff members can set up for the anesthetic delivery and educate the patient about the effect of the anesthesia and its duration.
Tooth preparation.
In almost all geographic areas, surgical cutting of tooth structure is the domain of the dentist. However, excellent assistance from the dental assisting staff can decrease the time needed to accomplish this part of the procedure.4
Tissue management.
Where legal and within the comfort zone of the supervising dentist, tissue management by nondentist personnel can save a significant amount of time, especially with multiunit cases. I prefer to accomplish the tissue management myself in the cases that are difficult from either a physiological or a psychological standpoint, but simple tissue management cases may be delegated. On the dentist’s return to the operatory, making the impression is the next step.
Making impressions.
In most geographic areas, impressions must be accomplished by the dentist.5,6 It has been estimated by dental laboratories that a high percentage of fixed prostheses produced in the United States are single units. In my opinion, impressions for the majority of these single units are made in double-arch impression trays. Time, money and effort are saved with the double-arch impression technique, where indicated and when properly executed.6 Qualified dental assistants may take over supervision of the patient as soon as the impression is secure in the mouth. The staff member may supervise the patient while the impression sets and evaluate its acceptability when it is removed. If the impression is defective, the staff member, where legal, may prepare the tissue for another impression.
Making a multiunit fixed prosthodontic impression is one of the most difficult procedures in dentistry.7,8 Proper tissue management and involvement of several staff members for the exact two or three minutes required to make the impression greatly reduce the unpredictability of, and time involved in, the impression-making procedure.
Provisional restorations.
Making provisional restorations requires about as much time as preparing the teeth.9 Nondentist staff members can become highly proficient at making provisional restorations. In my experience, this clinical task should be delegated to staff members wherever it is legal.
Trying restorations in the mouth.
Where anesthetic is not needed for seating restorations, staff members may remove the provisional restorations, clean the teeth off well (using gauze and toothpicks to avoid pain) and try the water-warmed restorations in the mouth. If all aspects of the simple restorations are acceptable, the time required of the dentist has been reduced in the seating appointment by several minutes. If anesthetic is needed, the same staff delegation may take place after the patient has received it.
Seating the crowns or fixed prostheses.
Seating crowns or fixed prostheses is a task for the dentist.10 For success, it requires clinical judgment, experience and knowledge of proper forces to place on the restoration. However, after the restoration has been seated, qualified nondentist staff members may take over, remove cement at the proper time and clean the area well before calling the dentist back into the operatory.
Educating the patient during the seating appointment.
While removing debris, the staff member may educate the patient about the new restorations: when to chew on them, the possibility of slight postoperative tooth sensitivity, expected changes in occlusion, potential future need for replacement and oral hygiene. A patient handout containing details on this information may be given to the patient at this time, since patients sometimes do not remember suggestions well when in the excitement and anxiety of a dental environment.
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SUMMARY
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American dentists should be pleased with the level of care they provide to their patients in the area of fixed prosthodontics. The American public is served with good, competent care at a moderate cost. However, this article has addressed the potential for increasing the quality level of care, increasing the speed of treatment and maintaining the moderate cost by delegating some of the clinical tasks to qualified staff members. In my opinion and experience, these results are achievable by delegating up to one-half of the time involved in fixed prosthodontic clinical tasks to qualified, educated, supervised non-dentist staff members, where such delegation is legal.
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