Special Healthcare Needs Require Specialized Care — Transcript
[00:00:15] Welcome, and thanks to teams working through COVID
All right, everyone. I wanted to welcome you all to our presentation tonight. My name is Mandy Ashley. I’m a pediatric dentist practicing here in Bowling Green, Kentucky, and this is a presentation on Special Healthcare Needs Require Specialized Care, brought to you by Sprig. I want to thank you all for joining this Sprig webinar.
First off, a few housekeeping items. If you have any questions at all, please type them in. There’s a little question and answer session at the end of this presentation, and I’m very happy to answer your questions as we go along. If you miss the chance to write in questions, I’ll post my cell phone number and my email at the end, so you’re more than welcome to reach out if you think of a question afterwards. I’m happy to help you out.
I do want to give a big, big thank you and a shout-out to all of you who are on this webinar. Thank you all for working during COVID. Thank you for double masking. Thank you for denting your face like I have. Thank you for having your own oxygen saturation go down into the low 90s because you’re breathing through so many layers of mask, sweating all over, not being able to sip coffee gently throughout your workday. And thank you for carrying on and continuing to work. You have continued to serve the underserved in your community, and you continue to provide dental care for kids and for adults and children with special needs. I really want to thank you from the bottom of my heart.
Cavities didn’t wait for COVID, so we had to be on deck. And with that, we’re going to start our presentation.
[00:02:13] Background: from Barrow, Alaska to three Kentucky offices
I want to give you a little bit of background on me. I graduated from the University of Pennsylvania. I was lucky enough to have a program where you could go at night for a master’s in education. It was a great dual degree program from UPenn.
I joined the Indian Health Service in 1999 because it was my goal to go to the most underserved, hardest-to-fill site in the whole US, and at the time, in ’99, that was Barrow, Alaska. That’s right where Alaska makes the peak. I was the town dentist for 11 years, serving the Iñupiaq people of Barrow, Alaska, and we’d fly out on little Cessna 207s to all the surrounding villages and provide care for an area the size of Minnesota.
I did that for 11 years, and then I decided to finally go back to school, to the Ohio State pedo residency. I was happy that they took me after being out for so long. I had a wonderful education there. I came out of residency and temped for some fantastic pediatric dentists. They became my mentors. I learned so much.
Then I opened SKY Pediatric Dentistry with three employees back in 2013. We’ve grown. I now have three office locations that spread out over an area of about 110 miles across southern Kentucky. We also have a mobile program that goes out to schools during non-COVID times. We provide care at Head Start programs. I also have a temp agency, ReadyDentPro. I’m very interested in financial mentoring, and I have a graphics and design company as well. So I try to keep a little busy.
[00:04:06] Life outside the office
I hope all of you out there are living your absolute best life and experiencing complete marital bliss. But I do want to say to those of you who may possibly be pre-, in the middle of, or post-divorce, that it definitely gets better on the flip side. So I’m here to say it’s better.
Fall break. I love to travel, but COVID pretty much derailed all of our family vacation plans. So I brought fall break back from the brink with a 26-foot travel trailer. I don’t have a CDL. I didn’t grow up driving anything larger than a Prius, so I really had no experience with this whatsoever, towing this gigantic thing behind my car. It’s also much taller than my car, I’ve learned as well.
But these are unique times, and I believe we are all capable of rising up beyond our own limits and surpassing what we thought we could do. Remember back in March, April, May, whenever it was that you returned to work after your shutdown. We returned to work May 18th. Do you remember the first week on the job? You might have thought it wasn’t going to be possible to wear three layers of mask, be able to breathe, socially distance everybody, not catch COVID yourself and pass it on to your entire family. But we’ve succeeded. We’ve done this, and we can all continue to work in our communities safely and provide excellent dental care for our patients.
With that, I want to say that there will be a return to fun times. It’s going to come back.
I have four kids. They’re 13, 11, nine and six, so we stay quite busy with all of our adventures. I’m super into CrossFit, and lately, because of trying to socially distance, into the Pelotons. I’m Dr. Mandy in Kentucky. If you want to ride or run the tread with me and be a little competitive, I’m down with that. Once COVID’s done, we’ll resume world travel. And I do have a hobby of financial planning and mentoring as well.
[00:06:25] Sprig’s story and Saturday’s happy hour
All right, so where does Sprig come in? Why are we interested in pediatric zirconium crowns? And we want to say cheers. Cheers to Sprig.
Sprig’s story: back in 2006, they were founded as EZ-Pedo, and they developed the world’s first pediatric zirconium crown. In 2009, the EZ-Pedo zirconium crown was seated for the first time on a pediatric patient. In 2013, EZ-Pedo introduced the Zirconium Preparation CE Course, which I took in August of 2013. In 2017, as the company expanded and grew, they rebranded as Sprig Oral Health Technologies to encompass more than just the crowns. Then they became Medical Device Single Audit Program certified, and they continued their international growth.
And as a super fun event, this Saturday, Sprig and the Spriggies will celebrate a decade of beautiful smiles and wonderful products. They’re going to have a virtual happy hour, and I really encourage you all to join. They have some fantastic prizes, including the Shofu EyeSpecial camera that I use, which I’ll talk about in a little bit. It’ll be a great opportunity, very casual, and you can ask whatever questions you have. So please join us this Saturday.
[00:08:02] My zirconium journey, today’s agenda and case photography
All right, my zirconium journey. I did not use zirconium crowns in my residency program, so I didn’t have those in my training. I know quite a few residency programs now are able to get their residents hands-on with zirconium crowns, which is wonderful: to be able to try that while you have guidance, hands-on training, hands-on guidance.
I started my journey in August of 2013 when my practice opened. I wanted to have a better option, so I got the introductory kit and started using that. I watched the videos, and I wanted some more hands-on, so I went to California for one of their first hands-on courses. It was amazing. I learned so much.
I saw the EZCrowns. They mimic the shape of natural teeth. In a lot of cases like this, they look even better than the patient’s natural teeth. They look absolutely fantastic. They’re beautiful.
I have placed, so far, over 8,000 anteriors since the fall of 2013. When I took that course, I flew home, and I hadn’t even opened my strip crown kit. It was still vacuum-packed, so I sent it back. I’d never opened it. I’ve never done a strip crown in my private practice. I’ve only done the Sprig crowns. And you’ll see the long-term follow-up that we have. It’s a really amazing product.
I’m going to speak about dental care for patients with special healthcare needs. We’ll talk about communication and scheduling. We’re going to talk about how I’ve adapted the physical and the social environment of care in my office. We’re going to dive into first cases: tomorrow morning, what you might want to try. And then some cases maybe you want to try after you’ve done a hundred of the easier ones. I want to show you my failures.
I take photos of each and every case preoperatively and postoperatively, immediate post-op in the OR. Then, as time allows, my dental assistants take post-op photos in the office when the patients come back in. Like I said, I use the Shofu EyeSpecial camera. I have version two; they’re now on version four. Again, if you participate in the Sprig happy hour this Saturday, that is one of the prizes. The great thing about it is it has a ring flash built in. It has a touch screen. It’s very easy to use. My dental assistants are the ones that pretty much exclusively use the camera. I really don’t touch it at all myself. I hold the retractors for retracted photos. We get consent for each and every one of these pre-op and post-op photos.
I used to use mirrors for every case, but then I realized that was another step I really didn’t need to do. With the Shofu camera and the ring flash, you get a beautiful view, and the mirror is really just optional.
At the end of this, we’ll go into our question and answer session. Feel free to type your questions in as we go along. I’m able to see those in real time, so I’ll do my best to answer them.
[00:11:38] Poll: who’s in the audience
Now I’m going to start a poll. I would like to know: who’s in our audience? You can select one of these: a pediatric dentist using zirconium crowns, a pediatric dentist not using zirconium crowns (maybe you’re interested in using them), a general dentist using the crowns, a general dentist not using the crowns, or support staff.
It looks like, as our poll is coming in, we have a really good mix of pediatric dentists using the crowns and not using the crowns. I’m going to close the poll and share the results with you all. That’s great. Thank you all for participating in this lecture. I’m glad to see some general dentists and support staff. Support staff, I’m going to be talking about you very shortly. So that’s wonderful.
[00:12:39] Language, communication and home-care adaptations
And we roll on. Dental care for patients with special healthcare needs. I think one of the very first things you can do, whether your practice is in existence or you’re starting your practice, is figure out what language you want to use for your communication.
For example, instead of saying wheelchair-bound, we use the term wheelchair protocol. We think of the patient as someone who is using the wheelchair. They are not bound or attached to their wheelchair. In my office, wheelchair protocol means that our patient is coming in using a wheelchair, so we will see them in a room where we can either push the dental chair to the side, or we see them in one of our non-traditional treatment areas, and I’ll show that later on. We also talk about wheelchair transfer and how to safely move patients, if needed, from their wheelchair onto the dental chair.
I think it’s very important, especially if your practice sees adults with special needs, to address the patient. They may come in with support staff, but many of our patients at least participate in, or even actively make, their own healthcare and dental care decisions. So it’s very important to speak directly to them.
This is something I was really not aware of until I was educated: the word buddy can sometimes have a connotation of intellectual disability. So be aware that buddy is a term you can use to call patients if that’s what they prefer to be called, but adults with special needs may prefer that you just use their name.
It’d be great for you to learn about the patient’s adaptations: how they adapt, and how you can adapt your oral healthcare visit for them. For instance, there’s a company called Specialized Care that provides three-brush Surround toothbrushes, and we use those quite often. They’re a great way to surround a tooth on three sides with a brush. We tell the parents, basically, you get it in the mouth and you keep it moving, and you can brush all three surfaces, buccal, occlusal and lingual, at the same time. We also have soft mouth props that we use to help safely prop the mouth open. So, different adaptations. It’s great to talk with parents and caregivers about how we can better adapt oral healthcare home routines to something that will work for the family.
Animal support. We do have guide dogs that come into our office. We have emotional support animals. But last summer, we did say no to what was deemed an emotional support sugar glider for the mother of a patient. So there are some parameters that we do have.
[00:15:48] Scheduling: “special purples” instead of special days
As far as how our office does scheduling: when I opened the office, we wanted to look beyond limiting patients with special healthcare needs to special days. In talking with many families of kids with special healthcare needs, there are so many difficulties they have with arranging Medicaid transportation, arranging a van, getting to the appointment, getting to see a multitude of specialists. The last thing I wanted to do was complicate their life further by limiting access for their visits to the dental office.
But we needed a way to not have eight kids with severe autism come in at the same time that we already had six adults with special needs in each one of our closed private treatment areas. So what we did was change the color of the appointment block for adults and kids that have special needs. That means they need significantly more time, or they need a special protocol, in order to be seen compassionately at my office. We turned the color of their appointment purple, so they became special purples.
We allow access pretty much any day of the week, any time, except for the very last appointment of the day for new patients. Special purples are populated throughout the schedule, and that gives parents almost complete freedom in how they choose to access dental care. That has worked very well for us. And it’s allowed me as a practitioner to manage all of my patients, including my patients that come in for regular recall appointments.
All right, we’re going to have a second poll. How does your office schedule patients with special needs? When I say special needs, I mean severe autism, cerebral palsy, Down syndrome, mobility aids like wheelchairs or guide dogs. I’m curious to see how you all schedule these patients and what we’re doing nowadays.
I’m going to close the poll and share the results. Great. Like any other patient, 43%, no restriction on date and time. Nearly any date or time, that’s like I do at my office. And then there are some offices that still have a set day and time of the week for patients with special healthcare needs. Thank you for participating in my poll.
[00:18:44] Medicaid: no-show policy, the referral gate and clinic block
Okay, Medicaid. I don’t think it’s possible to talk about patients with special healthcare needs without talking about Medicaid. I love Medicaid. I spent 11 years serving the underserved in one of the most remote communities in the country. I really strongly believe in Medicaid. I believe in providing coverage for everyone. There has to be a way, though, to open the floodgates and see patients with Medicaid, but control the flow so that you can have low no-show rates and a successful practice. So I’d like to briefly talk about how I do it at my office.
We do have a no-show policy. It’s very generous. All you have to do is call before your appointment, or, if there’s a reasonable excuse, before 5:00 PM on that day, and we’ll reschedule. But if 5:00 PM goes by and you haven’t called or showed, you’re considered a no-show.
If you do not have Medicaid, so if you are self-pay or you have private insurance, I charge a no-show fee, and that’s not per person, it’s one charge per family. You could have six kids; there’s just one charge. It’s $25 to reschedule. If you never come and see me, you never have to pay the fee. It doesn’t stay on our books, it doesn’t mess up billing, it doesn’t go into accounts receivable. It’s gone. You only have to pay it if you actually want to come back into the practice. I donate 100% of that to our local free clinic, the Commonwealth Health Dental Clinic. It’s a free clinic mostly for migrants and people without any access to insurance. So I donate 100%, and we give a tax-deductible receipt for it.
You cannot charge Medicaid for this fee. So I do not charge Medicaid, but I still had to have some way to tamp down no-shows for my Medicaid population. The way we did that, starting about five years ago, two years into the practice, was to require a referral. All that means is one gate that you have to pass by. You get a referral from a general dentist, your pediatrician, a speech therapist, basically anyone. All I want to see is that a person has made an effort to contact a provider and gotten a referral to my office. That’s the gate.
And then, if you miss an appointment and you have Medicaid, again, I can’t charge you the no-show fee to reschedule. If you miss an appointment and you want to come back, it’s no problem. You go into clinic block. That’s a system where, one day a month, we have 20-minute increments throughout the day. Clinic block gets people into the office. We’re not able to accomplish a lot of treatment, but it gets people in the door, and from there they can schedule a regular appointment again.
It was a system that we started about five years ago to be able to continue to see Medicaid, but to tamp down on what a lot of people refer to as the bad actors. I think it’s more than possible to have a very successful practice and to see children with Medicaid. They didn’t choose that insurance. We’re here to help them.
All right, how does your office handle Medicaid? Let’s do a poll. […] It looks like the numbers are stabilizing. We’re going to close the poll, and I’ll share our results. This is very typical. 34% of our viewers are not seeing any Medicaid. 18% are seeing new patients with Medicaid with a referral, and 39% no restrictions. So that’s good. I just wanted to see where everybody was at.
[00:23:01] Car visits: taking the appointment to the patient
How do you adapt the physical environment of care? Can you see patients at their car? This was something we had done a handful of times before COVID. We had an adult who was upwards of about 600 pounds, and it was very difficult for the ambulance that brought him to transfer him into the office, with the staff they had, without the lift he had at his nursing facility. So we started seeing him at the ambulance in our parking lot. We use a Midwest Prophy; it’s a cordless prophy. We have a lighted mouth mirror or a headlight, we bring an assistant, we chart, and we do the entire cleaning appointment there at the ambulance.
So we expanded that for some of our kids that have special healthcare needs and mobility issues. We’ve had a few patients, especially in the past year, because now we’re really a center for kids on the autism spectrum, and you’ll see how I’ve designed the physical environment of care to make ourselves a center. We see kids where the visit isn’t going well once they leave their car. The car is the bubble. When they’re in the car, it’s good, but the moment they leave the car, I see it from the window: parents are dragging them in, or three people are going out to try to pull the child in. And we started thinking, “Why are we doing this? We could change this.”
So we have car visits now. You roll up, you call us, and we’ll come right out to the car and do as much as we can possibly do. Many of you participated in teledentistry during COVID. This is teledentistry, but it’s hands-on. We’re going right to the car to deliver treatment.
[00:24:57] The social environment of care
Social environment of care, going a step further: how do you and your staff sound to parents and caregivers? Are you supportive? Are you accepting of these families in your practice? Do you want them to be there? Do you work with the family and try to think outside the box on different ways to make their appointment pleasant? How does your staff relate to families with special healthcare needs?
Many of my staff started coming to my office as parents of children with special healthcare needs, and when their home environment allowed, they became employees.
One goal that I have is vocational rehab. Vocational rehab in Alaska offered a stipend to employ workers with special healthcare needs. So the entire 11 years I worked there, I always had one or two workers with special healthcare needs; it was typically fetal alcohol syndrome. Voc rehab paid for a portion of their salary. One of the post-COVID goals at my practice is to have an adult with special healthcare needs working full-time at my office.
I think it’s important, if you see families and adults with special healthcare needs, that you make all parents aware that you are an office that sees adults and children with special healthcare needs. We had a situation about a week ago where an adult my age with developmental delay saw a little girl at the toy wall, and she became very angry that this little girl was perhaps picking out the present she had wanted, and so there was an episode. To me, it was a great teaching moment for us to talk to the parent of the child, in a private and HIPAA-confidential way, and say, “This is why we’re here. We are here at my office to see adults with special healthcare needs. There are not a lot of options, so we see a wide range of families at our practice, and thank you for understanding that.”
[00:27:11] Sensory treatment rooms and “roll up, call up”
Our physical environment of care: like I said, we have three offices spread out across southern Kentucky. Some of them are about 30 miles from the Tennessee border.
Adaptive treatment rooms. We have multiple rooms at each of the offices with dark ceiling tiles, and we use fiber optic lights that we poked through the ceiling tiles and sheared off level with the ceiling. That illuminates the room with a twinkly glow. I modeled that after our local college here in Bowling Green: Western Kentucky University has a Kelly Autism Program, and they have sensory rooms. So I modeled our treatment rooms after their sensory rooms for kids on the autism spectrum.
After making exclusively dark sensory rooms, we realized that sometimes kids want the light and the bright, so we added rooms with more colorful decorations, like these little panels on the floor: you step on them, and the liquid mutates and flows around. These are non-traditional treatment rooms, and with the Midwest cordless prophy, we can do dental treatment in them. It’s a great way to make it non-threatening. It doesn’t look like a room where we’re about to give a shot. It doesn’t look scary. There’s nothing they can pull off the wall or damage. You can come in in a full body suit and helmet with two armed guards, like some of our patients who come from one of the psychiatric hospitals nearby, and you can be very safe in one of these rooms. It was a way that we were able to create an adaptive treatment room for our community.
All right, roll up, call up. This is something I put in place at our offices way before COVID. It’s a system where we have parking in the back of the office with direct access into the treatment room corridor. It was to cater to the families who said that a busy waiting room was not conducive to their child having a great visit, because the child got too amped up and too stimulated in the waiting room with other kids.
When I built my first office, to adapt to that, we created these roll up, call up areas, where parents can pull right around the back of the office, park and call our number. My staff meets them right at their car. If they haven’t filled out online paperwork, we bring everything to them. We facilitate all of the paperwork, and then we get their treatment room ready, so they go skipping the lobby, directly into the treatment room.
You can imagine this was really pertinent during COVID, because it was a great way for us to super socially distance everybody; we already had it set up. So that worked out well for us, and we’ve been using roll up, call up all the time since COVID.
COVID protocols: extra gear, a temperature check. My buildings are all on lockdown. Even if you want to deliver the oxygen tanks, you get your temperature checked and you wear a mask.
[00:30:22] Poll: dental visits outside the office
Another poll here. How many of you have completed a dental visit at a patient’s car, transport van or ambulance? How many people have gone outside of the office? There are so many little portable devices. The Midwest Prophy, I believe, is about $1,700. It’s a great little cordless Midwest.
Let’s share the results. We do have some people saying that it’s a routine part of their practice. Fantastic. Yes, very rare occurrence, but I think you can get excited and make it happen more. And for those of you that answered no, I was in the same category before, so consider it.
[00:31:14] EZCrowns: mimicking natural teeth, and why hemostasis matters
Okay, now on to EZCrowns. Let’s get you there: from your first case to having done a few hundred and being super comfortable.
These are zirconium crowns on the anteriors. When you’re prepping the teeth, if you look at the upper picture, you can see the angulation of the teeth. One of the things I love about the EZCrowns is you can very easily mimic the shape of the natural teeth. You can see how, as I restored C through H, I was able to mimic the angulation that was present on E and F.
This would be very difficult to restore with just composite: notched central incisors with lingual caries going up the back. That would be very challenging. The child would bite down and flake off that composite incisal edge, and now here you have a great option.
Here are pre-op and post-op. These are all photos that I’ve taken in my practice, cases I’ve done with my own hands. Here’s D, E, F, G.
If you have a lot of heme, I tend to use these retraction caps by Henry Schein. They have a little divot in them, and I’ll do a little demonstration shortly. If you need more hemostasis, more control, you can use a great product by Sprig called HemeRX. They’re little soaked pellets that you press into the gingival sulcus, and they stop the blood.
As you’ll see later on, that’s an extremely important part of cementing beautiful zirconium crowns. You can do the best prep, you can have the best size, the color matches, they’re gorgeous, and then you get a whole bunch of blood in your prep, in your cementation, and the case is ruined. So I want to save you from those failures.
[00:33:18] Plaque, durability, and helping parents believe in dentistry
All right, plaque on OR day. Have you seen this? Sure. Kids come in all the time covered with plaque. The cool thing about zirconium is it’s very biocompatible, and plaque does not stick to the zirconium crown.
I’m going to show you in this next one. This is a recall visit. The child came in pre-op, we restored C through H, and this is their recall. You just don’t see plaque covering the teeth anymore in a thick biofilm.
Three-year post-op: you can see on this patient, who had D, E, F, G restored with EZCrowns, that you don’t have plaque. This is when they first came in, so we haven’t done the prophy yet. You don’t have plaque on D, E, F, G, but you have it at the cervical margin of the canines, along with those early white spot lesions.
Smile restoration. How are you going to take this smile on D, E, F, G and do composite? You’re then giving the parent very specific instructions on what the child can eat: “Don’t bite with your front teeth.” I have four kids. My kids, when they were toddlers, chewed on the tables. I still have teeth marks. There’s no way to tell most parents to have their kids avoid eating certain foods or bumping into things with their front teeth. It just happens. And the wonderful thing about the EZCrowns is they are so strong that they can withstand just about anything kids will do.
All right, I love this picture. This is parents making an effort. This is a very young child who came in with a ton of plaque. You can see early childhood caries. They had those facial lesions on E and F, but the parents brushed. Look at how, as the tooth erupted further, you have this healthy margin of beautiful enamel. This is a parent turning the corner.
So what are you going to do? Are you going to go in and say, “I’ll restore this. I’m going to put composites on E facial and F facial”? And then the child bites on something, the tooth flexes, and the composites pop out. Now you have a parent that believed in dentistry. They didn’t believe, then you got them to believe. You got them to allow you to do these restorations, and now they’ve lost their belief again.
So what I want is for parents to believe. I want parents to believe despite their own dental experiences: poor restorations, issues with cavities, losing their teeth. I have so many parents that are edentulous, and they’re nearly half my age. To me, having parents believe in dentistry for their child makes all the difference in the world. When you do long-lasting, durable restorations like the EZCrowns, you can change a parent’s belief, and they can see that dentistry works. Maybe that wasn’t their opinion before they saw you.
What other options do you have for this child? You don’t have that much left on the left central incisor, but you can restore these teeth with zirconium crowns.
[00:36:28] OR days, getting faster, and losing OR access
I do long days in the OR. We tell our families that I’m typically starting around 6:30, 6:45, and my last case goes till 6:00 PM. After 6:00 PM, we typically do 10 cases in a day, and I can do 10 cases of major restorations. Usually my last two cases are adults. I do wisdom teeth, I do root canals; we’ll do it all. But my first eight cases are typically kids.
You can do a start-to-finish case of eight posterior crowns and four or six anterior crowns in 30 to 40 minutes as you get practice with this. You will get better, and you will get faster. Not sloppy fast, but precise fast. Efficient.
COVID consequences, they keep coming. One of the big ones I’ve been hearing about is reduced access to the operating room. Anesthesia does pay less for dental versus medical; I’ve heard this from my anesthesiologist friends. I have two hospitals in my community, a nonprofit and a for-profit. I still go to the nonprofit hospital, but our for-profit hospital used COVID for six months to block my access to my one-day-a-week OR block, where I would do 10 cases. And very recently, they terminated my access, saying that dental is not in line with their core mission, and dental is not a viable option during their OR nursing shortages. So I will be starting in-office general anesthesia next month.
So I’m curious to see if this is an isolated issue with me, or if this is something you all may be seeing. Are any of you losing access to the operating room, with the hospital perhaps saying it’s because of COVID, but if you dig a little deeper, maybe it’s because of reimbursement rates? I would like to know because, to me, the operating room is the last resort. If I can do anything in the office to save a child from going to the OR, I will.
It looks like 39% of our attendees have lost access to one or more of their operating rooms. So I’m not alone, but maybe we could work together with the AAPD and get our access back, because kids need it.
[00:39:02] Frenum cases: when to cut, and how to keep the field dry
This might not be your first case. The pacifier habit. The anteriors are flared, and we have a thick frenum. I needed to do a frenectomy to fully seat E and F.
I have done this both ways. I have seated the crowns as much as I could, then quickly gone in with a Bovie, cut the frenum and pushed the crowns on the rest of the way. That can be very tricky because, as I’ll show you later, our cement mix is very thick and it sets quickly. What I now prefer to do is the frenectomy first, then I hold a wet gauze right over the cut frenum. Whether I placed sutures or it was just a cut and cauterize, I’ll hold pressure there, and then I’ll cement the crowns. With that, I can typically get great hemostasis, I don’t have blood dripping down, and I can get the zirconium crowns to fully seat.
I am not a cutter of every frenum at all. I really only cut the maxillary labial frenum if it’s absolutely necessary. This is an example of a frenum that was thick, but it attached high enough that there was absolutely no need to cut it. So I left it right there and put the crowns on.
[00:40:17] Cementation: cleanup and a live demo
All right, let’s do this. This is an example of where I use the slow-speed round bur. If I have to do an indirect pulp cap, you’ll see a little later that I use calcium hydroxide. Very rarely, I would say in less than 0.5% of the anterior crowns that you see, have I done pulpectomies. Very rare.
I like to use the spoon now instead of the explorer. When the cement reaches a matte finish, I’ll peel it off. It’s like a rubbery layer that peels off. Then I’ll floss the interproximal contacts, and then I’ll go back over the teeth with coarse prophy paste.
I would like to demo a cementation. We’ll see how well this goes. This is the patient. I’m going to prop him wide open. These are the retraction caps that I use. I set them on the teeth. And this is why I only do four teeth at one time now: I just don’t have enough fingers to hold these all on.
Now, think about it. You’re in the operating room. You have a throat pack. My assistant has loaded up the four crowns on the back of her hand. She points to the delta for me. As she points to it, I pick that crown up from her hand, I drop the retraction cap that I’ve been holding pressure with into the throat pack, and I put on my crown. Drop the cap into the throat pack, put on the crown. Drop it into the throat pack, put on the crown. Drop it into the throat pack, put on the crown. Now I hold pressure. I’m telling you, I am blanching my nail beds. I’m holding as tightly as I can, and I wait for the cement to set up.
I use Ketac in a hand mix. I don’t use the Aplicap; I felt like that was a little too liquidy. So my assistants do a hand mix, and they add very slightly more powder. Once the cement has set, I release my hands, and then I peel the cement layer off the teeth with the explorer. Again, that’s the reason why I’ve limited myself to doing four crowns at a time.
This is the retraction cap again. You can very nicely put your HemeRX pellet into that little concavity and hold. That’s a great way to get super hemostasis. And again, use a lot of firm pressure.
[00:43:00] Hemostasis, cement mix, masking dark decay and seating order
All right: hemostasis and the perfect cement mix. That is the key to success.
What I found when I first started doing zirconium anterior crowns was that if you have a really dark color from decay, or from SDF, which we’ll get into a little later on, you can see it through the crown. This is not a blockus. This is not a giant square brick that you’re putting on the teeth. These are naturally shaped, thin-margin, beautiful crowns that look like natural teeth. They’re not super thick in the gingival third. So if you have dark decay there, you will need to do some type of preparation to mask it if you don’t want to see it through your crown. In this case, I excavated the decay with a slow-speed round bur, placed calcium hydroxide as an indirect pulp cap, and then cemented the crowns over the top.
The order of seating: whatever method you pick, find something that works for you, and make sure that when you cement the crowns, you cement in the order you tried them on. Don’t go out of order for your cementation. It’s very important, because you don’t want to put on a crown that doesn’t fit really well, and sometimes it’s like a jigsaw puzzle; they have a certain way they go together. I typically do a canine, then the four across the front, and then the other canine, if the treatment needs are such.
[00:44:31] Good starter cases, and replacing stainless steel crowns
I think a great starter case is a diastema. The bigger the gap, the better. These are really simple cases to do because you can see your racetrack around the tooth, and we’ll speak about that very shortly. You can see your entire prep very clearly when there’s space.
A great starter case: D, E, F, G, beautiful space between the teeth. Not crummy gingiva; the gingiva looks reasonably healthy. You’re not going to get a ton of heme with this. This is a great case for the OR.
Is there a thick frenum? Just watch out. You may have a perfect case with the diastema, but the diastema may be there because you have a railroad track of a frenum running in between. Be careful with that. Make sure you will be able to seat your crowns and not have that rebounding, because a frenum case may not be the greatest first case.
Caries creates the diastema. This would be a slam dunk, great OR case for your first case. You’ve got lots of room. You’re not going to have to do a lot of interproximal prep; it’s already there from the decay. Start to finish: again, a great starter case. We’ve got a nice diastema there, and then a one-year follow-up on these crowns.
I saw a patient at one of our Head Starts when we were doing our Mobile Smiles Head Start program. If D, E, F and G are functioning as stainless steel crowns and the parent is okay with that, we leave them alone. But with this kid, the parent realized there was a significant amount of additional decay. It was a foster child, and they weren’t happy with the aesthetics. So we went to the OR to restore all of the teeth, and we corrected those stainless steel crowns. Here’s the grill to chill. Three-year follow-up. They look pretty fantastic.
I did have to make a minor adjustment on the occlusal surface of Q. That was the only tooth suspending the bite, so I took that down. But we do not recommend making adjustments on your zirconium crowns. What you want to do is adjust your prep and not have to adjust the zirconium crowns.
For your follow-up, again, look at this gingiva. It looks fantastic. You’re just not going to see that if you covered these teeth with composite.
Here’s a great case. This is where I was using those mirrors; it’s one of my earlier cases. You can see on the lingual of E and F, you would have had to mask that somehow, because otherwise the dark decay that was on there would have shown through the thin edge of the zirconium crown.
[00:47:17] Silver diamine fluoride, and the case against composites
I’ve included a handout if you’d like to read the AAPD Chairside Guide on silver diamine fluoride. I love SDF. We used it off-label back in Alaska in the early aughts. It’s a fantastic product. It will slam dunk, limit decay. I started using it in my practice only after it became FDA-approved, and it’s made by a company called Elevate. It works great. It’s a wonderful way to arrest decay, wait for the eruption of the rest of the teeth, and then restore.
I’m telling you something: it will stain everything. If you have beautiful offices, you don’t want blotches everywhere. It will drive you crazy. As careful as we were being with SDF, we realized the assistants would have some on their gloves, and it really didn’t take much to touch and transfer it onto clothing and countertops. So my advice is, if you use SDF, change your gloves immediately afterwards, put everything immediately into the trash, and you’re going to have some great arrested decay.
Here are some SDF cases. EZCrowns on E and F, and all we needed to do on G was some coarse polish. Another great case: we arrested this decay, but it’s kind of unsightly, so we restored it with crowns on D, E, F, G. A little more involved case here: we had some significant decay on the four anteriors, again restored. And another case with notch decay there on the echo, and we restored that with zirconium crowns.
Here are some tough cases. I just don’t know how you would restore D, E, F and G for this patient with wraparound composites going completely around the tooth. They’re going to bite into something, the tooth will flex, and your composites pop out. Better to cover the tooth with strong, biocompatible zirconium.
Again, the case against composites. E and F, the mesials. Who likes doing class threes on the mesial of primary teeth? Zirconium crowns are very long-lasting. They look beautiful.
[00:49:35] Very young patients, extractions, and overlapping teeth
EZCrowns on a one-year-old. This is a bit tough. These teeth have not fully erupted. Another one-year-old case: this is where the parent insisted that we proceed to restorations and not do SDF. The teeth were getting quite soft, and she was afraid we would have no teeth left if we waited, even with SDF.
I love prepping the canines. When I teach the hands-on Sprig University, a lot of times people get a little fearful about prepping the canines. I think it’s just about the easiest prep you can do in the world. I’ll show you in a couple of later slides, but it’s basically reduction: incisal reduction, cingulum reduction, your ring-around-the-rosy, and you have a gorgeous prep.
Tips for very young patients. On this patient, D, E, F and G, you need to prep to where the tooth will be when it’s fully erupted. If you stay supragingival, you’re not going to get deep enough onto the tooth, and when the tooth fully erupts, you’re going to have that Tom Cruise in the ’80s margin, like he had on the PFMs on eight and nine. You don’t want that margin growing in. So you need to cut a little deeper when you’re working on, say, an 18-month-old whose incisors have not fully erupted.
Here’s a case: severe attrition, but we had a solid root. I did not do a pulpectomy, and we’re still years out on this case. EZCrowns on the six anteriors. I just don’t know how you would do this case with strip crowns and have any kind of durability.
I’m not super heroic in every case. This is a case where I had to take teeth out: D and G, I took these out. The parent wanted them restored, and we consented to having the laterals extracted. I want parents to believe. If I put a crown on a tooth that I know is going to fail, I feel like that robs them of this hope and this belief in dentistry. So I’m honest. There are teeth that I can fix and teeth that are beyond, and I will have no hesitation taking the teeth that are beyond out of the mouth.
Overlap case. Zirconium crowns have no ability to squish by each other. They can’t do that. You have to create space. Teeth slip into each other; zirconium crowns do not. In this case, I had to over-prep the mesial of D, the lateral incisor, to open that space up. Here’s another case: E and F, the central incisors, have basically fallen into each other. There’s no way you can overlap your zirconium crowns, so you have to straighten up the mesial edge of E and take a little more off F.
[00:52:28] Lessons learned: my failures
Now, here are some lessons learned. I’ve done 8,000 of these, so you live and learn, and you make mistakes, and we have to learn from them. That’s why I think it’s a great idea to start documenting each and every case you do, now. You will learn so much from your pre-op and post-op photos, and you’ll become better at placing these crowns.
This is our new norm. This is me in the PAPR, full hood, full on, wrapped up, ready for the OR.
This is a heme failure. This was before I started doing those indirect pulp caps, on the delta. I had a crater created by the decay. When I excavated the decay and didn’t have the greatest hemostasis, I cemented the crown, the blood pooled in the crater, and that caused the discoloration you can see there.
I tried to be a hero. I don’t have tons of digits on each hand, so I tried to load all these crowns at the same time, and they all came out not ideal. So I think it’s best to limit yourself to four crowns at a time. Quite a few practitioners limit themselves to two crowns at a time. Do what feels right for you, but not six.
Here’s a case where one central was wider than the other. F, the left central, was naturally way wider than E. I wanted to match the crown size, but I did not prep F enough on the distal, and you can see that. Imagine me cementing the crown on F: it was tilted and tipped mesially because I didn’t take enough off that distal. So consider that when you have a width discrepancy in your teeth, whether from caries or the natural shape.
F, the left central, is flicked forward because I did not realize that my Molt mouth prop, my mouth gag, had slipped forward and was putting facial pressure on the lingual of that tooth. As the cement was setting (this was when we used a thinner mix, and it took a minute or two longer to set), that tooth tipped out, facially.
[00:54:48] Successes and long-term follow-up
All right, success. The gingiva loves the EZCrowns. Super healthy. There’s no way composites would stay on, wrapping around these teeth like ribbons on a present. The kid’s going to eat something, and they’ll all pop out. With EZCrowns, they eat what they want. We just went through Halloween, and even last Halloween, when the kids actually went out and got candy, we just don’t have failures from these crowns. They can eat basically what they need to eat.
Parents love these. They post pictures. They ask me to send them their post-op pictures. The parents consent to all these pictures, even though we don’t take photos where you can see the face; they’re retracted views of the teeth alone. But parents many times will ask me to send those to them, and then they post them, because we get tagged on Facebook. I think it’s great. If parents are posting about a dental product, that’s pretty fantastic.
Another dramatic case: gross decay on E and F, but very nice restorations. A one-year follow-up. Two-year follow-ups. Different cases, but I wanted to give you an idea of longevity. Three years, four years, five years.
We use a code, not sure if you’re all aware of this: code 0191. It’s optional for all of our OR patients. We don’t bill for it; there’s no reimbursement. It gets patients into the office for a one-week follow-up check after the OR (not during COVID times), and that’s often how I get these post-op photos. My assistants take them during that check. We look at oral hygiene and whether it has improved, any issues at all with treatment, and we learn a lot about the parent’s experience during that OR day.
[00:56:31] Clinical technique: the ASAP prep
All right, clinical technique. This is our ASAP: accelerated sub-gingival atraumatic preparation. This is a great technique to take you from wanting to try zirconium crowns to being really good at it.
Benefits of a step-by-step approach: Sprig has this laid out. They have a great EZ-Prep system, a diamond bur system. You improve speed and efficiency. You’re saving chair time and money. It’s a system you can follow, like a cookbook. This customized bur system will speed up your learning curve and get you to being proud of your preps and making fewer mistakes.
When you think of the anterior prep, you want a cylindrical design. Anterior and posterior, you need to create your occlusal space or your incisal space. With the posterior, you’re lopping off the occlusal surface. Anterior, the incisal edge is gone. Your reduction is about a millimeter and a half to two millimeters, which is the thickness of your donut bur.
For your posterior prep, you need to go supragingival. You don’t want to bang up the tissue, so you’re going around the tooth, creating your supragingival reduction. Same thing with the anterior, but with the anterior you have a second plane of reduction, so you need to create that second plane.
When you look right down at your prep, you see the racetrack. And as you can imagine, if you have a diastema, you can see the racetrack a whole lot better. You do a ring-around-the-rosy: you’re going around the tooth to create more space.
I love reducing the cingulum. If you have an anterior crown that’s not fitting, you probably didn’t take the cingulum off. You need to remove that cingulum to get as tight a fit with as small a crown as possible.
Then refine your margin. You want to make sure you have no ledges as you cement your crown. You don’t want any hang-ups on the edge. You don’t need to taper; you really don’t want to taper for these crowns. You want to go straight up and down.
Prep errors: a lot of times, if you haven’t prepped enough, or if you left that cingulum, you’re going to have to pick a crown that’s too big, and it won’t fit well.
Also think of it this way: these are not snap-lock-fit stainless steel crowns. You want a passive fit. You don’t need to force them on. When I said I use pressure, I use pressure for the hemostasis. I’m not using pressure to push the crown on. You don’t need to do that.
[00:59:19] Evidence, and “you’ve got this”
Scientific evidence: a great study, 53 crowns evaluated on kids. We have terrific outcomes. This is with the EZ-Pedo primary maxillary anterior zirconium crowns. They’re clinically acceptable, parents are satisfied, and they’re a great restoration.
So I want to say you can definitely do this. If I can do this, if I can learn a new technique after being out of school for 13 years, you’ve got this.
[00:59:51] Resources, CE, workshops and closing
Sprig has a great website. They have clinical videos, which are outstanding, their webinars, and photography tips. If you do choose to, start documenting with your very first case.
Practice isn’t the thing here. Once you’re good, you really need to make sure the practice is what makes you great.
Please check your email. Your CE certificate is going to be emailed out after this webinar. Sprig has discounts so that you can get a great deal when you order your anterior kit and your posterior kit, because you’ll be psyched and ready to try it. So check your email before you order, and please join us for Saturday’s Sprig Happy Hour.
I think a great way to learn is the upcoming hands-on workshops. Sprig has taken extremely proactive steps with social distancing to make a safe environment. They are on this, and they have ways to teach you, keep you safe, and make sure the environment you’re working in follows COVID protocols as closely as possible. So please come to one of the workshops in 2021.
And this is my ending slide. When everything was going down, I had just bought a Harley. When everything was completely quiet in the streets, there was nothing like riding full tilt. Kind of the apocalypse, but it’s all good.
Thank you so much for joining the webinar. I really appreciate it. We’re going to roll into questions. I’ll leave my information up, and I’m more than happy to answer whatever questions you have. Please get in touch either by text or by email. And also education@sprigusa.com: that’s how you get more information on those really great hands-on courses. For those of you who have taken courses in the past, where we sat next to each other in a U-shaped format, we now have our own tables, so you will be super socially distanced. It’s a great way to take Sprig University. I’m going to leave it on my info slide and jump into these questions.
[01:02:18] Q&A: treatment time, office vs OR, cement and occlusion
Question (Leslie): Am I seeing them during the 20-minute block on those days?
For my OR cases, eight posterior stainless steel crowns and my four or six anteriors, I typically take about 30 to 40 minutes of treatment time. That’s my speed. Again, I’ve been doing this now for 21 years.
Question (Adena): “Are all these crowns done in the OR? I use strip crowns in the office on kids as young as two, because zirconia, it’s too invasive.”
I totally understand. My first 100 of these cases were all in the OR. I needed 100, a little over 100, to really learn the technique so I could be fast enough. But today alone, in the office with nitrous and with sedation, we probably did over 20 of these anterior zirconium crowns. So once you really get your technique down, you are definitely able to do these in the office, either with sedation or, for specific cases, with nitrous. I often do sedation.
Question (Shazad): Also about the OR and the dental chair, and cement of choice.
I love Ketac. I use the hand-mix Ketac, which is the powder and liquid. I don’t use the Aplicap. Hand mix is a little cheaper, and it allows you to add a little more powder if you want a slightly thicker cement.
Question: Do I check or adjust the occlusion, or does the bite settle spontaneously?
I used to be a general dentist, and when I was cementing PFM crowns, I would have them bite on articulating paper. I loved to do that, would do that all day. No, not so much. With pediatric dentistry and with these crowns, the bite, in my mind, settles in. Now, you did see that one grill-to-chill case with the anteriors that were stainless steel. That one, his bite was pivoting on one crown, so I did adjust that one crown, but typically I do not.
[01:04:29] Q&A: Medicaid for a startup, billing, and supplies
Question (Leslie): Any advice for a startup pediatric practice that wants to see Medicaid?
Totally. Take Medicaid. You are serving the most underserved members of your community. But I think you have to have some parameters, some plans in place, in order to be successful, so that you can grow your practice and not have as many bad actors in your practice. Like everything in the world, you have people that abuse the system and people that follow the rules. Out of our patients with Medicaid, the vast majority follow the rules. They treat my office and my office staff with respect. They come in at the appropriate time, in appropriate attire, and we have great appointments.
But we do have some bad actors, and I’ve brought this up in our state dental meetings: I wish there was a better way for me to lodge a complaint against the very few bad actors who I feel are ruining it for other practices. So I think you should have some parameters in place; maybe you take a referral. That puts one simple step in place. They have to make a physical appointment at another office and get a referral to you. That shows you they value the time, they have transportation, and they’re going to come to this appointment.
Because when I had no restrictions whatsoever on Medicaid, we had some days with an 87% no-show rate with Medicaid. You just cannot have that and have a successful practice. With these simple parameters in place, we’ve tamped that down to under 10%.
Question: “Medicaid doesn’t cover zirconium crowns, so that’s why I’ve been doing strip crowns. Are you doing zirconium crowns on Medicaid patients?”
That’s a great question. You can bill the zirconium crown as 2029, and then you submit a written request, a written annotation, saying that Medicaid is able to downgrade it to a lesser code. So even if Medicaid doesn’t cover 2029, you can request a downgrade, and typically they do that. It’s a better product, so you can downgrade it all the way down to a stainless steel crown.
Question (Tim Nichols): Do you know the brand of lighted dental mirror?
Yes, I use the DentLight, D-E-N-T L-I-G-H-T. But I will say, since COVID, we haven’t been able to get those at all. So we’ve gone to using little headlight flashlights and simple disposable mirrors that we give away to the parent after the appointment.
Question (Rebecca): What material are you using for an indirect pulp cap?
I use calcium hydroxide made by Ultradent, the UltraBlend calcium hydroxide. It’s very easy. You don’t have to mix it. It’s in a syringe; you squirt it out and cure it.
All right, thank you. A couple of you commented on my energy. I’m glad that worked for you all.
[01:07:53] Q&A: posteriors, crossbites, Hall-style caries management and insurance
Question (Shana): Do you use stainless steel crowns on posteriors?
Yes, I use stainless steel crowns on posteriors. I have not dived in and done as much with the posterior zirconium crowns as I could. I think I’ve really perfected my technique and my speed with the anteriors. I’m very quick with the posterior stainless steel crowns, and I think I can get there, but I have to push myself. So one of my goals for 2021 is to do more posteriors.
Now, I will do single-unit posteriors quite frequently. Quite a few of our parents come in where a tooth needs a crown, and if that’s the only tooth in the mouth that needs a crown, they really don’t want one flagship stainless steel crown. So I will very often do those single posteriors in my office with sedation.
Question (Steve): Any tips for posterior back-to-back crowns?
Great question. Yes, Sprig has these fantastic little space-loss crowns. They’re squished. It’s like taking a Howe plier to a stainless steel crown and squishing it. So that’s a great idea for posteriors. You also always have to have a place in the posterior where you’re reducing more tooth structure. For me, if I need to gain some space, I’ll typically do that on the distal of the second molars, because I don’t want to cause an ectopic or hung-up eruption of the adult teeth as they come in. Or, if I have to prep the first molar and second molar, I’ll do that interproximally.
Question: How should the occlusion ideally look for the anterior crowns?
The cool thing is you can put these crowns on teeth that are in crossbite. When I did my first few cases of an anterior crossbite, I thought I would wear down the lower opposing incisors to nubbins. I thought: the parent wants this, they’re in crossbite, I’m going to destroy these teeth. It really hasn’t happened. The primary teeth adjust. Basically, I don’t want to create a smile where the only contact is in the anterior. I want to make sure I have posterior occlusion. But I’m really not that concerned about contact occlusion on each and every anterior tooth.
Question: Do I remove all the decay, or can you leave some decay behind to avoid pulp exposure and cement, like Hall crowns?
Totally. Before COVID, I really thought the only people in the world who did Hall crowns were us public health service dentists, and me during the times I volunteered in Nepal, where we had no electricity and were just putting crowns on teeth. Then COVID happened, and the AAPD was talking about Hall crowns at every webinar. So yes, you can definitely leave some decay behind, especially if you use a glass ionomer cement. Like I said, I really don’t do a lot of pulpectomies anymore at all on these anterior crowns. I like to avoid pulp exposure. Great question.
Question: Does insurance pay for zirconium crowns, and do you charge patients out of pocket?
I follow the rules with Medicaid. I do not want to get grounded by Medicaid. We see quite a bit of Medicaid, so I do not charge our Medicaid patients anything whatsoever out of pocket, ever. They don’t have to pay for their zirconium crowns at all.
For private insurance, some of the private insurers will not recognize that 2029 code, so typically we downgrade it to a stainless steel crown code. And I personally don’t charge anything more for the zirconium crowns, although my out-of-pocket cost is greater because they cost more than stainless steel. I do that when it’s possible. And, as I told you, I’m working on improving my posterior technique and my posterior efficiency, so we don’t have a price differential.
Question: How long do I usually hold pressure with the retraction cap to control bleeding prior to cementing?
Great question. My hospital assistants are very adept at mixing the Ketac by hand. From the start of the mix to having the crowns loaded and placed on the back of their palm, for me to pick off one at a time, takes them about two minutes. During that time, I’m holding pressure. And these caps are pennies each, so if I’m doing four teeth, we have maybe six or seven of them out on the Mayo table in the OR. If one gets bloody, I change it out. We also have the HemeRX pellets if needed, where we can stuff the pellet into the concavity and use that. So I would say I’m holding pressure for two minutes at most.
Question (Shana): Any changes to the prep if the patient has an anterior crossbite?
It really depends on the angulation of the teeth. If there is an anterior crossbite, you want to make sure you’re fully seated. That was one of the challenges when I first started doing preps for kids with anterior crossbite: I was trying so hard to avoid the crossbite, or to correct it with my prep, that I didn’t prep enough. So be aware that you may need to prep slightly more.
I think I have made it through all of the questions. Thank you very, very much for participating in the webinar. If you have more questions, please join us this Saturday for Sprig’s Happy Hour, and I am more than happy to answer any questions you have whatsoever. Texting is the easiest way to reach me. My email address is right there too. Thank you very much. I hope you all have a great night.
