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The technician as part of the prevention team
In the design of his laboratory work, the technician should consider the patient’s preventive home care procedures. He should work with the dentist and his other auxiliaries as part of the prevention team.
The technician as part of the prevention team
C harles J. King, DDS, MAT Joseph T. Richardson, DDS, MAT Joseph L. C leveland, Jr., DDS, Charleston, S C i H
In spite of the current emphasis on preventive dentistry, the dental laboratory technician who has not been involved in a team concept program probably feels that responsibility for prevention is relegated to only those who work in the pa tient’s mouth—the dentist, the assistant, and the hygienist. Even those dentists whose offices have a special area designated for patient education may not think of the technician as part of their prevention program. Therefore, attention is dir ected to the responsibility for prevention in den tistry, the patient who is to receive prevention service, the necessary communication, and to prevention philosophies that should be common to both the dentist and the laboratory technician.
P revention in d en tistry In 1971, the A D A adopted policies with respect to dentistry’s position in a national health pro gram 1in which preventive procedures were given high-priority in dental health services but still recognizing the restoration and replacement of teeth as important elements in the program. Also 374 ■ JADA, Vol. 92, February 1976
included in the guidelines were the recruitment and training of auxiliaries. In regard to the latter, many educational institutions established dental technician schools with curriculums for certifi cate training. While the dental student training program it self is being changed to place more emphasis on prevention, the curriculum is also being changed to lessen emphasis on the laboratory phases of dental practice. This shifts more re sponsibility on to the dental technician in some respects. Consideration of prevention in crown and bridge has been limited. This area of dentistry treats the results of disease, habits, and acci dents. The technician was complimented if his bridge went to place with little adjustment at the chair, but all this was done with little comment on the relationship of the laboratory work to the patient’s preventive home care. Textbooks have been written on restorative procedures—without including home care suggestions or discussing laboratory techniques that would favor better and easier home care. The attitude is changing. Continuing educa tion programs on prevention are being offered
that may have this as a central theme. And now the dental technician is usually invited to such continuing education meetings so he can be knowledgeable in enhancing better home care and thereby provide a better service.
The patie nt and prevention It is the responsibility of the dentist to educate the patient in the care of an appliance or restora tion just as he would specify proper home care measures after an extraction. The patient is re sponsible for carrying out such suggestions once he has learned the procedure. It is the laboratory technician’s responsibility to make this proce dure easier for both dentist and patient by con structing a bridge or other appliance that makes preventive procedures easier to describe and follow. A patient’s despair over the mutilation or loss of a strategic tooth could be alleviated by restor ing appearance, comfort, and function. These are closely related to such things as preventing bruxism through proper occlusion in a restora tion2 and good anatomical contours that may be directly concerned with the patient’s well-being. For example, an inadequate gingival embrasure space often leads to swollen, red gingiva. A per son with pink, healthy tissues that can be easily and properly cleaned most assuredly would be a happier dental patient.
C om m unication and m otivation Proper education depends on good communica tion between the technician and the dentist and concerns what is best for the patient’s welfare. What service can be supplied by the technician and what service the dentist is able to render all depend on good communication. Although the dental assistant may be the intermediate person, the technician and dentist should agree on a phil osophy first. The further apart physically these two people are, the less chance for common un derstanding. The patient is “ their patient,” and thus the technician becomes part of the dental team (Fig 1). Such philosophy cannot detract from a prevention concept—it only enhances it. Communication between educators of dental technicians and the educators of dentists, which in the past was often sadly lacking, is now receiv ing attention. Continuing education programs
Fig 1 ■ Dental team philosophy should include close com m un ication w ith technician.
for dentists often include technicians, and peri odicals such as this one are important in putting forth coordinated information. Textbooks now explain the “ why” of procedures so that techni cal methods may be more meaningful to those responsible for prosthesis fabrication. For ex ample, it is much easier to allow an adequate gin gival embrasure at a solder joint if all concerned realize a patient must be able to floss debris from the area.
Lab orato ry designs fo r prevention in crow n and bridg e With these thoughts in mind, a few concepts about preventive laboratory procedures in crown and bridge are briefly discussed. A classic example is in the new concepts of pontic construction as related to gingival adap tation. At one time, it was thought that the pon tic should cover a large area of the ridge lingual to the crest, and the cast should be scraped to result in definite tissue pressure, so that irrita ting materials could be kept from lodging under the pontic. Now research has shown that the tis sue is more likely to accept a pontic with “ pin point” contact on the buccal or labial areas of the ridge3 (Fig 2). With this construction, the areas of plaque accumulation can be reached easily by a patient with floss. The design elim inates any concavity, so the deposits are vulner able. The gingival embrasures should be accessible for the patient following his proper home treat ment instructions.4,5 As a rule of thumb, we judge the adequacy of a gingival embrasure by having the patient try to place the floss easily as the bridge sits on the working cast (Fig 3).
King—Richardson—Cleveland: TECHNICIAN ON PREVENTION TEAM ■ 375
Fig 2 ■ P ontic design on left is frequently used by many dental laboratories. This would preclude plaque removal from gingival surface because of poor access. Corrected po n tic design is shown at right. Technician should be advised as to rationale of m odified po ntic that perm its easy preventive access w ithou t sacrifice of occlusal concepts.
Fig 3 ■ Adequate gingival embrasures in laboratory stage should be com mon goal fo r both dentist and technician. This w ill per m it interproxim al flossing by patient.
Contact or solder area placement is important to permit food particles to escape to the lingual aspect of posterior maxillary teeth and to pro tect the labial gingival tissues (Fig 4). Regarding solder joints, El Ebrashi6 has sig nificantly added to our research knowledge about the shape of the joints. He found that a rounded one is far superior in resisting fracture. Also, such a shape is much easier to floss. Crowns usually should be contoured accord ing to normal tooth morphology (Fig 5). Exag gerated forms often cause more problems than those already present. A case in point is the ac centuated buccal contouring, with the conse quence of possible lack of gingival stimulation under the buccal shelf. Experience has shown that the beginning student technician tends to accentuate contours if these are emphasized. Crown contours are nicely discussed in two pub lications.7,8
O cclu sio n as a p reventive m ethod
Fig 4 ■ Fabrication of well-rounded solder joints, proper con tact areas, and desired occlusal m orphology are preventive objectives.
376 ■ JADA, Vol. 92, February 1976
This subject is most necessary to the technician if he is to be knowledgeable in the “ why” of his designs for prosthesis. The person at the bench must have a continuing interest in the research and clinical information that is now becoming available as never before. Techniques and back grounds in occlusion are important concerns in everything from a study of muscles of the jaw all the way to the occlusal morphology in crown and bridge.9 The manner of transferring the case
of view; this must be encouraged. An effort should be made to communicate with the technician on the preventive team and make him part of it. There is seldom a case that is of fered to the technician in which no exchange of information is helpful or about which no ques tion can be asked. A little personal history about the patient might seem ideal and impractical at the time, but could save hours of remake if the final restoration were technically excellent, but functionally undesirable. The concept of the team, and the realization that each member can contribute to the whole, is the objective of modem dental thinking. The ability to establish a responsibility of all team members can only improve its efficiency and ul timately benefit the patient.
Fig 5 ■ C om m unication between dental team participants w ill prom ote th is preferred gently buccal contour. Technician should understand purpose behind nonexaggerated crown form.
to an articulator, use of proper materials to mount and wax the case, and the treatment of the metal or porcelain to prepare it for restora tion of the patient’s arch are all of little value if valid occlusion thinking is ignored. This, in itself, is prevention.
C o n clu sio n s
The technician should avail himself of the liter ature, continuing education courses, and the benefit of association meetings related to his part in preventive dentistry. A strong voice by labor atory associations in publications other than technicians’ periodicals would be helpful in pre senting the technicians’ responsibilities. In one article,10 a former laboratory owner, now a den tist, brings forth the laboratory person’s point
Dr. King is d ire ctor of clinics and professor of crow n and bridge dentistry at the College of Dental M edicine, Medical U ni versity of South Carolina, 80 Barre St, C harleston, 29401. Dr. Richardson is associate professor and acting chairm an, depart ment o f crow n and bridge dentistry, and Dr. Cleveland is assoc iate professor, departm ent of crown and bridge dentistry, Medi cal University of South Carolina. Address requests fo r reprints to Dr. King. 1. G uidelines fo r dentistry's position in a national health pro gram. JADA 83:1226 Dec 1971. 2. Ram fjord, S.P., and Ash, M.M., Jr. O cclusion, ed 2. Phil adelphia, W. B. Saunders Co., 1971, p 115. 3. Stein, R.S. Pontic-residual ridge re la tionsh ip: a research report. J Prosthet Dent 16:251 March-April 1966. 4. Skurow, H.M., and Lytle, J.D. The interproxim al embrasure. Dent Clin North Am 15:641 July 1971. 5. G lickm an, I. Clinical periodontology, ed 3. Philadelphia, W. B. Saunders Co., 1964, p 765. 6. El Ebrashi, M. Stress analysis and design of fixed dental structures, PhD thesis. University of M ichigan, Ann Arbor, 1968, p 149. 7. G lickm an, I. Clinical periodontology, ed 3. Philadelphia, W. B. Saunders Co., 1964, p 756. 8. Perel, M.L. Axial crown contours. J Prosthet Dent 25:642 June 1971. 9. Lundeen, H.C. Occlusal m o rpho logic considerations fo r fixed restorations. Dent Clin North Am 15:649 July 1971. 10. Durban, E.R. How to get along w ith your lab technician. Dent Econ 62:26 May 1972.
King—Richardson—Cleveland: TECHNICIAN ON PREVENTION TEAM ■
377
The technician as part of the prevention team
C harles J. King, DDS, MAT Joseph T. Richardson, DDS, MAT Joseph L. C leveland, Jr., DDS, Charleston, S C i H
In spite of the current emphasis on preventive dentistry, the dental laboratory technician who has not been involved in a team concept program probably feels that responsibility for prevention is relegated to only those who work in the pa tient’s mouth—the dentist, the assistant, and the hygienist. Even those dentists whose offices have a special area designated for patient education may not think of the technician as part of their prevention program. Therefore, attention is dir ected to the responsibility for prevention in den tistry, the patient who is to receive prevention service, the necessary communication, and to prevention philosophies that should be common to both the dentist and the laboratory technician.
P revention in d en tistry In 1971, the A D A adopted policies with respect to dentistry’s position in a national health pro gram 1in which preventive procedures were given high-priority in dental health services but still recognizing the restoration and replacement of teeth as important elements in the program. Also 374 ■ JADA, Vol. 92, February 1976
included in the guidelines were the recruitment and training of auxiliaries. In regard to the latter, many educational institutions established dental technician schools with curriculums for certifi cate training. While the dental student training program it self is being changed to place more emphasis on prevention, the curriculum is also being changed to lessen emphasis on the laboratory phases of dental practice. This shifts more re sponsibility on to the dental technician in some respects. Consideration of prevention in crown and bridge has been limited. This area of dentistry treats the results of disease, habits, and acci dents. The technician was complimented if his bridge went to place with little adjustment at the chair, but all this was done with little comment on the relationship of the laboratory work to the patient’s preventive home care. Textbooks have been written on restorative procedures—without including home care suggestions or discussing laboratory techniques that would favor better and easier home care. The attitude is changing. Continuing educa tion programs on prevention are being offered
that may have this as a central theme. And now the dental technician is usually invited to such continuing education meetings so he can be knowledgeable in enhancing better home care and thereby provide a better service.
The patie nt and prevention It is the responsibility of the dentist to educate the patient in the care of an appliance or restora tion just as he would specify proper home care measures after an extraction. The patient is re sponsible for carrying out such suggestions once he has learned the procedure. It is the laboratory technician’s responsibility to make this proce dure easier for both dentist and patient by con structing a bridge or other appliance that makes preventive procedures easier to describe and follow. A patient’s despair over the mutilation or loss of a strategic tooth could be alleviated by restor ing appearance, comfort, and function. These are closely related to such things as preventing bruxism through proper occlusion in a restora tion2 and good anatomical contours that may be directly concerned with the patient’s well-being. For example, an inadequate gingival embrasure space often leads to swollen, red gingiva. A per son with pink, healthy tissues that can be easily and properly cleaned most assuredly would be a happier dental patient.
C om m unication and m otivation Proper education depends on good communica tion between the technician and the dentist and concerns what is best for the patient’s welfare. What service can be supplied by the technician and what service the dentist is able to render all depend on good communication. Although the dental assistant may be the intermediate person, the technician and dentist should agree on a phil osophy first. The further apart physically these two people are, the less chance for common un derstanding. The patient is “ their patient,” and thus the technician becomes part of the dental team (Fig 1). Such philosophy cannot detract from a prevention concept—it only enhances it. Communication between educators of dental technicians and the educators of dentists, which in the past was often sadly lacking, is now receiv ing attention. Continuing education programs
Fig 1 ■ Dental team philosophy should include close com m un ication w ith technician.
for dentists often include technicians, and peri odicals such as this one are important in putting forth coordinated information. Textbooks now explain the “ why” of procedures so that techni cal methods may be more meaningful to those responsible for prosthesis fabrication. For ex ample, it is much easier to allow an adequate gin gival embrasure at a solder joint if all concerned realize a patient must be able to floss debris from the area.
Lab orato ry designs fo r prevention in crow n and bridg e With these thoughts in mind, a few concepts about preventive laboratory procedures in crown and bridge are briefly discussed. A classic example is in the new concepts of pontic construction as related to gingival adap tation. At one time, it was thought that the pon tic should cover a large area of the ridge lingual to the crest, and the cast should be scraped to result in definite tissue pressure, so that irrita ting materials could be kept from lodging under the pontic. Now research has shown that the tis sue is more likely to accept a pontic with “ pin point” contact on the buccal or labial areas of the ridge3 (Fig 2). With this construction, the areas of plaque accumulation can be reached easily by a patient with floss. The design elim inates any concavity, so the deposits are vulner able. The gingival embrasures should be accessible for the patient following his proper home treat ment instructions.4,5 As a rule of thumb, we judge the adequacy of a gingival embrasure by having the patient try to place the floss easily as the bridge sits on the working cast (Fig 3).
King—Richardson—Cleveland: TECHNICIAN ON PREVENTION TEAM ■ 375
Fig 2 ■ P ontic design on left is frequently used by many dental laboratories. This would preclude plaque removal from gingival surface because of poor access. Corrected po n tic design is shown at right. Technician should be advised as to rationale of m odified po ntic that perm its easy preventive access w ithou t sacrifice of occlusal concepts.
Fig 3 ■ Adequate gingival embrasures in laboratory stage should be com mon goal fo r both dentist and technician. This w ill per m it interproxim al flossing by patient.
Contact or solder area placement is important to permit food particles to escape to the lingual aspect of posterior maxillary teeth and to pro tect the labial gingival tissues (Fig 4). Regarding solder joints, El Ebrashi6 has sig nificantly added to our research knowledge about the shape of the joints. He found that a rounded one is far superior in resisting fracture. Also, such a shape is much easier to floss. Crowns usually should be contoured accord ing to normal tooth morphology (Fig 5). Exag gerated forms often cause more problems than those already present. A case in point is the ac centuated buccal contouring, with the conse quence of possible lack of gingival stimulation under the buccal shelf. Experience has shown that the beginning student technician tends to accentuate contours if these are emphasized. Crown contours are nicely discussed in two pub lications.7,8
O cclu sio n as a p reventive m ethod
Fig 4 ■ Fabrication of well-rounded solder joints, proper con tact areas, and desired occlusal m orphology are preventive objectives.
376 ■ JADA, Vol. 92, February 1976
This subject is most necessary to the technician if he is to be knowledgeable in the “ why” of his designs for prosthesis. The person at the bench must have a continuing interest in the research and clinical information that is now becoming available as never before. Techniques and back grounds in occlusion are important concerns in everything from a study of muscles of the jaw all the way to the occlusal morphology in crown and bridge.9 The manner of transferring the case
of view; this must be encouraged. An effort should be made to communicate with the technician on the preventive team and make him part of it. There is seldom a case that is of fered to the technician in which no exchange of information is helpful or about which no ques tion can be asked. A little personal history about the patient might seem ideal and impractical at the time, but could save hours of remake if the final restoration were technically excellent, but functionally undesirable. The concept of the team, and the realization that each member can contribute to the whole, is the objective of modem dental thinking. The ability to establish a responsibility of all team members can only improve its efficiency and ul timately benefit the patient.
Fig 5 ■ C om m unication between dental team participants w ill prom ote th is preferred gently buccal contour. Technician should understand purpose behind nonexaggerated crown form.
to an articulator, use of proper materials to mount and wax the case, and the treatment of the metal or porcelain to prepare it for restora tion of the patient’s arch are all of little value if valid occlusion thinking is ignored. This, in itself, is prevention.
C o n clu sio n s
The technician should avail himself of the liter ature, continuing education courses, and the benefit of association meetings related to his part in preventive dentistry. A strong voice by labor atory associations in publications other than technicians’ periodicals would be helpful in pre senting the technicians’ responsibilities. In one article,10 a former laboratory owner, now a den tist, brings forth the laboratory person’s point
Dr. King is d ire ctor of clinics and professor of crow n and bridge dentistry at the College of Dental M edicine, Medical U ni versity of South Carolina, 80 Barre St, C harleston, 29401. Dr. Richardson is associate professor and acting chairm an, depart ment o f crow n and bridge dentistry, and Dr. Cleveland is assoc iate professor, departm ent of crown and bridge dentistry, Medi cal University of South Carolina. Address requests fo r reprints to Dr. King. 1. G uidelines fo r dentistry's position in a national health pro gram. JADA 83:1226 Dec 1971. 2. Ram fjord, S.P., and Ash, M.M., Jr. O cclusion, ed 2. Phil adelphia, W. B. Saunders Co., 1971, p 115. 3. Stein, R.S. Pontic-residual ridge re la tionsh ip: a research report. J Prosthet Dent 16:251 March-April 1966. 4. Skurow, H.M., and Lytle, J.D. The interproxim al embrasure. Dent Clin North Am 15:641 July 1971. 5. G lickm an, I. Clinical periodontology, ed 3. Philadelphia, W. B. Saunders Co., 1964, p 765. 6. El Ebrashi, M. Stress analysis and design of fixed dental structures, PhD thesis. University of M ichigan, Ann Arbor, 1968, p 149. 7. G lickm an, I. Clinical periodontology, ed 3. Philadelphia, W. B. Saunders Co., 1964, p 756. 8. Perel, M.L. Axial crown contours. J Prosthet Dent 25:642 June 1971. 9. Lundeen, H.C. Occlusal m o rpho logic considerations fo r fixed restorations. Dent Clin North Am 15:649 July 1971. 10. Durban, E.R. How to get along w ith your lab technician. Dent Econ 62:26 May 1972.
King—Richardson—Cleveland: TECHNICIAN ON PREVENTION TEAM ■
377