6 Protocols for Predictable Aesthetic Dental Restorations
prophylactic procedures are sufficient, and the
probability of success of aesthetic restorations
or implants is high. This is not the case with
moderate- to high-risk periodontal patients, who
require extensive periodontal therapy and more
frequent recalls ensuring that periodontal health
is established and maintained. In the latter,
patients should be informed that unless their
periodontal status is maintained, aesthetic
restorations or implant longevity may be severely
compromised.
The next question is how predictably and
accurately to assess risk. A recent study shows
that only 20% agreement was evident among
expert clinicians, indicating that inter-evaluator
assessment is unreliable. The clinical significance
is that either over or under-treatment is pre-
scribed depending on the opinion of the exam-
iner.
5
A quantitative analysis using the Previser
Risk Calculator has been proposed, which accu-
rately predicts risk of periodontal disease, from
a scale of 1 (low risk) to 5 (high risk). This test
uses the latest computer technology and has been
clinically evaluated over a 15-year period. As
well as assessing risk, the test also provides a
rating for current disease status from 1 (peri-
odontal health) to 100 (severe generalised peri-
odontitis).
6
This objective evaluation is a step
towards the clinician being able to modify treat-
ment according to risk, achieve and maintain
periodontal health, and prevent future complex
and costly therapies. This quantitative analysis is
a paradigm shift from a repair to a wellness
model.
Evidence-based decision making
and treatment
Historically, dentistry was far ahead of medicine
with regard to implementing preventive meas-
ures for caries and periodontal disease. These
prophylactic interventions were underpinned by
nearly four decades of scientific research and
clinical trials. However, today the profession is
so enamoured with technology that it has shed
the solid scientific platform in favour of spurious
marketing claims. Inventive materials and
devices are readily embraced, endorsed by
charismatic lecturers, and used on patients
without evidence of long-term clinical success.
Many ‘opinion leaders’ that lecture frequently at
dental symposia reiterate a particular point of
view, which may or may not be evidence-
based. An opinion that is repeated perpetually
eventually becomes the truth, irrespective of its
validity.
There is nothing wrong with this approach as
long as delegates are informed beforehand that
the speakers are expressing their empirical expe-
rience, not scientifically proven rules and guide-
lines. As stated below, clinical experience forms
a part of an evidence-based approach. Added
to this are peer and media pressure, castigat-
ing those who prefer the traditional scientific
approach as archaic or old-fashioned. However,
sometimes faith is not enough, and seeing or
reading anecdotal case studies are insufficient for
sound clinical decision making.
7
Viewed from a manufacturer’s perspective,
dental companies are keen to introduce novel
products and make profits, which indirectly
filter back to the profession in sponsorship for
educational symposia. Furthermore, research is
onerous, expensive and protracted, and by the
time the results are published, the product
may be obsolete, often replaced by a newer
version. This vicious cycle is then repeated and
perpetuated.
The scientific approach, although utopian,
hampers innovation and technological advance-
ment. Many new technologies have faced
problems before a reliable product eventually
emerges. Ultimately, it is the dentist, not the
manufacturer, who is responsible for clinical
decision making that impacts on patients’ treat-
ment. If things go wrong, the patient is unlikely
to blame the manufacturer for the failure. There-
fore, the onus is on the dentist to choose ap-
propriate materials, backed by evidence-based
research, to avoid rebuke or professional negli-
gence litigation in the event of failure. Evidence-
based treatment
8
is succinctly summarised as a
combination of (Fig. 1.8):
! Clinical erudition
! Sound scientific research
! Patients’ needs and wants
prophylactic procedures are sufficient, and the
probability of success of aesthetic restorations
or implants is high. This is not the case with
moderate- to high-risk periodontal patients, who
require extensive periodontal therapy and more
frequent recalls ensuring that periodontal health
is established and maintained. In the latter,
patients should be informed that unless their
periodontal status is maintained, aesthetic
restorations or implant longevity may be severely
compromised.
The next question is how predictably and
accurately to assess risk. A recent study shows
that only 20% agreement was evident among
expert clinicians, indicating that inter-evaluator
assessment is unreliable. The clinical significance
is that either over or under-treatment is pre-
scribed depending on the opinion of the exam-
iner.
5
A quantitative analysis using the Previser
Risk Calculator has been proposed, which accu-
rately predicts risk of periodontal disease, from
a scale of 1 (low risk) to 5 (high risk). This test
uses the latest computer technology and has been
clinically evaluated over a 15-year period. As
well as assessing risk, the test also provides a
rating for current disease status from 1 (peri-
odontal health) to 100 (severe generalised peri-
odontitis).
6
This objective evaluation is a step
towards the clinician being able to modify treat-
ment according to risk, achieve and maintain
periodontal health, and prevent future complex
and costly therapies. This quantitative analysis is
a paradigm shift from a repair to a wellness
model.
Evidence-based decision making
and treatment
Historically, dentistry was far ahead of medicine
with regard to implementing preventive meas-
ures for caries and periodontal disease. These
prophylactic interventions were underpinned by
nearly four decades of scientific research and
clinical trials. However, today the profession is
so enamoured with technology that it has shed
the solid scientific platform in favour of spurious
marketing claims. Inventive materials and
devices are readily embraced, endorsed by
charismatic lecturers, and used on patients
without evidence of long-term clinical success.
Many ‘opinion leaders’ that lecture frequently at
dental symposia reiterate a particular point of
view, which may or may not be evidence-
based. An opinion that is repeated perpetually
eventually becomes the truth, irrespective of its
validity.
There is nothing wrong with this approach as
long as delegates are informed beforehand that
the speakers are expressing their empirical expe-
rience, not scientifically proven rules and guide-
lines. As stated below, clinical experience forms
a part of an evidence-based approach. Added
to this are peer and media pressure, castigat-
ing those who prefer the traditional scientific
approach as archaic or old-fashioned. However,
sometimes faith is not enough, and seeing or
reading anecdotal case studies are insufficient for
sound clinical decision making.
7
Viewed from a manufacturer’s perspective,
dental companies are keen to introduce novel
products and make profits, which indirectly
filter back to the profession in sponsorship for
educational symposia. Furthermore, research is
onerous, expensive and protracted, and by the
time the results are published, the product
may be obsolete, often replaced by a newer
version. This vicious cycle is then repeated and
perpetuated.
The scientific approach, although utopian,
hampers innovation and technological advance-
ment. Many new technologies have faced
problems before a reliable product eventually
emerges. Ultimately, it is the dentist, not the
manufacturer, who is responsible for clinical
decision making that impacts on patients’ treat-
ment. If things go wrong, the patient is unlikely
to blame the manufacturer for the failure. There-
fore, the onus is on the dentist to choose ap-
propriate materials, backed by evidence-based
research, to avoid rebuke or professional negli-
gence litigation in the event of failure. Evidence-
based treatment
8
is succinctly summarised as a
combination of (Fig. 1.8):
! Clinical erudition
! Sound scientific research
! Patients’ needs and wants
Treatment planning – assessment planning and treatment 7
Performing successful treatment is a combina-
tion of evidence-based information, clinical
judgement and personal experience. It is this
combination, rather than just one factor, which
ensures validity and successful outcomes. Each
factor requires scrutiny. Evidence-based infor-
mation relies on randomised clinical trials as the
gold standard, not merely a single anecdotal case
study relying on chance events. Clinical judge-
ment relies on reading appropriate literature and
attending reputable symposia. Finally, personal
experience, although invaluable, should not
shroud or bias decision making. What works for
one patient, is not a universal therapy for every
patient.
Choosing the most appropriate treatment for
a given clinical finding is influenced by the three
components of evidence-based therapy: clinical
erudition, sound scientific research and patients’
needs and wants. For any given predicament,
there are many solutions that yield the desired
result. However, each modality should be as-
sessed according to risks and, eventually, bene-
fits.
9
For example, an accidental fracture of the
maxillary incisor has the following treatment
options (Fig. 1.9):
(1) Restore with a direct composite filling:
! Benefits – minimally invasive, immedi-
ate, economical
! Risks – technique-sensitive bonding pro-
cedures, future staining of composite,
microleakage leading to endodontic
involvement and compromised aesthet-
ics, requiring replacement fillings and
possible root canal therapy (RCT)
(2) Restore with indirect ceramic prosthesis
(veneer or full coverage crown):
! Benefits – excellent aesthetics using an
all-ceramic restoration
! Risks – highly destructive, technique-
sensitive procedures, possible endodon-
tic involvement due to tooth preparation
trauma, use of a skilled (and therefore
costly) ceramist to match a single crown
with adjacent teeth, protracted, expen-
sive, porcelain fracture due to improper
clinical or laboratory protocols
(3) Extraction and immediate replacement with
endosseous implant and implant supported
crown:
! Benefits – immediate, avoids future
endodontic complications
! Risks – surgical involvement, possible
unpredictable soft and hard tissue
healing with compromised aesthetics,
use of a skilled (and therefore costly)
ceramist to match a single crown with
adjacent teeth, protracted, expensive
Patients’ needs and wants
Clinical
erudition
EB
treatment
Scientific
research
Figure 1.8 Components of evidence-based (EB) treatment. Figure 1.9 External trauma resulting in a fractured right
maxillary lateral incisor.
Performing successful treatment is a combina-
tion of evidence-based information, clinical
judgement and personal experience. It is this
combination, rather than just one factor, which
ensures validity and successful outcomes. Each
factor requires scrutiny. Evidence-based infor-
mation relies on randomised clinical trials as the
gold standard, not merely a single anecdotal case
study relying on chance events. Clinical judge-
ment relies on reading appropriate literature and
attending reputable symposia. Finally, personal
experience, although invaluable, should not
shroud or bias decision making. What works for
one patient, is not a universal therapy for every
patient.
Choosing the most appropriate treatment for
a given clinical finding is influenced by the three
components of evidence-based therapy: clinical
erudition, sound scientific research and patients’
needs and wants. For any given predicament,
there are many solutions that yield the desired
result. However, each modality should be as-
sessed according to risks and, eventually, bene-
fits.
9
For example, an accidental fracture of the
maxillary incisor has the following treatment
options (Fig. 1.9):
(1) Restore with a direct composite filling:
! Benefits – minimally invasive, immedi-
ate, economical
! Risks – technique-sensitive bonding pro-
cedures, future staining of composite,
microleakage leading to endodontic
involvement and compromised aesthet-
ics, requiring replacement fillings and
possible root canal therapy (RCT)
(2) Restore with indirect ceramic prosthesis
(veneer or full coverage crown):
! Benefits – excellent aesthetics using an
all-ceramic restoration
! Risks – highly destructive, technique-
sensitive procedures, possible endodon-
tic involvement due to tooth preparation
trauma, use of a skilled (and therefore
costly) ceramist to match a single crown
with adjacent teeth, protracted, expen-
sive, porcelain fracture due to improper
clinical or laboratory protocols
(3) Extraction and immediate replacement with
endosseous implant and implant supported
crown:
! Benefits – immediate, avoids future
endodontic complications
! Risks – surgical involvement, possible
unpredictable soft and hard tissue
healing with compromised aesthetics,
use of a skilled (and therefore costly)
ceramist to match a single crown with
adjacent teeth, protracted, expensive
Patients’ needs and wants
Clinical
erudition
EB
treatment
Scientific
research
Figure 1.8 Components of evidence-based (EB) treatment. Figure 1.9 External trauma resulting in a fractured right
maxillary lateral incisor.
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