Ensuring Beautiful and Healthy Smiles

Esthetic dentistry is a growing facet of the oral health care field as patients desire more attractive and functional smiles. Ronald E. Goldstein, DDS, an esthetic dentist with more than 50 years of experience in practice, education, and publishing, shares his thoughts on the important contributions dental hygienists make in this setting, and how they can help their patients achieve successful outcomes in restorative and esthetic therapy.

The shape of some esthetic restorations create conditions like ridge-lap, tight contacts, and open embrasures, which can interfere with oral hygiene. When this occurs, dental hygienists need to counsel their patients on special oral hygiene techniques to manage these areas. What should clinicians watch for over time?

If the restoration is in part or wholly preventing the patient from adequately cleaning the area, the dental hygienist will need to collaborate with the dentist to find a solution. For instance, if the cause is an overcontoured restoration impinging on the gingival papilla, then either an intraoral photo or radiograph will demonstrate the problem. Based on this visual information, the dental hygienist can begin a dialogue with the dentist to see if he or she can reshape the restoration in the gingival area in order to reduce tissue inflammation. Contouring restorations can be challenging because the tissue may be somewhat retracted at the time of insertion or it may have been inflamed due to an ill-fitting temporary, which adds difficulty to the decision of how thick the gingival contours should be. If the dentist’s poor restorative results are a chronic problem, however, then the dental hygienist may want to suggest that the prosthetics produced by the laboratory are the issue. I have discussed this problem with laboratories, both large and small, and they almost always cite lack of sufficient information from the dentist as the cause for ill-fitting prosthetics.

Improperly fitted restorations can result in stained margins, caries, and periodontal diseases. Dental hygienists should feel comfortable asking dentists to check the margin on a specific tooth to see if it can be improved. This type of discussion, however, should occur in private. A disagreement in front of a patient could be uncomfortable for all parties.

When patients are undergoing orthodontic treatment in advance of esthetic restorative treatment plans, how can dental hygienists best support the final outcome?

After patients receive an interdisciplinary treatment plan where orthodontics may be the second step following hygiene treatment, they tend to forget the planned final restorative treatment. Dental hygienists are responsible for reinforcing the ensuing restorative treatment, whether it will consist of minor adjustments or major procedures. The reason for this is to help patients obtain the best esthetic and functional results possible. Following orthodontic treatment, patients look in the mirror and see a much improved smile. They may be unaware of just how much better they can look after the final esthetic therapy is completed. Even though orthodontists refer patients back to restorative dentists, patients may not schedule the post-orthodontic consultation. But with constant reinforcement from dental hygienists at recare visits during orthodontic treatment, there is a much better chance patients will follow through.

What role do you think dental hygienists should play in helping dentists better understand the type of patient they will be seeing?

Every member of the dental team should help the dentist decide how to best approach patients, especially new ones. Even more important, team members should consider whether a new patient is a good fit for their office or if a referral would be more appropriate. Dental hygienists typically have a unique relationship with patients, and their insight is invaluable.

Dental hygienists also play a dental psychologist role, which can be crucial when treating patients who have not cared for their mouths in the past. Dental hygienists can help determine the reasons for patients’ disregard of their oral health. Does fear play a role, and, if so, why? Is it lack of time for oral hygiene, or is the patient unaware of the intimate relationship between oral and systemic health? Frankly, if this problem is not solved early in treatment, there will be a much shorter life expectancy for the final restorative treatment. Few dentists spend the necessary time to impress upon patients just how long restorative treatment will last, but dental hygienists have the benefit of consistently seeing their patients and discovering how self-care must be improved to protect patients’ investments. Moreover, dental hygienists can find out why patients are more stressed than normal. Dentists depend on dental hygienists to advise them of special circumstances, such as the loss of a loved one or a job, that may affect treatment and patients’ oral health.

What is on the horizon for esthetic dentistry?

Esthetic dentistry has changed so much during the past decade, especially in the area of technology. New scanners and computer-aided design/computer-aided manufacturing technologies are helping us create more patient-friendly solutions to problems like impression taking, where soft materials can gag patients. I just treated a patient who had put off addressing a lingual caries lesion on a bicuspid for 4 years because she was so afraid of the needle injection. We used a painless dental injection system to administer the anesthesia and she was fine.

Diagnostics now play such an important role both for dentists and dental hygienists. Although the intraoral camera has been around for several decades, it took some time for many practices to get on board. Our office was an early adapter of this technology. We have intraoral cameras in each of the operatories, which makes it easy for dental hygienists to take good close-up photos of any area that may need attention—both for the dentist to view during the exam and for the patient to understand what may be a problem. By using this technology, dental hygienists can play a meaningful role in helping guide patient outcomes.

I also like the laser caries diagnostic instruments, especially for pit and fissure caries discovery. We have one in the hygiene department, so a stained pit or fissure can be measured after prophylaxis. This has helped make minimally invasive restorative techniques possible. Cone-beam technology is becoming more useful to diagnose hidden causes of pain not seen in two-dimensional X-rays.

As far as esthetic techniques, the minimally invasive tooth preparation for porcelain veneers has become one of the most popular procedures for both dentists and patients, when possible. Also, the use of clear aligners in orthodontic treatment has transformed the treatment of malocclusion for adults. By understanding the benefits of the new and now-proven techniques available in restorative dentistry, dental hygienists can play an important role in patient education and supporting successful outcomes.

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From Dimensions of Dental Hygiene. March 2014;12(3):18,20.