Just as it takes a team to win a football game, it takes a concerted approach to provide consistent quality care in the dental office.

Risk management and patient safety can be thought of as a football team: every team consists of offensive and defensive players; each player possessing a unique set of skills practiced and honed throughout the season. A recent seminar attendee described his office manager as his team’s quarterback, “Nothing happens around here without her—she keeps the schedules, calls the plays, and helps us have a winning day.”

Here are five strategies you can use to improve your quality and safety initiatives (and score big points with your patients):

1. Recruit the Right Players
Hire Smart. Anyone can look good on paper or on a resume, but this is not necessarily indicative of their skills or ability to work well with others. Besides validating references, take it a step further by verifying licensure credentials by checking with the state licensing board. There have been documented cases of identity theft involving imposters who posed as dental professionals.

2. Conditioning/Learning from Others
Once you have the right players in place, continue to learn new plays and strategies. Take into account patient safety and risk management expertise outside the field of dentistry. This body of knowledge can help you condition your team and identify areas for improvement. For example, results of a study conducted in 2000 by the American Academy of Family Practitioners showed 44% of errors in physician offices were attributed to communication and discontinuity of care. These types of errors can easily occur in a dental office. Why not consider implementing a blame-free environment that encourages staff to report errors and near misses.

3. Practice/Training
Train your team well. Training shortcuts will quickly become evident once your team shows up on the field. Often training is done in a ‘trial by fire’ method—new staff members are shown the ropes while seeing patients. Of course, the new staff member can’t absorb everything thoroughly much less understand the mission, vision and philosophy of the practice through this haphazard method.

Hygienists, assistants and business staff make up more than ¾ of the dental industry, and these staff members are doing most of the interacting with patients. With a thorough training and orientation program your staff will become good spokespeople on your behalf, ready to provide quality care in a safe manner once the game begins.

4. Game On!
The excitement is in the air! Our game is on when the patient is sitting in the chair. Just like a football team, we have an offense and a defense; however we have to play both roles (no wonder our feet hurt so much!). While patient safety and risk management are on the same team; patient safety can be likened to an offensive strategy, whereas risk management is more defensive in nature. Here is a brief snapshot of how the roles play out:

Offense (Patient Safety): The foundation of all dental care is patient safety, so naturally this is your offense. While dental procedures don’t typically involve life and death surgery, we are performing procedures and/or administering medications that affect a patient’s total body health and safety. As compared to risk management, the dental patient safety movement is still in its infancy. Currently, most patient safety information is from the hospital environment, although the body of knowledge about patient safety in other settings like dental offices is growing steadily.
Defense (Risk Management): Risk management has always been a concern for dental practices and with our litigious society the hazards increase every year. Even if a practitioner is never involved in a lawsuit, the number of complaints filed with the dental boards is on the rise. An investigation by the dental board that results in probable cause and subsequent sanctions can easily cost $10,000 or more. Tangible losses include lost production and legal expenses as well as fines and penalties paid to the board. On-going, up-to-date risk prevention practices are the best approach.

5. Stats/Recordkeeping
While most of us don’t have a Jumbotron™ in the office to track every play, we can set benchmarks for recordkeeping success. Remember, the quality of your work is judged by your written word (patient chart), which is all dental boards have to rely on in disciplinary cases. Here are three quick tips to make sure your stats are reliable:

• Stay alert to recordkeeping techniques whether electronic or paper. Remember if you are frequently making corrections, it may be a sign that you aren’t mentally engaged with the process at hand. Follow a logical sequence (e.g. SOAP) when documenting to keep you mentally on task and minimize opportunities for forgetting key information.

• Focus on your choice of words and intent before putting it to paper or computer. Poorly phrased entries will be interpreted quite differently by an attorney or peer review panel. Read and re-read what you wrote. This doesn’t sound like a short-cut but it saves time from making corrections and finding problematic errors down the road that could make you appear negligent.

• Don’t wait to document. Do it during or at the end of each patient appointment as needed. In disciplinary cases dentists are commonly charged with simple documentation errors, such as failing to document an adequate medical history. Contemporaneous documentation ensures that critical patient care information is not omitted.

Follow these tips to ensure your team always has a winning season.

Linda Harvey, RDH, MS
As a licensed healthcare risk manager and experienced dental professional, Linda Harvey teaches dental teams how to leverage teamwork to reduce risk, promote safety and reach results while enjoying dentistry. Her courses are approved by the Florida Board of Dentistry for disciplinary cases. She works with private practices as well as facilities that are AAAHC and JCAHO accredited. To obtain sample Dental Risk Prevention for Auxiliaries pages, or for information on in-office training or seminars email Linda@dentalriskprevention.com or call 904-573-2232.

Who doesn’t want to have a million-dollar practice? Is that a goal at the top of your list or have you already reached million-dollar status? Regardless of whether you are already there or still working toward that goal, this chapter teaches you how to leverage risk management and patient safety to help you achieve and/or maintain your million- dollar practice.

Dentistry has experienced significant changes in recent decades that have dramatically impacted the delivery of care to our patients. New communication and technology tools offer exciting advancements for patient care, but they also present new risks.

The single biggest fear of any licensed healthcare practitioner is being sued by a patient. But in reality, that is but one of the many risks you face, and when the worst happens, it is often the result of entirely preventable missteps along the way. These very missteps create cracks in the foundation of your practice that little by little erode precious time, energy, and finances until the foundation begins to crumble.

Building a solid foundation for your million-dollar practice

The cornerstone of your practice was put in place during dental school, where you received extensive training in the clinical aspects of dentistry and perhaps even furthered your education by specializing. While dental school prepared you to enter the clinical world of dentistry, after that, it was up to you to enhance and refine your skills level and develop business acumen.

Designing and building a risk-proof practice doesn’t happen overnight. It begins with a clear vision of what you hope to accomplish. With your vision in place, you begin with site selection, proceed to develop a set of well-designed blueprints, and finally secure a top-notch builder to direct each detail of the building process.

As much as you’d like to be done with it, we all know the building process doesn’t stop once you move in. Ongoing maintenance, periodic performance checks, and routine updates must be performed regularly to protect your investment and keep the office running smoothly. There’s still much work that lies ahead.

Do the details of running a million-dollar practice keep you awake at night as you ponder how you will grow and protect this valuable asset? Perhaps you have missed the obvious answer–that is, utilizing risk management as a core operational function to tie all the other vital clinical, business, and financial functions of your practice together.

Traditional view of risk management

In the traditional view of risk management, risks or loss exposures were grouped into four broad categories: property, personnel, liability, and net income. Early risk management strategies employed to protect these loss exposures were insurance driven, focusing upon different types of insurance coverage in an attempt to fully or partially transfer risk. Many dentists still rely heavily on conventional measures to protect assets.

Traditionally, the principles of risk management presented defensive strategies to guard against loss exposures, associating claims reduction and dollars saved versus people (patients or staff) and safety. Even though, risk management has always encompassed risk reduction strategies, the primary focus was how to avoid being sued.

More than ever it is evident that none of the risks you face are isolated. In fact, they are quite interwoven. The reality is that, even if a practitioner is never involved in a lawsuit, the number of complaints filed with dental boards is on the rise. One complaint filed with the dental board can easily cost you as much as $10,000, which may not be covered by your professional liability policy.

How do you view risk management in your practice? Is it a necessary evil? Something you put into place initially and think about only when you take a required course? Ask yourself, “Is risk management in my practice primarily insurance-based or reactive, or is it well built into the infrastructure of the practice?”

New view of risk management

Just as it is impractical to think the systems and processes of old can propel us toward our desired results, it is impractical to think the old view of risk management can serve us well today.

The new view recognizes that the best defense is a good offense. Successful dental offices are strategically and proactively integrating risk management throughout hiring, team building, financial planning, communication, and documentation practices. Risk management begins in the planning stage and should remain integrated into your systems and processes.

As new risks have emerged, conventional approaches to risk management no longer meet all of our needs. Events such as Y2K, 9/11, the Health Insurance Portability and Accountability Act (HIPAA), and other new regulations along with research and technology-based changes have created the need to reassess and redefine risk. These changes paved the way for Enterprise Risk Management (ERM), a progressive approach to risk management that incorporates traditional loss exposures, yet is significantly more comprehensive. ERM categorizes risks into six areas known as risk domains:
Operational. Risks resulting from your core business practices including clinical risk. This category includes all the critical operational aspects of your practice, such as patient records, coding and billing practices, and office policies and procedures.

Financial. Risks associated with the ability of your practice to make money and remain fiscally sound. What do your monthly, quarterly, and yearly financial reports tell you? Have you identified any trends regarding overhead, billing, or collections that need attention?
Human capital. Risks related to your staff, encompassing recruitment, training and maintenance of these individuals. With an ever-changing workforce, employee-related risks continue to grow. Consider possible employee-related risks ranging from property or identity theft to embezzlement or employment-related lawsuits within your practice.

Strategic. Risks associated with external events and trends that can impact the growth and value of your practice. Does what is happening on Wall Street affect your practice? How? What about trends in your local dental community?

Legal and Regulatory. Risks associated with state and federal rules, regulations, and statutes affecting dentistry. If an auditor, state regulator, or federal agent appeared at your doorstep, is your documentation up-to-date? How will you prove you are in compliance?

Technology. Risks resulting from rapidly evolving technologies and equipment, biomedical products, computers, or teledentistry. Is newer always better? Consider the impact that new piece of equipment or software will have on your practice (beyond the bottom line). Poorly maintained and operated equipment can provide a costly lesson. In the case of electronic equipment and devices, security measures must be addressed.
Risks, however, don’t necessarily exist in isolation from one another; the domains of ERM are flexible, so any given risk may exist in one or more domain. As you identify, evaluate, and select new products and equipment for your practice, you must continually identify, evaluate, and protect your practice from risk.

Key trends that are driving change

Two key trends are driving the changes we have witnessed in risk management.

The first is the patient safety movement, based on the documented medical errors crisis in our healthcare system. According to a national poll conducted by the National Patient Safety Foundation in 1997, 42 percent of the respondents believed they had been affected by a medical mistake either personally or through the experience of a relative or friend. This trend indicates the systems and processes we have had in place for both risk management and patient safety have not met the needs of patients or practitioners.

Compared with our medical counterparts, accidents, errors, and injuries are less frequent and severe in dentistry. Still, patient safety is equally important in dentistry.

All healthcare practitioners, including dental professionals, are encouraged to evaluate patient safety throughout our practice beginning with the culture of our practice. The culture of a practice (beliefs and norms of behavior) ultimately drives your risk management and patient safety endeavors. Is developing a culture of safety a priority in your practice?

A second key trend is an increased emphasis on communication dynamics and recordkeeping. All practitioners keep records, whether in written or electronic format, but the quality of the records varies widely. It is possible to write volumes of notes that may be lacking in quality, and thus, what is written could be legally unacceptable.

In the past we may have asked where is the documentation, is the informed consent signed, and are charts written up? Now, we must look beyond the fact of actually having documentation to the quality of the documentation and the quality of the communication behind the documentation.
Four simple steps for protecting your million-dollar practice

Protecting your assets, reputation, and, above all, your entire livelihood, is paramount. The four steps listed below form a blueprint for success formula known as“3R2”™, i.e., Reduce Risk + Refine Relationships = Reach Results. Just as reading, ‘riting and ‘rithmetic are the basics of elementary school learning, this elementary formula transcends the risk domains as well.

Think of risk management proactively. One of the foremost benefits of risk management is the ability to proactively identify vulnerable habits and practices. When you know how to identify vulnerabilities, you can mitigate situations before they lead to errors or result in litigation or a complaint to the dental board. Start by identifying the assets you wish to protect and the associated risks. See Figure 1 for a sample worksheet that will enable you to assess the risks you identify in each of the risk domains. First, assign a severity rating across the top of the worksheet. Next, assign a frequency rating in each column. Risks that are the most severe, with a high rate of frequency, require immediate attention. Risks that occur frequently but are not as severe must be evaluated based upon the nature of the risk, the potential cost of the risk, and the cost to remedy the risk. Incorporate this exercise along with your regular practice management assessments.

Hire right and train well. The value of thorough and consistent hiring practices must not be underrated. Don’t cut corners on hiring practices or staff training. Too often, reference and background checks are skipped and training is done in a trial by fire method. New staff is shown the ropes while seeing patients. Of course, the new staff member can’t absorb everything thoroughly and understand the mission, vision, and philosophy of the practice through this haphazard method. When it comes to hiring and training, cutting corners erodes your risk management and patient safety foundation.

Patient safety in medicine places a strong focus on nurses because these individuals make up the bulk of the medical industry. The same is true in dentistry. Hygienists, assistants, and business staff make up more than 75 percent of the industry, and these staff members do most of the interacting with patients. What your staff say (or don’t say) or do (or don’t do) speaks volumes about the culture of your practice. Refine the relationships in your practice by ensuring that members of your staff are good spokespeople on behalf of quality care and patient safety.
Keep Proper Records. Challenges arise when unusual occurrences, incidents, or patient conversations are not recorded in a legally sound format. It is possible to write volumes of notes containing information that suggests you were negligent or provided substandard care. Beyond the patient care information, documentation needs to be tailored to address the circumstances and nature of the situation itself. See Side Bar #1 for a sample listing of words that in certain circumstances can imply substandard performance or blame.

Unprofessional comments and uncaring attitudes can quickly undermine risk management efforts in your office. Consider these general principles that may assist in the prevention or defense of litigation by reducing risk and refining relationships:

1. Do not document your frustration with or disapproval of difficult patients. Stick to the clinical facts and omit personal opinions about the patient.
2. Avoid expressions that imply a negative value judgment of the patient. Personal opinions lessen the value of your documentation and must not override the importance of capturing clinical data in an objective fashion.
3. Answer questions from patients and/or family members in a serious manner. Flippant or inadequate answers that disregard patient concerns leave an uncaring impression that can lead to the breakdown of the patient-provider relationship.

Know thyself. While we are all responsible and accountable for our own behavior, you are ultimately held accountable for your staff. We all have definable communication and behavioral skills and patterns. Once you take time to identify your patterns and preferences as well as those of your coworkers, staff, and patients, you will gain a new understanding of how to leverage the strengths of your staff to achieve risk management and safety goals.

All relationships and all communications involve choice. We have a choice in everything that we do. How do you choose to view risk, safety, relationships, and the results you desire in your practice? We can’t change other people; however, we are responsible for our communication styles and how we react to those of others.

Frequently, it is the fear of the unknown that keeps us from breaking out of the cycle of poor communication habits. When we choose not to change, we choose to remain stuck in our same patterns of communication and behavior because they feel normal and create some level of success (although it’s often a false sense of success).

Dentistry is practiced in an ever-changing environment; as products and technology change, so do the risks, either by increasing or decreasing. Now is the time to rethink how risk management is implemented and sustained in your practice. Positioning risk management as part of your foundation will help you protect your million-dollar practice and achieve the results you desire.

Figure 1

Risk Assessment Worksheet

Adapted from Head, GL and Horn, S. Essentials of Risk Management, Vol 1, 2nd Ed, 1991. Insurance Institute of America. Malvern, Pennsylvania.

Side Bar 1

Words to Avoid When Documenting

1. Ching, W.R.H. 2004. Enterprise Risk Management: Laying a broader framework for health care risk management. In R. Carroll, (Ed) Risk Management Handbook for Health Care Organizations, 4th Ed. (pgs. 3-14). San Francisco, California Jossey Bass.
2. Tennenhouse, DJ, Harvey, LM & Owens, JA. (2005). Dental Risk Prevention. Jacksonville, Florida: Horizon Consulting Group, Inc.

Linda Harvey, RDH, MS
As a licensed healthcare risk manager and experienced dental professional, Linda Harvey teaches dental teams how to leverage teamwork to reduce risk, promote safety and reach results while enjoying dentistry. Her courses are approved by the Florida Board of Dentistry for disciplinary cases. She works with private practices as well as facilities that are AAAHC and JCAHO accredited. To obtain sample Dental Risk Prevention for Auxiliaries pages, or for information on in-office training or seminars email Linda@dentalriskprevention.com or call 904-573-2232.

There’s been a famous dental debate in the last decade: whether the mercury in amalgam fillings is toxic. At one extreme are those of the opinion that amalgam causes everything from ME to Alzheimer’s; and in the other corner are the hardened “amalgophiles” who point to the biggest informal case study of a dental material in human history - the millions upon millions of people who live with amalgam in their mouths and have no noticable side effects. We dentists should continue to use amalgam, they say, because it cannot be proven that it has any adverse health effects. Unfortunately for these stalwarts, our Western societies are becoming ever obsessed with safety and most patients have a “but what if…” bug implanted in the back of their minds. The practical reality is that it it doesn’t matter if it actually does or not - it’s the uncertainty about it in the minds of the patients that affects the daily practice of dentistry most.

An amalgam restoration

There’s also the wave of increased awareness on the part of our patients that they have the right to ask questions. ” Do I really need to have my new filling done with amalgam?” Is one of the more common ones. Here’s a hypothesis: if we answered that question with, “You can choose between a white filling and an amalgam one… they will both last equally as well, take the same length of time to place and cost the same amount”, what’s the decision likely to be? Virtually nobody is going to choose an amalgam filling over a white one in those circumstances. The question then becomes, “DOES a white filling last equally well, take the same length of time to place and cost the same amount as an amalgam?” The conservatives would say, “NO! Porcelain costs a lot more and takes longer; composite leaks in deep ginigval margins; and glass ionomer doesn’t have good enough wear resistance!” All good points. Case closed?

Composite wears well but doesn’t bond to dentine…

Sure porcelain is expensive and takes longer; and even with Cerec it doesn’t approach the cost-effectiveness or convenience of amalgam. But look at composite and glass ionomer again: Composite has a problem with marginal leakage in deep interproximal and cervical areas because it doesn’t bond chemically with dentine. It also shrinks a little when it sets. And it needs a very dry environment. It IS possible to get a good seal with composite in a deep proximal box - but it’s very difficult and not realistic for the majority of dentists to achieve. Some big advances have been made with composite in recent years, but even with high filler content, fluoride release and self-etching primers, composite simply doesn’t achieve a good chemical bond with dentine, and dentine does not have the rigid prismatic structure to allow the micro-mechanical bonding that enamel does and which composite relies upon. However… modern composites DO have very good wear resistance, especially high-filler hybrids that have been designed for posterior teeth. I have a 2mm thick composite covering the incisal and palatal portions of my upper left canine because I ground about 1/3 of the tooth away through bruxing on it; and it’s been there for 3 years with no noticeable wear. It guides my occlusion on that side and the material is amazingly durable - if it’s supported well.

Glass Ionomer seals well but doesn’t have good wear resistance…

And what about Glass Ionomer? Again, recent years have seen big improvements in its durability, but if you do a big restoration that includes load-bearing areas it will wear pretty fast and that can result in undesirable tooth movement in the longer term. I wouldn’t want to use it to restore the surface of my canine! It’s also rather opaque and doesn’t look like enamel; actually, it has very similar optical characteristics to dentine which is undesirable for a visible restoration. BUT glass ionomer doesn’t shrink when it sets. It bonds very strongly to dentine with a chemical (as opposed to a mechanical) bond; it releases fluoride, buffers the pH in its vicinity and resists recurrent caries… exactly what’s needed to prevent leakage in a deep proximal box or cervical restoration.

One material’s weakness is the other’s strength!

So you gotta wonder… composite has great aesthetics and wear resistance, but doesn’t bond well and tends to leak in deep proximal and cervical areas. Glass ionomer bonds really well to dentine, doesn’t mind moisture and achieves a great result in deep areas, but has poor aesthetics and wear resistance. One material’s strength is the other’s weakness, and vice-versa. WHAT IF we could come up with a technique that gets the best of both materials!? Then we’d have a restoration that rivals amalgam for durability and cost effectiveness, and beats the #$%! out of it for aesthetics. Who in their right mind would choose to have an amalgam over one of those?

Composite / Glass Ionomer Hybrids

OK, well just to spice things up a bit more, let’s get really far-fetched. Amalgam stains dentine. And doesn’t support remaining cusps. In other words, it lasts well but the tooth gradually deteriorates around it (Note: I’m aware that it is possible to create tight, bonded amalgam restorations that are highly polished and don’t leak; but again we’re talking about what is realistic for the average dentist to achieve in an average appointment. The majority of amalgam restorations in the real world leak, stain the tooth and don’t support the remaining structure.) WHAT IF our new hybrid restoration was actually faster to place than amalgam, and also supported the remaining structure without dehydrating or staining it? If such a restoration was possible, it’d be a bit of no-brainer really. Well, in my opinion anyway.

And the amalgam debate would cease to be relevant.

Assuming that you agree with me, read on….

It’s not only possible to place such a restoration, it’s ridiculously easy…

Here are several basic principles: replace dentine with glass ionomer; replace enamel with composite; place all materials before any of them have set; apply pressure before the materials have set.

The handling properties of the composite and glass inomer are particularly important. You want a fairly viscous glass ionomer and a very low-viscosity composite that does not slump. You also need a compomer (a hybrid of glass ionomer and composite) to place between the two materials and bond them together. I use GC’s Fuji IX for the glass ionomer; FUJI LC for the compomer and Filtec P60 for the composite. P60 is very firm to handle (a bit strange when you first use it) which is ideal for this technique.

I’ll use an MOD in a lower 4 as an example since it has deep proximal areas, occlusal load-bearing areas and a need for good aesthetics. I’ll also overlay the cusps to illustrate a couple of trimming techniques. The prep is important but not terribly special. You just have to make sure that all your internal line angles are rounded (use a round bur to prepare them…) and that the cavity margins are bevelled. I use a slow-speed round bur to finish the interior of the cavity (the concave bits) and a fine tapered high-speed diamond to finish the cavity margins (the convex bits). You want smooth, continuous curves - NOT sharp angles.

Now you need a matrix. A degree of skill is involved in placing the matrix well, and I’m not going to try to give pointers on that here. We will assume you have some good techniques for placing matrices… the only stipulation is that it has to be have a curved shape and preferably be made of clear plastic. Make sure you wedge it well, and don’t blame the materials for the resulting periodontal problems if you create overhangs!

Once the matrix is in place, check that it contacts the adjacent teeth firmly (consider a contact matrix and bi-tine ring if it doesn’t) and that it’s higher than the marginal ridges of the teeth next door. You don’t want the composite to flow over it and stick to the neighbours!

Etch the whole cavity, but only for 10 seconds

The placement of the restoration is really fast, and requires good co-ordination between the dentist and assistant. I strongly suggest practicing it a few times on an extracted tooth or similar to get it fine-tuned before using it on patients.

The materials are prepared in the reverse order to that in which they are placed. So first, cut off a piece of composite with a spatula and pat it into approximately the shape of the cavity with your fingers (clean, powderless gloves essential, preferably vinyl) For an MOD, I’d roll it into a small sausage, then squeeze it into an elongated pancake, and then bend the ends of the pancake around my thumbnail to give it a magnet shape which will fit into the cavity. It takes a bit of practice to estimate the amount of composite and shape it right, but it’s not difficult.

Shaping the composite into an “inlay”

Now pick up the composite carefully with college tweezers. Don’t squash it. When you open them, it’ll cling to one of the beaks. Lie them on the tray with the beaks upwards so that the composite is ready to go into the cavity.

The composite will hold on to the beak of the tweezers

Next the assistant mixes the compomer and hands it to you on a pad with a microbrush. Then (s)he immediately mixes the glass ionomer and hands it to you in a syringe. You apply the glass ionomer to the floor of the cavity, about 1-2mm thick. Don’t overdo it or you’ll end up with a mess. Again, practice it first on an extracted tooth to get a feel for the right amount. You really just want to cover the floor of the cavity.

Applying the glass ionomer

Pass back the glass ionomer applicator and pick up the microbrush. Paint the compomer over the glass ionomer and the entire surface of the cavity. You can do it quickly, as long as the coating is even and coverage is complete it doesn’t require too much finesse. Try not to push the microbrush into the glass ionomer though!

Paint on the compomer

Drop the microbrush and pick up the tweezers, and place the unset composite “inlay” into the cavity. If you estimated the shape right, the two bent bits will fit into the proximal boxes and the composite will fill the rest of the cavity with little glass ionomer visible.

Place the “inlay” in the cavity. Note that the composite is still not cured!

Now this bit is important: place a thumb or finger over the matrix and apply gentle but firm pressure to the composite, and keep the pressure on for a few seconds. This causes the composite to acts like a plunger and force the glass ionomer into all the nooks and crannies, so there will be no air bubbles or porosities when you remove the matrix band.

Applying digital pressure

If you use a transparent band you can check that the visible margins are free of bubbles; if not, apply more pressure. If necessary, you can burnish the composite to remove any excess glass ionomer that has extruded from the margins; wipe the burnisher after each stroke to avoid plunging GIC from the burnisher into the composite on the next stroke.

Now you have a little time to shape the occlusal surface. Use a flat plastic to simultaneously create cusps, planes and fissures; marginal ridges will result automatically. Use a large ball burnisher to reduce the marginal ridges to the same height as their neighbours, and give some thought as to how high you want the cusps to be. It’s not critical that you finish this part before the glass ionomer sets, but it is preferable. I dip the instruments in a very small amount of unfilled resin to improve their ability to slide over the surface. Try to use as few strokes as possible to create the shape you want, if you can create each cusp plane with a single final stroke it will not require polishing.

Work up the occlusal surface with a flat plastic

Check that the contacts with the adjacent teeth are good (they should be if you placed the matrix well), grab the curing light and cure the whole restoration. I usually give it 10 seconds from each of the occlusal, lingual and buccal angles.

You don’t need to wait any longer; the glass ionomer will be set by now and you can remove the matrix as soon as you’ve finished curing. I leave the wedges in place until I’m completely finished to avoid any bleeding while I’m trimming the restoration.

The matrix is ready to remove immediately after curing

Next, grab a diamond bur and trim the excess away from the lingual and buccal sides. It shouldn’t take much if you’ve estimated the amounts of your materials well. Stop short of touching the enamel with the bur (if you can see the difference between the enamel and the composite!). Then use a sof-lex disc to finish trimming the margins. You should not need to trim near the gingivae if you have placed your matrix and applied the materials and pressure well. Unless there is a notable irregularity or overhang, don’t trim.

Trimming with a sof-lex disc

The restoration does NOT have to have a butt margin with the tooth. It can be feathered, the glass ionomer bonds extremely well with dentine, especially when pressure has been applied before setting.

So now you just have to check the occlusion with some bite paper and adjust. I use an ordinary cylindrical diamond to reduce cusp tips and planes, and a rugby-ball shaped diamond to reduce marginal ridges. Make your fissures reasonably deep and the adjustment should rarely extend to them.

Finally, polish any surfaces that you’ve adjusted. Usually the marginal ridges, occlusal contact planes and the lingual and buccal margins are the only areas that need polishing, and they are conveniently the most accessible. I use a fine plastic polishing strip to finish the proximal surfaces.

Polishing should be easy

One point of note - most of the trimming will be in composite and you can trim without water; but with a cusp restoration or other restorations where you might trim glass ionomer around the margins, be sure to keep it wet. Glass ionomer actually wears well on lateral surfaces, but it does not like to be dehydrated! Cover it with a thin layer of unfilled resin wherever it is exposed once you have finished with it.

The finished restoration

And there you have it: a restoration that looks great, has great wear resistance, great caries resistance, great marginal seal, great support for the remaining tooth structure, that won’t stain the tooth and that doesn’t have any mercury in it (which matters to the patient even if not to you!) In short, it’s a great restoration - and it’s faster to do and at least as cost effective as an amalgam. In my opinion that makes the amalgam debate a big waste of time.

How the restoration should look (ideally) in cross section

How the restoration really looks in cross section.
Note the similarity in appearance of the secondary dentine (arrow) to the glass ionomer.

Welcome to Dental Discussion!

This is a new community for dentists, dental students and anyone interested in becoming a dentist.

We’re working on some great educational content for you but in the meantime, check out our brand new Discussion Forum.