Clinical Protocol Manual For Fixed Prosthodontics

October, 2002

1. Clinical Objectives in Fixed Prosthodontics
2. Clinical Competency
3. Clinical Requirements
4. Procedural Requirements
5. Grading Criteria
6. The Evaluation Crown Procedure
7. General Information

The educational objectives of your clinical Prosthodontics experiences are:

1. To prepare you for the clinical management of missing or defective teeth by providing:
   1. Fundamental background material essential to adequate diagnosis and treatment planning
   2. An opportunity to develop basic clinical skills in fixed prosthodontics through the clinical application of scientifically based treatment concepts and techniques.
2. To successfully integrate those treatment concepts and techniques into those of related clinical dental specialties such that you can most effectively render basic care to your patients.
3. To foster and promote an attitude of professionalism, and encourage a sense of responsibility in the delivery of prosthodontic care.
4. To achieve these objectives, you are expected to achieve the following goals:
   1. To obtain accurate diagnostic information for your patient prior to the initiation of treatment.
   2. To prescribe and provide restorative care in a logically and properly organized sequence.
   3. To provide foundation restorations for both vital and non-vital teeth.
   4. To restore missing and/or defective teeth to appropriate form, function, and esthetics, while maintaining the integrity of the pulp and periodontal tissues.
   5. To provide individual metal, porcelain-fused-to-metal (PFM), and all-ceramic restorations for both anterior and posterior teeth when indicated.
   6. To provide fixed partial dentures (FPD's) to replace one or more missing teeth, utilizing metal, PFM, or all-ceramic materials when indicated.
   7. To understand the appropriate application of single or multiple tooth dental implants for replacing missing teeth.
   8. To demonstrate knowledge and skill in applying occlusal concepts when restoring teeth with crowns, fixed partial dentures and implants.
   9. To demonstrate basic knowledge in the selection and utilization of appropriate materials, instruments, and therapeutic agents.

The ultimate requirement for graduation is that you demonstrate clinical competency. This implies that, in a sample of patients of reasonable complexity, you can demonstrate an understanding of the patient's problem, the knowledge to prescribe a valid and properly sequenced plan of care (treatment plan), and the clinical skills required to complete treatment for your assigned patients.

1. A total of 16 units, with a minimum of 10 natural tooth preparations, are required by the end of the fourth year as a minimum basis for determining clinical competency in fixed prosthodontics. A minimum grade of C must be achieved for each unit completed. A "unit" is defined as:
   1. A single tooth crown (full cast gold, ¾ cast gold, all-ceramic, or PFM)
   2. A retainer for a conventional FPD
   3. A pontic
   4. Two (2) resin bonded FPD retainers
   5. A custom cast dowel/core (maximum of two (2) units toward the 16 unit requirement)
   6. A crown or retainer placed on an implant
   
   

   Failure to complete the 16 unit/10 preparation minimum by the end of the fourth year will necessitate your return to clinics for subsequent patient care following the fourth year.

2. Third year students are required to complete five (5) units composed of a minimum of three (3) restored natural tooth preparations by the end of the summer term. Failure to satisfy this unit/preparation requirement will result in a grade of INCOMPLETE. According to University policy, failure to remove a grade of INCOMPLETE by the end of the following semester will result in a grade of "F".

   NOTE: Any unit for which a daily or final grade or "F" is rendered will not be counted toward the 16 unit/10 preparation minimum requirement. In addition, any unit for which a cumulative grade of "D" is rendered will not count toward the 16 unit/10 preparation minimum requirement.

1. You are required to complete, within your family of patients, the following procedures:
   1. One FPD of conventional design. This does NOT include implant supported prostheses, or resin bonded prostheses.
   2. An evaluation crown procedure (see section VI below).
   3. Ten natural tooth preparations.
   4. All model and die work associated with PFM crowns, all-ceramic crowns and all FPD's.

Examples:

1 3-unit FPD (2 natural tooth preparations), 8 Crowns (8 natural tooth preparations) = 11 units and 10 preps.  Student would need 5 more units which could be 2 cast post/cores + 2 implants + evaluation crown, or any other combination of 5 units which included the evaluation crown.

2 3-unit FPD’s (4 natural tooth preparations), 6 Crowns (6 natural tooth preparations, evaluation crown (1 natural tooth preparation) = 13 units and 11 preps.  Student would need 3 more units.

1 3-unit FPD (2 natural tooth preparations), 6 Crowns (6 natural tooth preparations), 7 Implants = 16 units and 8 preparations.  Student would need 2 more natural tooth preparations, of which, one would have to be an evaluation crown.

NOTE:  All implant prostheses, FPD's and RPD survey crowns must to be supervised by faculty in the Fixed Prosthodontic Clinic (or Implant Clinic, as appropriate).  All other full veneer indirect restorations (crowns) and all foundations may be performed in either the Fixed Prosthodontic Clinic or the Comprehensive Care Clinic.

1. For any fixed prosthodontic procedure, the following clinical outcomes will result in a grade of "F".
   1. Failure to detect remaining caries on a prepared tooth.
   2. A mechanical exposure of the pulp.
   3. Damage to the adjacent tooth or teeth, which would necessitate a change in contour of the adjacent tooth or teeth.
   4. Failure to extend beyond existing foundation, caries, restorative material, or abrasion areas, by a minimum of 1.0 mm onto sound tooth structure.
   5. Damage to the periodontium during tooth preparation, retraction cord placement, impression procedures, or through delivery of an inappropriate provisional restoration.
   6. Failure to detect an open margin on a prosthesis prior to permanent cementation.
   7. Failure to detect an open proximal contact prior to permanent cementation.
   8. Failure to detect occlusal discrepancies (hyper-, infra-occlusion, or non-functional contacts) prior to permanent cementation.
   9. Failure to properly diagnose the need for periodontal crown extension surgery or endodontic therapy prior to initiation of tooth preparation.
   10. "Excessive preparation of the tooth", necessitating root canal therapy, periodontal intervention, or extraction.
   11. Failure to completely remove temporary or permanent luting agents after cementation.

The purpose of the evaluation crown is to allow you to assess you performance, and to work independently while allowing the faculty to evaluate your clinical competence in fixed prosthodontics.

1. The following are requirements for challenging the evaluation crown procedure:
   1. You must satisfactorily complete a minimum of five (5) definitive crown preparations and subsequently cement the final prostheses prior to initiating the evaluation crown procedure.
   2. You must complete the evaluation crown with a minimum grade of "C".
   3. You must complete the evaluation crown procedure in a maximum of:
      1. four (4) appointments for a gold crown, or
      2. five (5) appointments for a PFM or all-ceramic crown.
   4. Failure to meet the time requirements will result in a grade of "F" for the evaluation crown procedure, no unit credit, and will require that you clinically complete that crown prior to initiation of a subsequent evaluation procedure.
   5. Failure of two evaluation procedures, for any reason, will require that the Department faculty provide remediation to you prior to the initiation of a subsequent evaluation procedure. This remediation will be prescribed by the Department Chair in consultation with the Department faculty.
2. Grading Criteria:
   1. The grading criteria outlined in Section V.1. will be used to assess your competence during the evaluation procedure.
   2. Evaluations will be made by only full-time, clinical faculty, (including the Teaching Fellow) according to the published Quality Evaluation Criteria for Evaluation Crown Preparations and Restorations, after the student has performed their own self-evaluation. When appropriate, the clinical faculty member monitoring the Evaluation Crown may request a second faculty member to assist in the evaluation procedure.

   Using the categories in the Quality Evaluation Criteria for Evaluation Crown Preparations and Restorations Grading Sheets, grades will be determined by the following guidelines:

3. Guidelines:
   1. Tooth Selection: The tooth selected for the evaluation procedure must exhibit the following characteristics:
      1. There must be at least one proximal contact
      2. There must be an opposing natural or restored tooth (or teeth) or FPD such that appropriate occlusion can be developed for the proposed restoration. Opposing RPD’s or CD’s are not acceptable.
      3. The tooth selected may NOT be one of multiple consecutive teeth prepared for crowns (example: teeth 7, 8, 9, and 10 are to be crowned) UNLESS the prepared tooth meets the other criteria noted above (must have an adjacent natural tooth not involved with the preparations).
      4. If a FPD is selected, all abutment teeth are to be evaluated.

Clinical/Laboratory Requirements for the Evaluation Crown:

You are required to complete all model and die work for each evaluation crown:

1. Evaluator Assignment:

   Only full time faculty, including the Teaching Fellow, in the Department of Prosthodontics may serve as evaluators. Prior to the beginning of each semester, a list of evaluators, along with their clinic schedule, will be provided for the appropriate Clinical Affairs personnel. It is recommended that once an evaluator has been selected, you complete all exercises with that faculty. The Clinical Affairs staff will honor, to the best of their abilities, your request for evaluator sign-up.

2. Clinical Steps to be Evaluated:

   The following clinical end points are to be checked by the attending evaluator prior to your continuing treatment:

   1. Completed treatment plan, informed consent document, and diagnostic information
   2. Initial tooth preparation and provisional restoration
   3. Final tooth preparation immediately prior to impression
   4. Final provisional restoration prior to dismissing patient
   5. Final crown or FPD ready to cement
   6. Final restoration following cement removal

   Prior to initiating an evaluation procedure, you should be fully prepared to describe the rationale for placement of a crown, how the treatment relates to the overall plan of care, the current periodontal, pulpal, and occlusal status of the tooth to be crowned, the type and design of the proposed prosthesis, and any special problems and considerations the attending faculty should be aware of. A daily grade of "N" will be entered into the computerized student grading system, and will be identified by the attending faculty as an evaluation procedure.

Evaluation Form:

You should obtain an evaluation form with given grading criteria prior to initiating the evaluation crown. This form can be obtained from the clinical staff dental assistants, and will remain in the patient record until completion of the procedure. The form allows both you and the evaluator to assess your daily progress in this procedure.

In addition, the yellow crown and bridge card must be obtained, and half of the payment secured, prior to crown initiation. This form may be obtained from the Prosthodontics Dispensary staff.

1. Clinic Hours:
   1. Morning clinic hours: 10:00 a.m. - 12:30 p.m.
   2. Afternoon clinic hours: 2:00 p.m. - 4:30 p.m.
   3. Failure to have patients dismissed by these times may result in a reduction in the daily procedure grade.
2. General Operating Guidelines:
   1. The patient's record is required for any procedure to be performed in the Prosthodontics clinic
   2. Appropriate diagnostic records are required during patient treatment. These include:
      1. Signed and appropriately sequenced treatment plan
      2. Patient's record
      3. Signed informed consent document
      4. Mounted diagnostic casts, with diagnostic waxing and/or RPD survey/design are required for all cases.
      5. Prior to initiation of tooth preparation a yellow Departmental procedure card and blue DxTP form must be obtained.
      6. Final impressions for fixed pros preparations will not be allowed until a provisional restoration is completed. i.e. occluded, contoured, polished, and checked by your instructor as ready to cement. Dental assistants will not mix impression material until authorized by the faculty.
   3. If fixed prosthodontic procedures are initiated on a patient, you will be required to complete those procedures.  Transfer of patients with provisional restorations will not be allowed without authorization by the Chair of the Department of Prosthodontics. Prior to any transfers, the patient should be seen for evaluation of the provisional restoration, and the restoration cemented with a permanent cement.
   4. Transferring Patients: If remaining treatment needs exist for your patient at the end of your Senior year, other than teeth with provisional restorations, you must work with your Patient Care Coordinator (PCC) to transfer the patient to another pre-doctoral student. This transfer will require that all mounted diagnostic information is provided to the PCC prior to the transfer occurring.
   5. Work Authorizations: all laboratory authorizations (lab prescriptions) must be signed by full time Prosthodontics faculty.
   6. Clinical Progress: You are encouraged to stop by the Department of Prosthodontics office (Room 404 Brauer) to confirm your current level of completion of clinical requirements. The Department will use the data provided in the Student Clinical Summary to determine you progress. If your records do not match those in this database, please see the Department staff immediately.
   7. You are expected to comply with all infection control policies set for the in the School of Dentistry's "Manual of Infection Control Policies and Procedures".