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Providence VA Medical Center, Rhode Island

 

New technology allows the Dental Clinic to do amazing things

PVAMC DDS look on the progress of  the CEREC Milling system

David Oser, DDS, looks on the progress of the CEREC CAD/CAM Milling System

By Rick Kabrick
Monday, January 28, 2013

When you speak with a dentist or a dental hygienist, the first thing he or she will tell you is that one of the keys to good oral health is prevention:  regular brushing, flossing, professional cleanings, and regular check-ups. Yet, despite our best intentions, prevention isn’t always enough.  When a tooth decays or has a broken filling, it may reach the point of needing a crown.

At most dental facilities, fabricating and inserting a permanent crown normally requires two or three appointments involving over three hours of treatment.  For eligible Veterans at the Providence VA Medical Center, however, this lengthy process has recently changed.  That is because the Dental Clinic has recently purchased a CEREC CAD/CAM Milling System.  Providence was the first VA Medical Center in New England to purchase this innovative, state-of-the-art technology.

Three separate appointments

During fiscal year 2012, approximately 350 Veterans received a crown or bridge at Providence VA Medical Center’s Dental Clinic.  Like most dental facilities throughout the country, fabricating and inserting a crown often requires three separate appointments.  During the first appointment, the tooth is prepared by removing all of its decay.  Then, a temporary crown is made of acrylic and set in place.  This first appointment usually takes 1 ½ to 2 hours.  About a week later, the patient returns for a second appointment.  During this appointment, the temporary crown is removed, impressions of both the upper and lower teeth are made, and the temporary crown is replaced.  This phase takes about 1 hour.  The impressions are sent to the VA’s Central Dental Lab in Washington D.C., a fully-equipped lab where specially-trained dental technicians manufacture a crown that precisely matches the existing tooth from the impressions.  After another six weeks, the new crown is received, and the patient returns for a third appointment.  The temporary crown is once again removed, and the new, permanent crown inserted in its place.  This final appointment takes about 1 hour.

Dr. Peter Latham, Chief of Dental Service, explains: “The lengthy process of providing our Veterans with a crown or bridge has been in place for a long time. My staff and I had worked to tightened up the process as much as we could, but the timeframe was still way too long.  Instead of accepting this with a ‘that’s just the way it is’ attitude, we went out and looked at other options.  When we looked to the CAD/CAM milling system we knew we had the opportunity to turn this process around and make it Veteran friendly.”

Enter the CEREC CAD/CAM Milling System

The Providence VA Medical Center has a robust culture of continuous improvement.  At any given time, numerous process improvement teams throughout the Medical Center are proactively looking for ways to enhance patient-centered care while improving operational efficiencies. The Dental Clinic is no exception.  In 2012, the Dental Clinic decided it was time to explore ways to streamline the process for Veterans receiving crowns and bridges and shorten the timeframe.  With the encouragement of Heather Kohl (a member of the Medical Center’s Systems Redesign Team), the clinical staff looked at the entire process—from when a Veteran is diagnosed as needing a crown to when the permanent crown is finally fabricated and inserted.

“There were a few options,” Rick Kabrick from the Dental Service recalls.  “We had already looked at the things that were within our control: we streamlined scheduling, and we ensured that the packing shipping process to the Central Dental Lab was as efficient as it could be.  The bottom line was made clear when we looked at it as a system re-design.  We needed to look outside the box and look at the actual fabrication process.  This is where the CAD/CAM Milling System came in.  The way to speed the process up was take control of it and do it right here in the clinic.”

One of the options was the CEREC CAD/CAM Milling System.  A recent 10-year United States Air Force study showed the CEREC CAD/CAM Milling System to be rated #1 among some 16 other units.  It was also the best suited for the need and space considerations at the Clinic.  The team did some basic calculations, put together a proposal, and then Dr. Latham briefed the Medical Center senior leadership.  The Director and Chief of Staff liked the idea, so Rick met with the Acting Clinical Engineering Chief Kathleen Grunder to begin the acquisition process.  Kathleen worked tirelessly, meticulously putting together the documents and submitting the equipment request and justification to the VISN for funding. The VISN approved the request in September 2012 and in November the Milling System was here.

Dr. Victoria Baeger, Staff Prosthodontist who spearheaded the research on the options, remarked: “The CAD/CAM Milling System is the latest technological improvement in dentistry.  Staff dentists make a digital measurement and a virtual model of the tooth, and the patient gets to see that process on a screen.  Minutes later, they see the actual crown after it is milled from a porcelain block right in our own lab.  It is a great system, the Veterans love it, and it keeps Providence on the cutting edge.”

The CEREC Milling System allows the Veteran to receive a crown in one visit.  CEREC takes exact digital scans of the existing tooth and the surrounding teeth and sends the data to the CAD/CAM Milling Unit, which then actually mills the crown on site.  This milling takes about 10 minutes, and a screen shows the patient the time remaining and what the crown will look like in a 3D representation.  The crown is then permanently placed, and the procedure is complete.

The patient receives the crown in about 90 minutes.  Not only is this a huge plus for the Veteran, it’s also a gain for other eligible Veterans in need of dental care.  “Reducing the number of appointments from three to one is a huge patient-centered initiative,” says Rick Kabrick.  “Further we expect it to free up over 300 hours of clinical time a year that will go towards providing dental care to other eligible Veterans.”

The Dental Clinic spent 3 days of training from the manufacturer on November 7-9, 2012 and began using the system the final day of training, when 2 Veterans who were waiting for a crown via the old process received their crowns that afternoon.

Rick summed it up by saying: “This system will save both time and money.  But the thing we are proudest of is that it is Veteran friendly by saving the Veteran numerous trips and appointments.  This system re-design process could not have succeeded without the support of the facility leadership, Heather Kohl (Systems Redesign), and especially Kathleen Grunder (Clinical Engineering) and the dental team--it was a true team effort!”

The Providence VAMC continues to provide the best care to our Veterans through investments in cutting-edge technology and a dedicated and engaged staff committed to improving patient care.  For more information about the new CEREC Milling System, please contact the Dental Service at (401) 273-7100, ext. 4127.

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