Steve Nielsen This is a great letter from Dr. Steve Nielsen to the Board of Dentistry in Idaho on the role of dental assistants and their utilization in CEREC. We here at cerecdoctors.com totally support and agree with Dr. Nielsen's position on this matter. What are your thoughts? The letter follows:
September 11, 2013
Idaho Board of Dentistry cc: Members of the Board
P.O. Box 83720
Boise, ID 83720-0021
Dear Board of Dentistry,
Recently you made and published a determination regarding the use of CAD/CAM technology for dental offices in the State of Idaho. I feel an error has been made in that determination or its published statement that needs further review and re-clarification.
You correctly quoted 19.01.01.035.02.b “’the placement or carving of permanent restorative materials in any manner’ is a prohibited duty of a dental assistant.” You then stated, “The Board of Dentistry determined that the use of a CAD/CAM unit to fabricate a permanent crown is a prohibited duty. If a specific dental assisting duty is not authorized under the direct supervision of a dentist it is assumed to be prohibited.”
Now please consider the following sections:
State Board of Dentistry Rules of the Idaho State Board of Dentistry
Section 035.01 page 9 (permitted activities)
e. Take impressions for preparation of diagnostic models, bleach trays, fabrication of night guards,
temporary appliances, temporary crowns or bridges; (4-6-05)
f. Record diagnostic bite registration; (4-6-05)IDAHO ADMINISTRATIVE CODE IDAPA 19.01.01
Section 035 Page 10
g. Record bite registration for fabrication of restorations; (4-6-05)
These rules allow an assistant to take impressions for certain items and record diagnostic bite registrations and registrations for fabrication of restorations. In no instance is the assistant allowed to take master impressions for permanent restorations such as crowns or bridges, but are allowed to do some parts of the process. From that interpretation, it would appear that the assistant could take an opposing arch impression and a bite registration for a lab processed crown.
Now, I’d like to review the process for a CAD/CAM processed crown.
In some instances, it is appropriate to copy the existing tooth anatomy in the new crown. This is especially effective in restorations which are abutment teeth for removable partial dentures as it is important to have the rests and clasps fit. This is called “biocopy,” and requires images of the tooth before it is prepared (similar to a preliminary impression used to make temporaries in the lab processed crown).
When a new design for the tooth is needed, the opposing arch and a bite registration need to be made, similar to the lab processed cases. With CAD/CAM, that is accomplished with imaging with the camera. Based on the allowed activities for the lab processed crown, it seems reasonable to allow assistants to image the opposing arch, biocopy if needed, and the bite registration.
Once the preparation is imaged, the CAD/CAM operator has two choices:
1. Design and mill, polish, or stain/glaze the restoration
2. Send the digital information to a lab for the fabrication process.
When the crown is ready for cementation, it is understood that Idaho Code requires the dentist to do the cementation, although rules allow the assistant to clean up excess cement.
Since the Board of Dentistry has no limiting rules for the fabrication of crowns by a lab technician, I feel the virtual designing/milling, staining and glazing by a dental assistant should also have no limiting rules. The obtaining final impression of the preparation and cementation of the indirect restoration remains sole and not delegated responsibility of the doctor.
With that said, I should add that I personally prefer to do all the imaging, designing, stain/glaze because I teach the technology as a trainer of new operators as well as advanced training and I want the skill set and regular practice to enhance that teaching capacity.
Your statement “that the use of a CAD/CAM unit to fabricate a permanent crown is a prohibited duty” appears to prohibit the assistant from touching the CAD/CAM computer, and I feel it is inappropriately restrictive. I would request that you reconsider your statement. I would be happy to provide any further information or demonstration to the Board, if needed.
Sincerely,
Steven F. Nielsen, DDS
nielstev@isu.edu
IDEP Dental Materials instructor 1992-2013
Cerec CAD/CAM User
Cerec Technology Basic Trainer
cerecdoctors.com Mentor and Faculty member based in Scottsdale, Arizona
