OutcomesDentistry

2006

Outcomes | 2006

Quality counts when referring patients to hospitals

and physicians, so Cleveland Clinic has created a series

of outcomes books similar to this one for its institutes

and departments. Designed for a health care provider

audience, the outcomes books contain a summary of

our surgical and medical trends and approaches; data

on patient volume and outcomes; and a review of new

technologies and innovations. We hope you find these

data valuable. To view all our outcomes books, visit

Cleveland Clinic’s Quality Web site at

clevelandclinic.org/quality/outcomes.

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Dentistry | �

Section Head Letter 5

Quality & Outcome Measures

Maxillofacial Prosthetics 6

Implant Dentistry 8

Implant Retained Overdentures 9

Cosmetic Dentistry 10

Oral and Maxillofacial Surgery 11

Sports Dentistry 12

Periodontology 1�

Orthodontics and Dentofacial Orthopedics 1�

Oral Medicine 14

Craniofacial Pain and Jaw Disorders 15

Pediatric Dentistry 15

Patient Experience 16

Innovations 17

Staff Listing 18

Department Contacts | How to Refer Patients 20

Location 21

Cleveland Clinic Overview 22

Online Services 2�

Cleveland Clinic Contact Numbers 24

Table of Contents |

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Dentistry | 5

Cleveland Clinic Section of Dentistry, Department of Plastic Surgery, is committed to providing state-of-the-art dental care in an environment of research and education. The staff includes seven full-time and one part-time general and specialty dentists, three consultant staff, inclusive of the addition of a pediatric dentist, three hygienists and a very competent auxiliary staff, all of whom are committed to excellence and quality care.

The primary objective of the Section is to be a resource for Northeast Ohio physicians and dentists to evaluate and/or treat complex problems of the stomatognathic system. These include, but are not limited to, the dental management of the medically compromised patient.

We believe it is important to share our scope of services with our referring physicians, dentists, patients, and individuals interested in our dental program. We are grateful to all who have helped make the Dental Section one of the most successful in the country.

James M. Christian, D.D.S., M.B.A. Head, Section of Dentistry

Section Head Letter |

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Quality & Outcome Measures |

Section of Dentistry, Department of Plastic Surgery

Maxillofacial Prosthetics (MFP)

Considering there are fewer than 200 maxillofacial prosthodontists in the United States, the department is fortunate to have a full-time specialist on staff. Maxillofacial prosthodontists provide prosthetic rehabilitative services for patients with major oral and head and neck deformities. The wide-ranging services can generally be categorized into three patient groups:

Congenital: The MFP staff provide both intra- and extraoral prosthetic services to a wide range of patients with congenital abnormalities. Patients from newborns to adults can be treated for conditions such as cleft lip and palate, ectodermal dysplasia and congenitally missing teeth.

Post Head and Neck Surgery: Post head and neck surgery services include both extra and intraoral prosthetic rehabilitation. Typical patients are head and neck cancer survivors missing oral structures which cannot be surgically rehabilitated.

Post-trauma: Extra and intraoral prosthetic rehabilitation for deformities post motor vehicle accidents (MVAs), gunshot injuries and similar traumas.

Other services include the fabrication of unusual appliances and prostheses for various conditions:

Radiation Therapy Services: Treatment appliances in radiation therapy services help control side effects such as xerostomia, trismus, and various protectors, locators and stents.

Neurological Deficits: Prosthetic supportive therapy is available for patients with oral functional deficits of speech and swallowing secondary to stroke or neurologic impairments such as Amyotrophic Lateral Sclerosis (ALS).

Breast Cancer: Prosthetic rehabilitation is a service designed for post mastectomy patients.

Obstructive Sleep Apnea (OSA): Oral appliances can be beneficial in treating patients for primary or secondary treatment of obstructive sleep apnea for post mastectomy patients.

Dentistry | 7

Referrals

Severity / Year

02002 2003 2004 2005 2006

10

20

30 Number referred per moving avg.Number treated per moving avg.ReferredTreatedTreated w/ Post PolysomnogramMissing / faulty data

#

0

4

8

12

2002 2003 2004 2005 2006

MildModerateSevere

Pre Tx AHI

Referrals

0

5

10

15

20

25

2002 2003 2004 2005 2006

FemalesMales

#

Apnea-Hypopnea Index (AHI)

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Treatment Results by Severity

0

20

40

60

80

100

Mild Moderate Severe

Pre treatmentPost treatment

Average AHI

Implant Dentistry

Dental implants have made a huge impact in the way each of our dental staff practices his/her specialty. The predictability and success of the implant allow us to present our patients with treatment options not available only a few years ago. Although dental implants have been utilized in our practice since the early 1980s, the initial use was the “Branemark” protocol for stabilizing or eliminating a complete lower denture by fabricating a hybrid-type prosthesis. These early endeavors proved so successful, treatment rapidly expanded to all other areas of the mouth, replacing both single and multiple missing teeth. In addition, implants can be used to stabilize both complete and partial dentures.

Technological advancements in materials and texturing have resulted in dental implants becoming the most successful implant utilized in medicine, particularly due to its predictability in dental situations. Our maxillofacial prosthodontists also use the osteointegration of implants to place extra-oral implants to retain facial prostheses. The resources of all our dental disciplines and medical specialties allow for a thorough and comprehensive diagnosis. This ensures a treatment plan with the greatest opportunity for success for the implant patient. Truly, this is an exciting time for the dental consumer.

Statistics have been kept since 2000 on implants placed versus implants failed. Historically, there has been a 97% success. Remarkable results have also been obtained with immediately placed and provisionalized implants. This significantly reduces treatment time since the implant and temporary restoration are placed at the time of extraction.

Apnea-Hypopnea Index (AHI)

Dentistry | 9

Implant Retained Overdentures

Quality-of-Life Survey

A quality-of–life instrument developed at the University of Iowa was used to evaluate patients’ satisfaction levels with their current level of functioning. The survey consisted of 2� questions that evaluate interactions and interpersonal relationships, social interactions, speech, mastication, pain and/or discomfort and satisfaction with implant overdentures. Ninety-two surveys were distributed to patients rehabilitated with maxillary complete dentures and mandibular implant-retained overdentures using either two or three implants with ball (retentive anchor) attachments. Sixty-one (66.�%) of the anonymous surveys were returned.

Results indicated overwhelming satisfaction with their treatment.

0 20 40 60 80 100

%

Interpersonal relationships improved

Never or hardly ever had difficulty with mastication

Never or hardly ever experienced pain ordiscomfort with their overdentures

Never or hardly ever had problems in social settings

Satisfaction and less worry with their lives

Cosmetic Dentistry

The term “cosmetic dentistry” is somewhat of a misnomer, as all dentistry should have a cosmetic component. Most of the general public has been “educated” to associate cosmetic dentistry relative to porcelain restorations, bonding procedures and dental bleaching. Continued rapid advancements in each of these disciplines make it mandatory that a thorough knowledge of materials and chair-side techniques be utilized. These are necessary to perform a restoration which meets the patient’s expectations and enhances the patient’s appearance and self-image in conjunction with delivering acceptable longevity.

To consult with a patient, each staff acquires all necessary records in order to fabricate a treatment plan particular to the patient’s expectations and resources. We work closely with both our in-house laboratory and private laboratories to fabricate the specific prosthesis required. A large part of this success is due to utilizing specialty consults when needed. A distinct patient advantage is having these specialists available for consultation in our clinic.

One recent and exciting treatment alternative is the procurement and utilization of a CADCAM milling technique (CEREC �-D). Patients can undergo comprehensive treatment with a porcelain restoration from start to finish in one appointment. This eliminates multiple visits, using an interim (temporary) restoration and making an impression, and results in time savings and a less intrusive appointment for patients. Over 200 restorations have been completed within the past year. The success rate is nearly 100%. Follow-up of these patients will continue for evaluation of long-term success. We are confident our pursuit of continued advances in the dental sciences will open even greater opportunities in the future for our patients.

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Dentistry | 11

Third Molar Extractions

# of % Male % Female % Dry % Post-op % % Patients Patients Patients Socket Infections Paresthesia Other

127 42 58 2 2 <1 2

Oral and Maxillofacial Surgery

The subsection of Oral and Maxillofacial Surgery focuses on several areas for the upcoming year. First, a working relationship is being further developed with the Department of Oral and Maxillofacial Surgery at MetroHealth Hospital where a permanent upper level resident rotation has been established. This allows the subsection of Oral and Maxillofacial Surgery more presence in the hospital to manage inpatients more effectively, to participate in maxillofacial trauma call, and more interaction with plastic surgery, otolaryngology and general practice dental residencies. These efforts are all directed toward putting Cleveland Clinic “Patients First.”

Secondly, our subsection would like to concentrate on several surgical areas: orthognathic surgery – continuing our treatment expertise with patients who have jaw deformities; telegnathic surgery – working closely with our sleep medicine colleagues, offering maxillary/mandibular advancement for patients with moderate-to-severe obstructive sleep apnea; jaw reconstructive surgery – treating patients who require autogenous/allogeneic bone grafting and endosteal dental implant placement, then working in conjunction with our prosthodontist colleagues to restore these patients to full masticatory function; and temporomandibular joint surgery – treating select patients who have symptomatic joint pathology.

Thirdly, our section looks to establishing one or more surgical outcome studies to compare our results with nationally accepted norms, e.g. the incidence of complications for third molar surgery over the past year.

While we can monitor the respiratory disorder index after telegnathic surgery for obstructive sleep apnea, finding objective parameters to measure is challenging as we strive to continually improve our outcomes.

Lastly, it is important to continue to manage our patients effectively and efficiently with daily routine dentoalveolar surgeries, i.e., dental extractions including third molars (wisdom teeth), tooth exposure, oral tissue biopsies, etc.

Sports Dentistry

Sports Dentistry is the prevention and treatment of oral/facial injuries attained during athletic activity. Our efforts center on athlete and parent education, mouthguard fabrication and use, and dissemination of information.

The use of athletic mouthguards has been recommended for decades, although it has met varying levels of athlete acceptance. Issues related to compliance center around the ability to breathe and speak while wearing the mouthguard, and the effect this has on athletic performance. Fabrication techniques have changed over time to a two-layer Ethylene Vinyl Acetate mouthguard fabricated on a high-pressure machine. This new technique permits better control over thickness, providing a better fit and, thereby, improving acceptance.

It is important dental injuries be diagnosed and treated early to minimize necessary treatment and long-term sequela. The subsection of Sports Dentistry provides early oral/facial diagnosis, mouthguard fabrication and athlete and parent education as part of the division of Cleveland Clinic Sports Health.

It is our privilege and honor to be dental consultants for the NFL’s Cleveland Browns and the NBA’s Cleveland Cavaliers.

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Dentistry | 1�

Periodontology

Disease of the periodontium continues to be one of man’s most common infections. In fact, more than 75% of adults over age �5 have some form of periodontal disease, commonly known as gum disease. Periodontal disease is the leading cause of adult tooth loss. Evidence also continues to mount suggesting people with periodontal disease may be more at risk for heart and respiratory disease, may have more difficulty controlling sugar levels if they are diabetic, and may even experience premature delivery during pregnancy.

The mission of the subsection of Periodontology is to advance oral health and, therefore, improve physical well-being through: patient education and expertise in periodontal therapy and medicine utilizing physician, dental, and dental hygienist interaction; oral plastic and reconstructive surgery utilizing soft tissue and guided bone regeneration techniques to repair damage done to the periodontium; and working in a team approach with the Maxillofacial Prosthodontic and General Dentistry Sections to treat routine and compromised patients who are candidates for dental implant surgery and maxillofacial rehabilitation.

Maximizing the unique skills of Medicine and Dentistry in the same facility, we are able to achieve the highest quality of comprehensive periodontal care.

Orthodontics and Dentofacial Orthopedics

Orthodontics and Dentofacial Orthopedics are the specialty areas of dentistry concerned with supervision, guidance and correction of the growing or mature dentofacial structures, including conditions that require movement of teeth or correction of malrelationships and malformations of their related structures and the adjustment of relationships between and among teeth and facial bones. The goal of orthodontic treatment is to attain and maintain optimal relations and physiologic and esthetic harmony among facial and craniofacial structures. In the past,

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Oral Medicine

The subsection of oral medicine addresses the treatment needs of the medically complex hospital patient. A large patient population is cardiovascular surgery patients. Each year the department sees nearly 600 patients prior to open-heart surgery (OHS). The responsibility of our dentists is to ensure OHS patients are free of odontogenic infection prior to surgery.

OHS patients are extremely high-risk patients who often need extensive treatment while inpatients in the immediate days prior to surgery. Treatment requires the dentists to work closely with the physicians and nursing staff for the modification of the medical management of these patients. This aggressive approach is taken primarily to prevent infection of the heart valves post-surgery from bacteria from the mouth.

The oral medicine section also sees patients undergoing various treatments that include bone-marrow transplantation, radiation therapy, chemotherapy and organ transplantation. Similar to the OHS patients, these patients must be free of oral infection in order to complete treatment without complications due to infection.

Patients with oral soft tissue lesions are diagnosed and managed by the section of oral medicine. This includes the management of herpes simplex, aphthous stomatitis, candidiasis, lichen planus, pemphigus, pemphigoid, Sjögren’s syndrome, xerostomia, and oral cancer.

orthodontic treatment was considered mainly for the preadolescent and adolescent population. In the last 15 years, however, the adult population seeking orthodontic treatment has dramatically increased.

The Section of Dentistry has provided orthodontic services for the last ten years. These have included not only the treatment of simple dental malocclusions but also the treatment of complex skeletal/dental abnormalities such as those found in patients with craniofacial anomalies and those with clefts of the lip and palate.

Dentistry | 15

Craniofacial Pain and Jaw Disorders

The Section of Dentistry provides diagnoses and treatments of jaw disorders commonly referred to as temporomandibular disorders or TMD. Patients with TMD often suffer with a myriad of symptoms, which may include joint and facial pain, clicking and popping, limited range of motion, tooth pain, ear pain, tinnitus, stuffiness in the ears, dizziness and disequilibrium, and headache. The relationship between many of these seemingly unrelated symptoms can often be explained by a comprehensive TMD evaluation.

A comprehensive evaluation of the functional disharmony between the temporomandibular joints, teeth and muscles can, in many cases, identify the source of a patient’s complaint. Chronic daily headaches or the frequency of migraines may be helped by establishing harmony in the masticatory system by use of dental orthotics or splint therapy. In addition, the deleterious effects of habits such as clenching and bruxing can be reduced by occlusal splints.

The Cleveland Clinic Section of Dentistry can play an important role in the management of patient’s facial pain and headaches. Conservative treatments including dental orthotics, physical therapy and correction of bite discrepancies can provide successful management of many TMD-related complaints.

Pediatric Dentistry

This past year a new service to our Section of Dentistry was added. A part-time pediatric dentist is on staff for the needs of children ages 2 to 12, inclusive of special needs or physically challenged children. With the use of the operating room, children who have specific health challenges may now have necessary routine dental work done under general anesthesia when necessary.

Dentistry | 16

We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we provide excellent care, we are committed to continuous improvement.

Excellent Very Good Good Fair Poor

%

80

40

0

100

60

20

ExtremelyLikely

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

%

80

40

0

100

60

20

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Patient Experience |

Outpatient Overall Rating of Care 2006

Outpatient Would Recommend Provider 2006

Dentistry | 17

In reality, no one likes going to the dentist and all patients demand a value for their money. CEREC �-D provides instant optical impressions and gives patients better results in less time.

Getting patients out of the chair faster is not the only reason CEREC �-D pleases patients: there are no impressions, no temporaries and fewer injections. Patients prefer instant optical impressions over a bulky tray full of material and, above all, they appreciate being provided a restorative procedure that fulfills their needs and expectations in a single visit.

Whether we are replacing old amalgams, creating new crowns or designing a new smile, the state-of-the-art technology in the CEREC �-D does it all in a way that is more accepted, more convenient, and more appreciated by millions of today’s educated patients. Over �00 patients have been treated with this new technique.

Innovations |

James M. Christian, D.D.S., M.B.A. Oral and Maxillofacial Surgery Head, Section of Dentistry, Department of Plastic Surgery

Appointed: 2004

Specialty Interests: orthognathic surgery; obstructive sleep apnea; jaw reconstruction; implants; and temporomandibular joint dysfunction

Dental School: D.D.S. – Temple University School of Dentistry, Philadelphia, PA

Other Education: B.A. – Lehigh University, Bethlehem, PA; M.B.A. – West Virginia University, Morgantown, WV.

Residency: University of Connecticut Health Center, Farmington, CT

Staff Listing | Section Head

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Dentistry | 19

Section of Dentistry Staff James M. Christian, D.D.S., M.B.A. Oral and Maxillofacial Surgery Head, Section of Dentistry

Lisa Browning, D.D.S. General Restorative and Cosmetic Dentistry

Christina A. Gitto, D.D.S. Maxillofacial Prosthetics and Prosthodontics

Todd Coy, D.D.S. General Restorative and Cosmetic Dentistry Oral Medicine

Michael J. Matheis, D.D.S. General Restorative and Cosmetic Dentistry

Karyn A. Kahn, D.D.S. General Restorative and Cosmetic Dentistry TMD, Myofascial Pain, Jaw Disorders

Consulting Staff Aimee Cassinelli, D.D.S. Pediatric Dentistry

Richard Harper, D.M.D., M.S.D. Restorative Dentistry and Dental Materials

Donald P. Lewis, Jr., D.D.S. Oral and Maxillofacial Surgery Implantology

Rex T. Raper, D.D.S. Periodontics and Implantology

Mohammad Razavi, D.D.S., M.S.D. Orthodontics

Howard J. Synenberg, D.D.S. Endodontics

For more information about our staff, visit www.clevelandclinic.org/staff

Staff Listing |

Cleveland Clinic Main Campus Department of Dentistry 1.800.CCF.CARE ext. 46907

Appointments and Patient Referrals 216.444.6907

For more information about Dentistry, visit: www.clevelandclinic.org/dentistry For more details about maps and locations visit: www.clevelandclinic.org/maps

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Department Contacts | How to Refer Patients

Dentistry | 21

Location |

Lake Erie

ClevelandClinicCleveland

Lorain

Independence

Cleveland Clinic Main Campus Department of Dentistry 1.800.CCF.CARE ext. 46907

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Cleveland Clinic Overview |

Cleveland Clinic, founded in 1921, is a not-for-profit academic medical center that integrates clinical and hospital care with research and education. Today, 1,700 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties.

Cleveland Clinic’s main campus, with 41 buildings on 1�0 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, subspecialty centers and supporting labs and facilities. Cleveland Clinic also operates 1� family health centers, eight community hospitals, two affiliate hospitals, and a medical facility in Weston, Florida.

At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time.

In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first �2 students as physician- scientists in 2009.

For more details about Cleveland Clinic, visit clevelandclinic.org

Dentistry | 2�

Online Services |

eCleveland Clinic

eCleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second opinions through a secure Web site to patients around the world; personalized medical record access for patients; patient treatment progress access for referring physicians (see below); and imaging interpretations by the Department of eRadiology’s subspecialty trained academic radiologists. For more information, please visit eclevelandclinic.org.

DrConnect

Online Access to Your Patient’s Treatment Progress

Whether you are referring from near or far, our new eCleveland Clinic service, DrConnect, can streamline communication from Cleveland Clinic physicians to your office. This new online tool offers you secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect Web site. To establish a DrConnect account, visit eclevelandclinic.org or e-mail drconnect@ccf.org

MyConsult

MyConsult Remote Second Medical Opinion is a secure, online service providing specialist consultations and remote second medical opinions for more than 600 life-threatening and life-altering diagnoses. MyConsult remote second medical opinion service allows you to gather information from nationally recognized specialists without the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, e-mail eclevelandclinic@ccf.org or call 800.22�.227�, ext 4�22�.

24 | Dentistry 2006

Cleveland Clinic Contact Numbers |

Cleveland Clinic Contact Numbers

How to Refer Patients 24/7 Hospital Transfers or Physician Consults 800.55�.5056

General Information 216.444.2200

Hospital Patient Information 216.444.2000

Patient Appointments 216.444.227� or 800.22�.227�

Medical Concierge Complimentary assistance for out-of-state patients and families 800.22�.227�, ext. 55580, or email: medicalconcierge@ccf.org

International Center Complimentary assistance for international patients and families 216.444.6404 or visit www.clevelandclinic.org/ic

Cleveland Clinic in Florida 866.29�.7866

www.clevelandclinic.org

Cleveland Clinic is determined to exceed the expectations of patients,

families and referring physicians. In light of this goal, we are committed

to providing accurate and timely information about our patient care.

Through participation in national initiatives, we support transparent public

reporting of healthcare quality data and participate in the following public

reporting initiatives:

• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)

• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)

• Leapfrog Group (www.leapfroggroup.org)

• Ohio Department of Health Service Reporting (www.odh.state.oh.us)

In addition, this publication was produced to assist patients and referring

physicians in making informed decisions. To that end, information about

care and services is provided, with a focus on outcomes of care. For

more information, please visit the Cleveland Clinic Quality Web site at

clevelandclinic.org/quality.

Cover photograph by Stephen Travarca