Pedo Tuscaloosa

For those who are curious, here is what to expect on this rotation:

Breakdown of the clinic:

• There are 3 operatories. Two of them are mainly used for prophies and exams and the 3rd chair is where most operative procedures are done.

• They start scheduling patients at like 8:30 and they will typically schedule 4-6 patients per hour. There are a lot of no-shows so they compensate by over-booking. 

• The last patient in the morning is scheduled for 11AM and the last patient in the afternoon is scheduled for 3pm. When I was there, we were off to lunch by 11:20am and we were done for the day by 3:10pm. You all will go out to lunch with Dr. Thornton which is awesome. There are two D3's, two D4's, and one resident.

What you will be doing

1. Exam & Prophy - mainly you will just be doing an exam and a prophy. These are very simple. The biggest challenge is just patient management. You won't use any scalers. The prophy consists of brushing their teeth using either A) a prophy cup and paste, or B) a normal toothbrush, depending on their age and behavior. 
1. You will then take some fluoride varnish and paint it on all of their teeth.
2. Then just look around their mouth for any cavities, etc.
2. PRR & Sealant
1. I didnt actually see any of these done when I was there, but some people have told me that they have. If you don't feel comfortable doing one of these, just ask a D4 to take over. But it would be good practice, I'm sure.
3. Assisting the resident
1. I assisted on 3 procedures and they were all pretty cool. One was an extraction and the other two were stainless steel crowns.  I'd recommend trying to at  least assist once. It's a lesson not only in patient management but also in doing a procedure we don't see very often.

Competencies

If nothing else, at least get 2 of the 3 competencies out of the way. Dr. Thornton wants you to get them done. He is most likely to allow you to do the health promotion and the treatment planning comptencies. At least one of the competencies needs to be done with Dr. Mitchell. My competency experience:

• Health promotion - just ask the mom what the child eats and drinks. Tell them to make sure they start drinking more water and less juice. Milk is okay too, but don't let them have the bottle/cup by their bed overnight. Candy is okay every now and then but make sure the parent knows the importance of brushing the child's teeth a few minutes after eating the candy. Boom, competency completed. Dr. Thornton is very easy going and basically tells you everything to do.
• Treatment planning - try to at least do one of the prophies yourself. It's very easy to stand in the background and just assist D4's, but make a point to do one on your own. That way, you can knock out the treatment planning competency. Basically what is involved: after cleaning their teeth, look around their mouth and make note of all the cavities that you see and what tooth number it is. Put it in the chart and write it in the progress note. You will need to record dental codes and all that as well. Make sure Dr. Thornton signs it. 

It's all very simple. Ask the D4's if you have any questions and they will be glad to help. The assistants are really great too. This is an easy-going rotation but also a very helpful one.

- Joe

Using the Sonic Scaler

Why use it?

 You lean your patient back. It's just a first-appointment-prophy or maybe a full mouth debridement. When the patient opens up, you are horrified to find calculus everywhere! You should stop right now and go get the sonic scaler from the sterilization window.

The sonic scaler will blast off all that calcululs with very little effort. I recommend going to sterilization as soon as you can because I heard they get taken quickly. You will need to fill out one of those annoying forms.

You don't need approval or a certain level of experience to use it!   At least I didnt. I just used it and faculty didnt say anything to me. So go for it.

How to Put it together

The package comes with the handpiece, a gray base thing, and 3 attachments.

1. Pick out the attachment you want to use. They vary according to the size of the tip and the bend of the shank. 
2. Use the gray base to attach the tip attachment to the handpiece. If I remember correctly, you put the tip attachment into the base. Then use the base as a modified-screwdriver to fasten the attachment to the handpiece. The gray base does not stay attached to the handpiece. It is only a means of fastening the attachment. 
3. Attach the handpiece to the high-speed hose. It uses a lot of water so an assistant maybe helpful. 

How to Use it

1. Take the tip and go around the gingival margin of all the teeth, especially those with visible calculus. Insert the tip 1-2mm into the ginigval sulcus to remove superficial subgingival calculus. 
2. DO NOT put pressure on the tooth. You can gently touch the tip to the tooth, but don't put much pressure on it because I think it can take off enamel with too much force.
3. Make sure you are constantly moving. Don't stay in one specific spot for very long. You can do short continuous strokes until the calculus is gone, but don't just hold the tip in one spot. 

 
The main purpose of the sonic scaler is to make it easier to clean up a patient with tons of calculus. It is not meant to be the only instrument you use on the patient. Once you have done a pass with the sonic scaler, switch to hand instruments to get any additional plaque and calculus left behind.

NOTE: This is not the same thing as an ultrasonic scaler. I think you actually DO need permission to use that one but I may be wrong. I have only used the sonic scaler. 

- Joe

Class V Composite Restorations

So far I have done about 12 Class V restorations, and a few of them have been more complicated than I expected, so I just wanted to type up a post on this in hopes that it may give someone a heads up on what to expect.

The hardest part about a Class V is if the lesion extends to the gingival margin. Using a rubber dam will probably be difficult with this type of lesion, so ask if its okay to do without a dam.

Anesthesia

 If it is only a couple of Class V's on the mandibular anterior, you can still do infiltration. Faculty have told me to use 4% Septocaine several times now when working on mandibular anteriors, so I figure that's pretty normal. 1 carpule should be plenty. Only give a lingual infiltration if the prep will extend to the lingual. Sometimes, you may not need anesthesia at all. It all depends on the patient and how deep the prep will be.

The Prep

There are two types of Class V lesions that I have encountered so far:

1. Abfraction lesion -  
1. for this type of lesion, there typically isnt any decay. That means that all you should need to do is bevel the enamel on the most incisal portion of the prep. Bevels need to be at least 1-2mm wide to allow the composite to blend in with tooth structure. Use a diamond bur for this.
2. Classic Class V lesions
1. these are the ones that have caries in them. You want to prep these until all of the caries has been removed. 
2. How do you tell when caries is removed? - air dry the prep and then take either a slow speed round bur or the spoon excavator. If the prep is still soft and you can scrape a decent amount of white tooth structure out of it, then decay is still present. This has been the hardest thing for me to visualize.

Packing Cord

It's necessary to pack cord with preps at the gingival margin. It doesn't really matter whether you pack the cord before or after you prep. Faculty have told me both ways, but it may be easier to go ahead and pack cord before you begin prepping.

I typically get 00 cord and dip it in hemodent. We have a bottle for hemodent in our cart, and you take it to supply for them to fill it up.

When Your prep gets close to the pulp

Several times now, my prep has gotten close to the pulp. You can tell you are getting close because the center of the prep will start to become a different color white. I would not prep too much more after noticing this color change. Go get your faculty and see what they say.

Once you are done prepping, faculty will probably want you to use Fuji glass ionomer liner on the prep. We should have this in our kit somewhere. You need the gun and the paste capsule, both of which we already have.

After mixing the Fuji, apply it to the prep and then light cure for 15-20 seconds. Afterwards, you can proceed with etchant, prime, and bond.

Finishing your restoration

I recommend using your finishing burs or the Enhance system. If you have a lot of excess, start with finishing burs and then switch to Enhance. Whether you use finishing burs on slow speed or high speed depends on how comfortable you are with it.

Don't be afraid to take the finishing burs subgingivally. It may damage the gingiva slightly, but it will heal. It's important that you get the composite margins flush with the rest of the tooth.You may want to warn the patient that their gums may be sore later on, and that they can take an Advil if needed.

When using Enhance to finish the buccal surface, use the cup. This allows for better contour. Also, use enhance finishing system on a dry field. Be careful not to leave the cup on the tooth for a long time though, because it will start to overheat the tooth.


Let me know if you have any more questions!
- Joe

Perio Competency - Exam/Diagnosis/TX Plan

This is just a quick run  down of my experience with this competency the other day:

I had Kyle Trammel (resident) grade my competency. Both he and Dr. Stevens attempted to discourage me from doing the competency due to lack of experience. So don't be shaken if they try to! If you are confident and know how to do a perio exam, then go for it because it's really not too bad.

The Competency

They basically just want you to fill out everything you can on the white Perio Eval sheet. Dr. Trammel said, "Basically we want you to fill out everything you can. Normally we wouldnt worry about things like Width of Keratinized Gingiva, but since this is a competency, I want you to record that as well"

Things that I recorded

1. Probing depths - probably the most important
2. Gingival Recession - one site per tooth
3. Width of Keratinized Gingiva - one site per tooth
4. Clinical Attachment Level - there isnt a column for this on the sheet so I just wrote it out above each tooth. Remember, CAL = PD + Gingival recession. This number is the important one when determining the severity of their periodontal disease
5. Mobility - remember to use either a hard object (mirror handle) and your finger, or two hard objects. And trust your judgement! I actually saw teeth move but was convinced I did it wrong. But Dr. Trammel checked, and they were actually moving. 
6. Plaque Index
7. Occlusion - I just recorded overjet, overbite, and then what molar classification and what dental classification they were.  I did not fill out that weird occlusion box on the back.
8. Review the check list - There is a list on the right side of the back page. Check to make sure none of those contributing factors are true for this patient (are they a smoker). Make sure you mark any that apply. 

Things They Actually Checked / Asked

1.  Probing depths - he went around and spot probed different areas
2. Mobility - all the teeth
3. radiographs - make sure you are familiar with the radiographs and what bone loss looks like, etc.

Diagnosing

1. Review how to diagnose periodontal disease. I heard Dr. Stevens say he considers 4-5mm pockets to be mild, 5-6mm pockets to be moderate, and anything over 6mm is severe. If they only have one or two 7's, then it would be localized severe for those areas.
2. It's generalized if it is >30% of the teeth (i think?) 

Treatment Planning

1. From my understanding, if they have generalized pockets, then the first line of treatment is ALWAYS scaling and root planing in the quadrants with deep pockets. This is because scaling and root planing typically can gain 1-2mm back and alleviate some of the problems.
2. So my treatment plan for a diagnosis of Generalized Severe Chronic Periodontitis looked like this:
1. UL, UR, LL, and LR quads of scaling and root planing.
2. Phase 1 Perio Eval (coded in salud as Limited Perio Reeval).
3. And that's it. You won't know whether to continue treatment until you get them back for the Phase 1 Eval.

hope this helped! Ask me if you have any other questions.
- Joe

Christ Health Center Rotation

Here's the rundown

You're on the rotation w/ one other D3 and two D4s

You'll go in the front door and then enter a door to the right of the receptionist windows. Make sure they see you cause they have to hit a button to let you go back. You head towards the right and the dental clinic is down the hall on the right.

Dr. Sides is the lady in charge. She's nice and easy to work with.

Right now we're not allowed to do anything but prophy and screen/treatment plan.. some realigning dentures.. but nothing serious. You can also assist the D4s… they'll do a lot

There is an assistant and a hygienist there to help. Also nice.. you can ask them any questions about where stuff is. 

At the new pt/treatment planning appt. you'll go get the pt from the waiting room. Their names are on the computer in the clinic but their chart is in the main front office.

When they get back  go over med hx (at some pt enter that in the computer).If they can't speak english they have two translators on site in the front office. They're names are veronica and andrea. 

Then she wants you to take a quick look in their mouth and decide what radiographs you'll need..bitewings only if they have max/man, PA's on broken down teeth or if only have one arch... then take them.

Next she wants you to look at their mouths and make a list of stuff.. you know the drill.  Basically you need to put together a preliminary TP of what you think needs to be done. 

She'll come check after and put together a TP and review the one you put together. You/ Dr. Sides will enter the TP into the computer and print out a copy of it to go over with the patient.  she expects you to present it to the pt. this part was kind of awkward because I wasn't sure exactly how CHC works.. they'll usually make their next appt out at the front office 

After the appt you make your note on the computer.. everything there is digital.

The computer system is pretty cool.  It has all of the patients listed for the day divided up into 4 rooms.  The system is color coded according to their appointments and isn’t really that hard to figure out.  

That's essentially what you'll do all week.. but ask questions they're nice!

- Lauren 

Patient gagging during impressions?

If you have a patient that just can't seem to stop themselves from gagging when you are trying to take impressions, one thing that may be worth trying is to take some topical and rub it on the posterior palate and back of the throat. This way the patient is less likely to be bothered by the alginate running down the back of their throat!

- Info from Tyler

Tooth Sensitivity - Gluma

My patient today complained of mild sensitivity on the occlusal-lingual surfaces of a maxillary molar. My faculty member suggested Gluma, which is at the supply window. They had trouble finding it because it's actually in the frig. It comes in a single dose.

Here is the basic procedure:

1) Dry the surrounding area by putting gauze or the larger cotton pellets around it.

2) Take the tube out of the pack and push it in (like a piston).  Then pull on it gently and a small brush with the liquid should appear. There are pictures on the back.

3) Apply the Gluma to the sensitive areas. My patient had exposed dentin due to wear and shaving down to adjust occlusion.

4) Let it dry for a bit (Chavali suggested 1 minute). And you're done.

___________________

The website says you can put it on every preparation before you restore it. Here is the product website and also wikipedia:

http://heraeus-dental-us.com/en/ourbrands1/dentistry/gluma/gluma_2.aspx
http://en.wikipedia.org/wiki/Gluma

- Joe