Glass Ionomers - The Fuji Bunch

So we had a pretty big final in Cariology, which includes treatment of caries, which is probably more than 80% of what we do in the clinic. Glass Ionomers are a material with many uses, and we use them all the time in the clinic. They release fluoride and some are stronger than others. I wanted to compile a little post to remind myself of what each one does so here goes:


Fuji Plus - Luting Cement 
Reinforced Luting Cement basically used to cement metal based, or all ceramic inlays, onlays and crowns. It can also be used to cement metal, ceramic or fiber posts.


Fuji II LC - RMGI
Resin Modified GI used for Class III and Class V lesions. It's good for the treatment of root caries, abfraction and cervical lesions. It's also used for restoration of primary teeth, as a base and a liner.
It is NOT used as a pulp cap.


Fuji IX - Heavy Body GI w/ Filler
Heavy Body GI w/ Filler Particles used on root caries lesions, or on roots of amalgams and composites with faulty margins. They can also be used in Class III and Class V lesions in patients with high caries risk. Fuji IX self cures (2.5 min).
It NOT used as a liner, base, pit and fissure sealant, pulp cap, a large core, or a definitive restoration in load bearing areas. It is NOT A RMGI, so does not handle loads well.


Fuji Triage - Flowable GI
Flowable GI used to seal pits and fissures when isolation is not possible, as a liner in deep restorations, or over CaOH, to fill an endo access or as a protective restoration. When used to fill endo access, Fuji Triage prevents Eugenol from the sealer from affecting the bond of the core. It's also pink and self cures (2.5min)
Triage is NOT used as a definitive restoration, base, direct pulp cap, core. It is NOT used to repair faulty amalgams or resins.


Vitrebond - Flowable GI
Flowable GI used as a liner in deep restorations, or over CaOH. It's used to restore endodontic accesses.
It is NOT used as a definitive restoration, base, direct pulp cap, to repair faulty amalgams/resins or as a core.

ECHM Town Hall

Our project of starting a community dental clinic is coming together, and is set to open to the public in February of 2014. On December 5th our group presented our progress thus far to faculty, students and staff in a Town Hall meeting. We wanted to give everyone an overview of whose involved, what's being planned, the location, population we'll be serving and how it's all going to come together. 

Kara, our project leader kicked off our presentation with introductions, and a summary of how we got involved, and an overview of what we all would be discussing. JoAnna then took it from there, discussing the surrounding area, and the need for a dental home at 1500 Broadway. She presented photos of the area, and elaborated on the fact that this is an underserved area. I discussed the collaborations that will be occurring at the clinic with LakeShore Behavioral, Catholic Health, Erie County and UB School of Public Health. We're hoping to be making many interdepartmental referrals, and seeing a different population pool than at Squire hall, which will be a great experience for students. Richie then engaged the audience with photos of our equipment and the blueprints and architectural renderings of the proposed facility.  Josh discussed when this would all be happening, and our plans for marketing and attracting patients. Since we're in an underserved area, we're expecting a large percentage of emergency-walk ins but we need to be prepared for many scenarios. By participating in the Buffalo Clean Sweep Initiatives, and marketing within the community we hope build some hype in the community prior to opening. Last but definitely not least, Hoda closed out the presentation with a discussion of how this clinic would fit into our schedules, what procedures would be done and our goals of going paperless. We plan to provide a broad range of palliative care procedures at first, however the vision is to become a comprehensive care clinic. More complex cases will be referred to Squire Hall, but simple operative, extractions and other procedures such as those could be performed on site. The logistics of how the rotation will work are being decided. Currently, the thought of having a vertically set up rotation, in which students rotate once a week through the clinic for the semester is gaining popularity as it would provide students with an experience that we do not already have. 

While we have made a great deal of progress, this is still a work in progress and the questions we received were all a great help. We're very excited to gain access to the building in January and begin our move in. If there are any other questions or concerns they can be directly to any of us via our emails. Hope everyone is as excited as we are about this new venture! 

D3 Fall Post Midterms

Crazy as it sounds, and as much sacrifice that this year has taken so far, D3 is great. Class all day Tuesdays and Thursdays is brutal, but seeing patients Monday, Wednesday and Fridays makes up for it. This past week we had exams in Fixed, Removable, Pharmacology and Endo. Pharm is the obvious killer. Public Health class is getting better, just hard to debate things at the end of the day. The other week we had an interesting talk about dental therapists. Talking about this issue in dental school makes me feel that I need to put in a little extra effort to get the whole story. For anyone just reading for fun, dental therapists, or mid level providers are dentistry's equivalent to physician's assistants and nurse practitioners in medicine. They would work under a dentist to provide care in uncomplicated cases. Simple restorations, preventative treatments and patient education would be their primary roles. The thought is that these practictioners will bring down health care costs in dentistry, and increase access to care in underserved areas of the nation. The concern about this strategy among dentists is that dental treatment is often irreversible, and complications arise without warning at times. Having a provider with less training and experience puts the patient at more risk than it benefits them. The issue has many more angles than I understand at my current position, but it's all very interesting. I've seen videos from states like Minnesota that are very appreciative of programs such as these and that patients that normally would not be seen, are receiving treatment.

The access to care issue is really interesting to me and it's disheartening to hear stories about the dental care crisis in the U.S. Again with many of these issues, there is are always many factors at play. I read an article the other day where dentists in Michigan are doing something really cool. Since dental insurance isn't as widespread as medical insurance, people often don't seek out continual dental care and end up in ERs with dental problems. The ERs are generally not prepared for these types of problems, and there is little that can be done many times, beside a referral to a dentist. Dentists in Calhoun County Michigan have set up a program where uninsured patients who have dental emergencies can recieve treatment, in exchange for community service. Since private offices established the program, there isn't as much paperwork as government run programs and they can run the program as they wish. The Medscape article can be found here. I'd encourage everyone to check it out.

But back to actual school. I've completed my first set of Interim Dentures! They'll be off to the lab tomorrow (fingers crossed). I set a lingualized occlusion, where the maxillary buccal cusps do not make any contact during excursions. There is 1mm of overbite and 1mm over jet. The next steps will be to finish and polish them once they are processed, then bring the patient back for extractions of the remaining anterior teeth, and insertion of the interims. Next semester we'll go through fabrication of the definitive upper and lower dentures which I'm looking forward to.

My first crown is finally back from the lab also! Upon initial evauluation on the cast, the mesial contact was actually open, but our lab in school was able to fix that no problem. There were no positives on the intaglio (inside) surface, the margins looked clean, and occlusion was correct. Moreover, the porcelain appears to be completely intact and sound. I can only hope the definitive restoration fits the natural tooth as well as the cast.

Also getting started on my implant case for this semester. Primary impressions were taken a while back. in the school the next steps involve meeting with an implant fellow, waxing in the tooth to be implanted, and creating a surgical guide. So far I've got the tooth waxed in but the guide needs to be done under the implant fellow's supervision because the machine we use is newer than the one we initially learned this with.


So in short, third year is great. Oral path exam this week and Medical Emergencies is finishing up also. More to come.

Cheers.

Buffalo Niagara Dental Convention 2013

Talks of 2013 were great. This year we got to stay for the full two days, rather than just one. Normally I'd lean toward hearing speakers outside of UB since it's nice to hear different perspectives, but this year I checked out Dr. Panteras Everyday Endodontics, and Dr. Brewer's Digital Dentistry. More than the talks, the vendors really appealed to me this year. Spending 3 days a week in the clinic, doing our own lab work and working with patients puts us in a much better place in terms of what we're looking for in materials and products. In the school we're using Straumann's Implants, but it was great to hear what else is out there. I spoke with AstraTech and got some interesting information on their system. I learned there are a ton of other bur distributors out there and I'm curious to try their products before graduation since one is a local company,

What I really loved though about this convention was the labs that were there. Spent some time talking to Vincent Martino Labs, which I got the impression was a small lab up around Buffalo. What I really was impressed with was Evolution Dental Science Labs. I have this intrinsic admiration of lab techs for what they do. Most of the magic in dentistry is all in the lab. The beautiful restorations all come from them for the most part. As dentists, we decide what is in the patient's best interest, and how to handle the case, but the technicians actually fabricate the solutions, and that's something incredible. Anyways, they're a bigger lab, that always has a presence at the convention. They're cool new thing this year was a system for digital dentures. The dentist takes upper and lower impressions and bite registration, and sends it in to them. They then have a digital scanning system that scans the impressions, digitizing them and allows them to create a denture virtually with sockets for the teeth to later be cured into. The design is then milled into a material denser than the usual denture acrylic. This material is denser, thus houses less bacteria and is stiffer, leading to a better, healthier fit. Since the denture is milled, there is no shrinkage to account for which alters the fit of traditionally made injection molded or compressed dentures.

The dentures they had ready made as models were great, normal looking dentures, but what I found really cool were these wooden dentures they had just for show. Not the greatest quality picture, but pretty cool having machines that can mill different materials.

I really admired the techs that were there that I had the opportunity to talk with and spend some time with later on at their sponsored event. They're passionate about what they're doing and willing to share their knowledge. Since we do our own lab work at the school it also was great to get some feedback from others doing the same work at a much higher level. A couple invited me out to the lab to check things out which I'd really love to do. Hopefully in the near future. 

Dr. Paul Farmer visits Canisius College

Dr. Paul Farmer was amazing last night. I think I might have been a little lost in the hype at first but he’s an incredible person. For everyone who doesn’t know, Dr. Farmer is one of the founders of Partners In Health, a large non-profit that works to bring medical care to the poorest places in the world. Dr. Farmer started PIH while he was a medical student at Harvard Medical school. He's also one of my personal role models and an inspiration as an aspiring health care professional. According to Kidder’s biography, Mountains Beyond Mountains, Farmer would skip classes during the week his first couple of years to work clinics in Haiti, and return to Boston for exams and clinical rotations. His passion for people and health were evident. 

Dr. Farmer premised his talk with a overview of the health care system in general. There were three parts in his eyes: Discovery, Development and Delivery. Discoveries made in labs, such as vaccines, medical equipment etc, need to be developed into products that can be utilized in the delivery of care. As a physician, Dr. Farmer sees the system in realm of delivery. He spoke about the enormous amounts of people in the world without access to care and sought to change that, and to a great extent, he has.  He mentioned the negative mentalities that people in high places had for years in terms of providing care to the poorest nations. Statistics about how it could never pay off, and was completely unfeasible. My favorite part was definitely his citing of  a couple quotes from a couple government agencies, which basically was them giving excuses why these poor nations are not worth even trying on. Dr. Farmer responded to these quotes with fervor, tearing them down and totally disproving them with his entire career. 

Issues of cost in health care came up as well. The vast disparities between cost of drugs and medical supplies in the U.S. is obscene. He mentioned that health care is a strange field in that aspect. If any other good or service ranged in cost to the extent that health care does, heads would be turning, but given the complexities involved in health care, somehow they get away with it. Nonetheless, even in the face of cost, Dr. Farmer was able to raise money and secure medications for his patients abroad in order to treat AIDS/HIV, Tuberculosis and even cancer in the poorest nations in the world. 

The motif that we can learn from these nations was recurring. The idea of “community based healthcare” and how in some parts of Rwanda, higher percentages of people are gaining access to health care than in parts of the United States. 

All in all, Dr. Farmer was inspiring. Despite what people say about him not being a great family man, he’s an incredible person. He found something worth fighting for and changed the world. Given the unbelievable turnout I know many others agree. After his talk he took 8 questions, but stuck around to speak with the long line of guests that waited to meet him. 

All Dr. Farmer spoke about medicine is even truer in dentistry today in the U.S. Costs of oral care are often too expensive for people, and insurance has not done much in the way of solving this problem. This article on DrBicuspid.com talks about America's Dental Care Crisis, and the people of Wisconsin, Minnesota and other states who are in pain, suffering from a lack of dental care. Dentistry as a whole requires a change if care is to be extended to the underserved populations in this country. Overhead for dental care in general is miles above that of a primary care physician's office. Progress is being made in the way of Community Dental Care Coordinators, to aid in the access to care issue. Today dentists, possibly even moreso than physicians should be concerned with our delivery of care, and how we can extend care to those in greatest need. 

Soda and Teeth

This intense video popped up on a LinkedIn dental group. The ominous music and narration really get the point across: drinking soda frequently will destroy your teeth.

Implant Dentistry

The UBSDM boasts an impressive 98.2% success rate for dental implants. I feel we've been getting a great education with regard to implant dentistry as a whole. Last semester we went through the treatment planning process,  risk factors, biomechanics and theory. At the start of this year, we went through a demonstration and hands on simulation of the surgical placement of the Straumann dental implants we will be working with.

A little bit about these implants - they're pretty awesome technology. Medical grade titanium, acid-etched and sand blasted surface chemistry that makes them very biocompatible. The surface is apparently so hydrophyllic that there are images of blood seeping up onto the implant surface as it is being placed. Sounds gross, but in dentistry, that's incredible.

The procedures I've followed thus far were pretty straightforward. Patient presents with either a tooth to be extracted, or an edentulous ridge desiring an implant. Space has been the primary consideration. Once a tooth is lost, the other teeth in the mouth begin to shift mesially, or toward the midline, to close the space. The opposing tooth, above, or below the edentulous space also supraerupts into this space. In some cases we can make a removable prosthesis with a tooth to maintain the space before implant placement and during healing. Treatment planning is essential from the start for a successful implant case. As I mentioned, space is critical. There are a number of different diameter implants and the diameter chosen is based on the mesio-distal space, amount of bone, and tooth to be restored. Ideally, we also want the implant to be at least 1.5mm away from any adjacent root structures. 

At UBSDM we utilize Cone Beam CT scans to analyze bone density, and locate critical anatomy such as the Inferior Alveolar Nerve that runs through the mandible. An implant must be placed away from this nerve, to minimize the risk of damage. After placement, the implant is given 3-6 weeks to osseointegrate, before being restored. In order to restore the implant a careful impression procedure is followed, and a temporary crown can be made in the lab prior to the placement of the definitive.

Third Floor Emergency

Coming back to Buffalo a couple weeks before school starting was one of the best chance decisions I've made. The school emailed 3rd and 4th year students early on about the opportunity to work in the Urgent Care Clinic in two week increments. Today marked the final day of emergency and I just wanted to reflect back on the experience.

Rotations are generally a hit or miss ordeal. Some days, chairs are booked and we're busier than we can handle, and others we're lucky to see a couple come on. People have lives outside dentistry and it's clear dentistry isn't always a person's number one priority. In emergency situations however, people tend to show up. I didn't really have expectations for this summer rotation, but am extremely pleased to say my chair was full about 95% of the time. After spending some time shadowing earlier in the summer, I had a better feel for the pace of practice and brought that to the clinic. Patients would present, the five of us were assigned a patient, and off we went. Initial assessment always involves a review of medical information, any allergies, heart conditions, joint replacements, adverse reactions to anesthesia, etc. And quickly onto the chief complaint. I've come to appreciate the "problem based exam" as an integral part of treatment. While patients will present for recall appoinmtments and be subject to comprehensive examinations; the limited exam gives us as students the chance to practice our diagnostics, and treatment planning simultaneously. It also forces one to think creatively, on your feet, which will be required constantly in practice. Just to recap a few things learned in the past 10 days:

1. Check Occlusion Manically: I had a couple of appointments where something being left slightly high in occlusion either caused a temporary bridge to fall out, or massive amounts of pain for a tooth that recently underwent a pulpectomy. According to one faculty,  a tooth with an acute apical abscess may hyperocclude after treatment, and it is integral for the tooth to be in light, or sometimes completely out of occlusion. Further, in terms of checking occlusion, one doctor had advised that we check occlusion in the prone and upright position since the differing direction of gravity on the jaw could alter occlusion.

2. Denture Adjustments: Dentures are an experience for patients. For patients that I saw requiring sore spot adjustments, this was not their first. PIP is a great tool for assessing gross sore spots, but a bit of indelible marker can also be helpful if the sore spot is localized.

3. Protective Restorations:  This seemed to be a "treatment of choice" the past couple weeks. These patients often require a crown, and possibly a core, but in the emergency setting we do not begin that kind of comprehensive treatment. Instead, if the fracture has not extended into the pulp, we pulp test the tooth to ensure it is vital. Often teeth that undergo trauma, can lose vitality. Faculty more often than not, advised I use Fuji IX as a temporary fix until the patient was assigned for comprehensive treatment by a student. Fuji IX is a true GI in that it is fluoride releasing, has a coefficient of thermal expansion similar to natural teeth and is wear resistant. I also have a few patients of my own currently in GI protective restorations so I'm looking forward to seeing how well it held up.

Besides the little clinical tidbits, just working in the school, getting to know the assistants, and the protocols for lab work, radiology, and the way things work was great. I'd have to say this rotation is one of the little things that makes a big difference in becoming comfortable clinically. Looking forward to getting back into the swing in the next couple of weeks.

Cheers.

Summer 2013 - BOARDS OVER!

This is a joyous day indeed. Leaving Prometric I definitely did not feel as confident and relieved as I wanted to. I assumed the worst and tried to accept that, so that in this miracle of God that I passed, I would be beyond relieved. And here I am, ever grateful and thankful for this. That being said, I can now be at complete peace for a few days before heading back to school.

This summer has been fantastic. After boards decided to head home for a few weeks, relax and rejuvenate before tackling D3. Currently reading Man: Medium Rare by Ian Brown - a book I found at the Allentown Art Fair. Somehow I always find myself reading sociology books when I have leisure reading time. Also been flipping through Everything Is Marketing  by Fred Joyal, a dental practice growth book. I brought home our Fast Foward MBA in Project Management book as well that we recieved as part of the 1500 Broadway project and thumbed through that as well.

More on the dental side, I've been shadowing a general dentist who I've shadowed since before being admitted to dental school and its incredible how much of a difference two years makes in understanding the ins and outs of dentistry. This summer more than ever, I've learned to appreciate the high skill level of an experienced dentist, the importance of compassion in the clinic and that dentistry really is a team sport. Also, there's so many materials out there and I really want to make a chart or something organizing what's available.

Earlier in July Dr. Rice from IgniteDDS gave a webinar on "Getting to Yes" which was really informative and interesting. The presentation made me think differently about how we treat people, basically disproving the golden rule. The concept is so simple I was surprised I never thought of it. Don't treat people how you would like to be treated, rather, treat others the way they would like to be treated. Makes perfect sense. He reviewed the DISC behavior analysis with the group and encouraged us to try this out for ourselves. I'd like to. It's really great that we have someone to teach us these things that aren't covered in school.  I know patients will surely appreciate the efforts we take to make them more comfortable.

And a preview of things to come:

Looks intense, should be a good time though. Got some great cases to work on so far and hopefully more to come. Pharmacology will be a challenge for sure.  Definitely excited for that Public Health course, and cariology.

Cheers.

Well, this is nice. :)

National Board Dental Exam Part I

So I've been scheduled for the exam for a while now, studying on and off lackadaisically, but this week starts the high gear learning. The exam basically covers all of the basic sciences we'ved learned up to this point. Gross Anatomy, Dental Anatomy & Occlusion, Microbiology & Pathology, Biochemistry & Physiology, and Ethics/Professionalism. I scored a set of the 09-10 Dental Decks off a friend, in addition to the First Aid for the NBDE Q&A which has a ton of practice questions. I'm still figuring whether I want to get the First Aid Review Book, or the Board Busters. The current plan involves getting through the decks for a foundation, then studying the details from a book and old lectures. Having gone through a handful of Dental cards, all Biochem and about half of Micro, things aren't too bad. I really feel like our classes have prepared us well for the exam, since most of the questions on the decks have been covered on previous exams and lectures. The craziest part about the exam to me is the length - 8 hours. Should be exciting.

So to set a plan in stone:

May 27th - 31st: Finish Micro/Path
June 1st - 7th : Gross Anatomy Decks
June 8th - 14th: Dental Anatomy/Occlusion Decks

June 15th - 18st: Review Biochem/Physio
June 19th - 21th: Review Micro/Path
June 22nd - 25th: Review Gross
June 26th- 29th: Review Dental Anatomy/Occlusion

June 30th - July 5th: Nonstop Practice Questions

Ethics will be thrown in there every time I'm totally exhausted from sciences. Been through those cards and they aren't bad. Power month coming up. God help me.

Cheers.

D3: Onwards and Upwards

Officially checked out B28 Preclinical Lab today, marking the end of the second year of dental school! I'd say I'm half a dentist, but it doesn't feel like half way just yet. After Part I of the NBDE, then I'll assume that title. Nonetheless, it was bittersweet handing in the key to my drawers after having spent so much time right there, developing skills that I'll take with me into the clinic and away after graduation. We often see upperclassmen in the lab so it's not so much a "farewell", than a "be back later" kind of deal, but it's a definite change.

We are issued a giant, heavy, white box of supplies, which serve as our new "lab drawers". Back in the day when students had their own chairs in the clinic, the boxes easily be brought to your chair and left there for easy access. These days, I dont think I've seen one person carrying those huge things around. Instead, we've donned "clinic bags" of sorts to bring up whatever supplies we'll need.  I was lucky enough to find a nice black cosmetics box in our attic at home, which fits my supplies perfectly! But like most things in school, people do what works for them. Some like the freedom of having everything on hand. So after unpacking the white box into my clinic bag, the box will sit nicely in the closet, probably until graduation.

Reflecting on D2, I'd say was way more fun than D1. Tons of lab work, but also a lot of dentistry. Constantly cramming just became a way of life. There's quizzes in every class, which keep you on your feet. At first I definitely remember feeling overwhelmed by the 5 or 6 casts we had to have poured, impressions and wax-ups that were due, and preparation for tests and quizzes, but all was well. Looking back on individual courses:

Endodontics I
Endo was awesome. Probably one of my favorite courses so far. The class is divided up into groups of about 8, and assigned different instructors who grade projects and teach technique. You can of course ask any professor for their opinion, but asking the one whose grading you is usually most wise. But preclinical endo is great. Dr. Pantera plays Pandora, or the occasional movie and we go at it on our extracted teeth. The projects are on different teeth each week, and the lecture part of the course correlates really well. Although I feel like I've learned a lot, I can see clinical endodontics being quite challenging. Visualization in posterior teeth, or even anteriors may be a challenge, since they are fixed, rather than in our hand. The only improvement I could think of is having a typodont where mounted teeth could be placed, to simulate clinical endodontics. Working with extracted teeth was a great experience though, to teach the complexity of the root canal system, how instruments feel cutting actual tooth structure, and tons of other things.

Ethics and Law

Awesome class, and I hope we get more of this because it's really important. Dr. Gary and Dr. Maggio are really passionate about the subject, and it doesn't hurt that Dr. Gary is also a lawyer AND a dentist. The class touches on a lot of subjects that will definitely arise in practice, and teaches the ethical and legal obligations to dentist. We also covered a bit of social media, which gave me some guidelines for this blog.  I personally thought quizzes and the class was overall fair, although like any ethics class, there are subjective areas that will encourage more discussion than probably was intended. Aside being amazingly relevant to dentistry, I liked the information the class taught about how the clinic at the school runs, and Dr. Maggio's survey results about successful students in clinic, and patient interaction. Simple things like communicating clearly, being more accommodating and courtesy can help dentistry run much smoothly and improve the patient experience a ton.

Indirect II

Indirect was a challenge for me at first. This class really showed me how important attention to detail is, and the professors drive that home over and over. Cheers to everyone for getting through the infamous 3-unit bridge project. Luckily, the competency was a #30CCC rather than a #18-20 FDP prep. But the bridge definitely got it's fair share of attention. I think I must have waxed, broken and rewaxed it 5 times, and casted it twice. We're not required to cast our own, but I'd suggest it for anyone with any interest in the casting process. We had a lecture from Dr. Conny about lab work and dental school which gave me some basis for constantly being in B28 second year. Dr. Conny is an incredible prosthodontist who has done his own lab work for many years in private practice and stressed the importance of dental students understanding the process lab technicians go through to fabricate restorations and dentures. Dentists these days are placing more indirect restorations thanks to CEREC and increased demand for more esthetic, tooth like solutions, yet, dental students are doing less lab work. He presented examples of dental lab work authorizations with outrageous requests, clearly showing that the dentist did not understand the process which must be followed to fabricate the crown/bridge/denture/etc. So if you're a dental student drowning in lab work thinking, "This is pointless, I'm not going to be a lab tech", know as a future dentist, you'll be a customer, and a supervisor of a dental lab one day. And supervising something you've never done before, might be quite difficult.

Removable II

Went through partial dentures this semester. Now those mysterious tooth replacing apparatuses in patients mouth's make a lot more sense. I can see removable being really tricky, but amazingly rewarding when things come together. Lecturers were again great, and Buffalo has really helpful prosthodontists that are really passionate. For my own future reference the process for removable includes: Primary impressions, secondary impressions, pouring of a diagnostic cast, surveying, determining the need for survey crowns, preparing guide planes, heights of contour modifications and rest seats, then taking an impression for the master cast. If a survey crown is indicated, we've learned its better to make your modifications before taking the impression of the crown prep, so that the lab can fabricate the crown according to the modifications. The specs of the crown should also be clearly communicated on the work authorization.  Some upperclassmen mentioned they hadn't had the survey crown experience so I'm really glad we had the opportunity to work on one. Survey crowns are crowns that are made to fit the partial denture framework. They're usually indicated on teeth that are excessively tilted, or that may require a crown due to caries or other pathology.

Oral Sciences II

Learned some valuable knowledge here and Oral Sci was really well run. Not really much to say about this course, except that brute memorization only goes so far. Dr. Cho really emphasizes understanding the material, for your own benefit as well as that it's on the board exam. So the three hours on Monday afternoons spent in a basement other than Squire's, was well spent. The coolest things I thought came out of Oral Sci was learning about the science behind periodontal treatments like  PDGF, and the experiments our own faculty went through to develop advances in their field.

So that's about it for D2. D3 starts full swing on Monday with a full day of clinic! #letsdoit

Sensitive Teeth?

Teeth are composed of a fewbasic tissues. Enamel, the hardest substance in the body covers the crown of the tooth, which is what we see clinically. Dentin underlies enamel, making up a bulk inner portion of the tooth. Cementum, which is normally under the gums, covers the root of the tooth and helps anchor the tooth into the jawbone. And finally, the pulp, which houses nerves and blood vessels is within the dentin and extends down into the root.

Gingival recession may occur in some patients due to mechanical or biological irritation. When the gums recede, this exposes the less mineralized cementum, and sometimes dentin. These tissues are more sensitive and when exposed to the oral environment may produce pain. The Hydrodyanmic Theory of dentinal sensitivity is an accepted mechanism that explains this sensation. Dentin is made up of tubules, containing fluid. Changes in osmolarity (concentration), or temperature, causes this fluid to move either inwards, or outwards, which is perceived as pain.


Treatment for dentinal sensitivity is focused on plugging these tubules, or covering them somehow. Colgate's Duraphat Fluoride varnish is a remarkably easy and effective treatment option for patients with sensitive teeth at UBSDM! It's a 5% Fluoride paste that's basically painted onto surfaces that are sensitive and is left on for the rest of the day. We advise patients to avoid hard foods for at least two hours.Restorations may also be placed subgingivally in some cases to treat sensitive teeth. It should be noted that every case is different and may require alternative treatment.

FirstCare* Dental

Clinic-in-the-making Update!

In the past couple of weeks we've made some progress on our start up community dental clinic at 1500 Broadway! We'll be known as UBDDS: FirstCare Dental. Great name since we're literally one of the only dental institutions for the community in that area, and we're anticipating a great deal of urgent care patients. ECMC also has had patients coming in with dental emergencies, so we are hoping to intercept those patients via referral or directly once people know who we are and what we do.

Marketing-wise we'll also be working on a presentation of sorts, to present to those interested in our start-up. Once that is underway, I'll be touching base with someone at the school who is experienced with grant writing. We'll be looking to find additional funds, being that we are a non-profit in an underserved area.

Fridays's meeting consisted of an awesome discussion of the potential services we'll be offering at FirstCare. Since we'll be primarily Medicaid based, our offered procedures will be heavily influenced by what is covered. But we will also have to strike a balance between what's covered, and the demands of patients.

Came across a pretty nice graphic of tooth decay on Tumblr!
Source: http://www.dentalcaretoday.com.au/patient-education---tooth-decay.html

1500 Broadway: Community Clinic in the Making

1500 Broadway. Future home of UBSDM's first student run dental clinic! Five other classmates and myself have had a couple of meetings with the administration already and things are finally starting to take shape.

This building was a community health center some years ago, but then was shut down, and has been closed up since. As a community health center, it not only provided health services, but also served as a place for people in the community, to socialize, and relax. Ideally I'd personally love to see it turn into something like that again.

Today our agenda included a detailed tour of the facility, to gain a better idea of what we will be working with, as well as checking out the equipment that has been purchased to be used once the renovations are complete. Our dental area of the building is situated next to what will be a mental health facility on the first floor. The second floor will be a medical clinic and the basement is mainly used for storage and other machinery. Since the building has been closed down for some time, it's not in the best condition, but we were all really excited to see the space, and I couldn't help imagining how awesome this will be once we're open.  While in the basement Kevin (our dental repair expert) gave us a brief rundown about the dental equipment. The heart of any practice is in the vacuum pump and the air compressor. In setting up a dental practice  these are two pieces of equipments that one should not look to take a cheaper option on, because without suction, or compressed air, there isn't much dentistry. According to Kevin, generally air compressors run ~$6K and vacuum pumps around $5K.

We also paid a visit to a storage facility where we're currently keeping the dental chairs, and furnishings for the clinic until it's renovated. I was thrilled to see the chairs were top of the line, all the usual instruments, attached sink, but also an LED monitor! All the more reason to push for intraoral cameras, and some other awesome gadgets. The chairs are made by Adec, which is a state of the art brand and go for around $17K -$25K.

We're now focusing on creating the business plan. We've divided up the project into parts so that we all have something to work on ourselves, although we will be involved in every section. The picking of sections could not have worked out better, since we all had interested in different things. I'll be taking on the technology role, and I really can't wait to do more. I'm considering talking to a local dentist to see what their opinion would be on reasonable technology.

Last week we met with the architects, and Erie County representatives, to discuss renovations which will be taking place. Our current projected floor plan includes 5-6 operatories, an IT room, break room, waiting area, reception, file room, sterilization, potential dental lab, and more.

This whole project takes me back to the bioengineering entrepreneurship days. Creating value, seeking out opportunities in change, and serving people. The big change up here has been the closure of many public health care facilities, leaving people to seek private care. So, we have the change, the people adversely affected, and now the funds to innovate. I see the vision being to improve the health and happiness of the people in  the community, and there are so many ways to do that. Clearly, as an oral health care facility we will be providing care, but deciding what specific services remains to be determined. We'll need to be ready to embrace any population that may present, and be willing to adapt to their needs as well. The greatest challenge and most exciting part of new ventures - nothing is for certain, except our commitment to the cause.

Crown Lengthening

When restoring a tooth with a crown, we strive to have at least a 2mm ferrule for proper retention. A ferrule can be thought of as the surface which the crown engages the tooth. Sometimes when there is little tooth structure left, a crown lengthening procedure can be done to gain the necessary tooth structure needed for the tooth preparation. The procedure can be broken down into five steps: (1)Achieving proper anesthesia, (2) opening an full thickness envelope flap, (3) debridement/gingivectomy, (4)osseous reduction and (5) suturing.

Primarily, the patient is administered lidocaine with epinephrine, or a suitable anesthetic and adequate time is given for the anesthesia to be achieved. We then make an incision on the buccal and lingual aspects of the tooth being lengthened. The incision however spans from the mid-buccal aspect of the tooth mesial and distal to the target. For example, If we are lengthening #4, the primary incision is made from the mid-buccal of #3 , along the gingival margin to the mid-buccal of #5. It's important to be sure that the incision is made straight through the periosteum for the creation of a clean flap. An identical incision is also made on the lingual aspect and the gingival full thickness flaps are freed from the bone using a periosteum, or curette. This step can be quite time consuming, as we want to be sure to clear all interproximal tissue before initiating the osseous reduction. Next, an end cutting bur is used in the reduction of the alveolar bone surrounding the tooth. The end cutting bur allows us to remove bone, with less risk of damaging tooth structure. Once the reduction is complete, two 4.0 silk sutures are placed, introducing each from the buccal aspect of the interproximal areas.

Post operative instructions are similar to those given in the case of an extracted tooth. The patient is advised that they will be sore in that area, and may ooze some blood, which may look like more than it is actually due to the blood mixing with saliva. They should brush the area, only very gently  and avoiding flossing the area for a couple of days. Ibuprofen is recommended to control pain, every 4-6 hours as needed.

Came across an incredible TED Talk on a friend's wall about the physical exam. Dr. Verghese's ideals can and should be taken into account with regard to our head, neck and oral exams. Love this.

"Rituals are about transformation, the crossing of a threshole, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: 'I will see you through this illness. I will be with you through thick and thin.' It is paramount that doctors not forget the importance of this ritual" - Abraham Verghese

Bridges

Bridges are used primarily for tooth replacement. In lab we're working on preparing a 3-unit bridge, replacing #19 (lower left first molar). To do so we prepare the adjacent teeth as abutments in a form that makes for adequate retention, support and stability. The hardest point thus far is creating a path of insertion parallel to both abutments, and not creating undercuts, so that the final restoration seats correctly.

Clinically, bridges present the ethical dilemma of preparing sound tooth structure, which is something we always want to avoid. In some cases, all teeth involved in the bridge may be carious and should be replaced, but this may not always be the case. With the advent of implants and their becoming more affordable, we should eventually be able to replace a tooth without having to compromise any others.

Once we prepare the teeth, an impression is taken, a Jadestone cast poured and the teeth are once again waxed up.The tooth being replaced is known as the pontic. In our case, #19 is our pontic. We create a heart-shaped/conical pontic, with a point contact on the mucosa to allow for cleansability. The teeth are waxed together as one unit by connectors placed in the interproximal region. Our connectors were made to be 3mm x 2.5mm, but this can vary. Ideally we also want the teeth to contact in the same places that they do on the contralateral side. In this case, I created contacts on the Buccal cusp inclines, and distal marginal ridges of #20, #19 and #18. Tricky, but all the more satisfying once complete.

Next step - investing, in our phosphate investment material - Formula One. Then casting. This time around, our rings are being cast by the lab  technicians. More fun to come! 

Spring2013

Back to the grind.
Removable, working on making upper and lower partials, Indirect, doing a 3 unit bridge, and Endo we're starting off with an anterior. Clinic starts in a couple of weeks and we've got to call our patients to see whose available and review their charts. Quizzes and projects galore 1.5 weeks in. Lets go.

FHI Haiti 2012: Final Clinic

12.31.12



Our site today was at a clinic in Carrefour, on Arachon 32 (a road). On the ride there I had no idea what I would be doing. I came prepared with the dental supplies, and luckily the Haitian dentists and students also arrived so the dentistry would continue! Initial setup was hectic since I had to basically create the dental clinic on my own. We were set up in a small room in a building next to the main clinic.  Terrible lighting, very small, but we managed to make do. We set up two chairs, one of which was a wheelchair, that locked in place, and we brought the mobile dental chair as well. Childrens' chairs were used as our tray tables, a bucket with a bag for dirty instruments, and clean ones on the other side of the room. Once again, we had a ton of patients, extractions and cleanings all day. Wilkey, was an awesome translator for me all day. He stood by my side through lunch and until the end where he refused to eat without me. At the end of the day when Dr. Marabishi Jasmin got us all together for a "closing ceremony", I know Wilkey must have said something to him because I was honored to get a shoutout for the hard work from Dr. Marabishi Jasmin.














(From left: Valesca, Sylvia, Jefferson(Haitian Dental students), Karen)



One moment that day I won't forget was when Wilkey started telling me that we'll have a special patient today. A tooth that has been bothering his mother for a long time needed to come out. I ensured him we would take excellent care of her. When she arrived however, I reviewed her medical form and found that her BP was much too high for us to do anything. My heart literally sank. There was nothing dwe could do and I felt helpless. Dr. Hubert and Watson also agreed that we needed to give her antihypertensives and wait. I talked to her with Wilkey about diet and exercise and explained the situation, and Wilkey understood. I know it's going to happen, but I never, ever want patients to leave my chair in pain.

Once again dental was the last to finish up and I had to turn away one patient since the traffic would be killer if we didn't stop when we did. New Year's is a big deal in Haiti because Haitian Independence day is January 1st as well. I was also told that the Haitian revolution was one of the only slave rebellions to lead to the development of an independent state during its time. So all the more reason to party hard. At the closing ceremony, Dr. Marabishi Jasmin spoke one last time and prayed. He presented our team leaders with a piece of Haitian artwork, and voiced his appreciation for the relationship we have, and the opportunity to work together to serve the people.

That night we had a bonfire and counted down to the new year. One of the best new year's ever.

FHI Haiti 2012: Empowerment

12.30.12

Incredible past two days of work alongside Haitian dentists, doctors, nurses and students. Yesterday we worked in a location in Carrefour where Dr. Marabishi Jasmin is trying to start a clinic. The people of the town had been expecting us for and were all very friendly and appreciative. We set up in a church. Registration and triage in the fron, dental in the back of the triage area, optometry a little further toward the back. Our dental team say about 17 patients, all extractions and cleanings. Worked through lunch as usual, but ate at one of the Haitian's house across the street, which was delicious. Chicken and rice, very well seasoned.

At the close of our clinic, Dr. Marabishi Jasmin gathered everyone, Haitians and Americans, in a circle outside the church. Hand in hand he said a prayer thanking us for our work and for the future of Haiti and those in need. He spoke sentence by sentence, the translator echoing his words in English. In those moments I knew what it meant to be connected, compassionate and genuinely happy. Afterwards I spoke with a Haitian who was volunteering in Spanish and that was really great. I had been adding random Spanish into my Creole unknowingly, so being able to just speak Spanish was great. He expressed such grace and gratitude toward our work, that all I could do was thank him and pull him in for a hug. I knew I wouldn't be able to find the words to say that they have given me so much more than I could give them.  He has dreams of becoming a doctor to serve his people and initiate change. I told him I hope I can be right there with him when he does.

Ryan and I carried the Haitian's dental chair down a muddy, rocky Carrefour street along with the others carrying supplies. We piled into the bus with the translators for the ride home. Spent the night on the rooftop of the hospital with the team with a couple guitars. Perfection.

Today clinic was held right at the Hopital Miracia in Merger. A bunch of us decided to take a hike up the hill but it ended up being much longer than expected. Got some gorgeous views though, and got a little bit of exercise. We did make it back in time for clinic, but time is always a scarce resource. The "Clinique Dentaire" had two operatories with actual dental chairs, however they were electronically nonfunctional, so no restorations today. While setting up I noticed the long line outside of about 30 people awaiting registration. Never a dull moment in Haiti. I worked with Dr. Timote and Dr. Noel who were very helpful and I really felt more empowered by their comments and teaching than I was empowering them. Dr. Noel was an amazing teacher, showing me exactly how to position the elevators and how to anchor the mandible with your free hand to get more leverage. Ryan commented to me about one maint difference of dentistry in Haiti vs. the US being the future planning. In the U.S. we always seek to restore missing teeth, whereas in Haiti the primary concern is removal of the diseased tooth, and prevention of infection. This allows them to be a little more aggressive with extractions than we may be here. Nonetheless, I still admired their ability to get these teeth out quickly and entirely.

Ryan graciously took the time that night to teach me the method in which we write prescriptions, so that I would be able to manage patients in future clinics more independently. He also will be leaving a day earlier and missing the last clinic so the dental team would be me and the Haitian dentists and dental students, who are not familiar with the American pharmaceutical code. The template is as follows:

To prescribe Amoxicillin, the directions are to take one tab every 8 hours, for 7 days. We write this "1 tab q8h x 7d." Then we calculate how much to dispense, 24/8=3, times 7 =21 tablets. So the script would be:

Amoxicillin: 500mg
Disp: 21 (twenty-one) tabs
Sig: 1 PO q8h x 7d

"PO" = "by mouth".
Sig = Instructions
Disp = Dispense

For Ibuprofen we used:

Ibuprofen 800mg
Disp: 42(forty-two) tabs
Sig: 1-2 tab PO q4-6h PRN

PRN = as needed for pain

If patients had allergies to Amoxicillin, we had clindamycin. If they were irritated by Ibuprofen we used aspirin. Of course dosing would change based on the patient's age, weight and height.

Tonight it's hitting me that I'll really miss all this. The morning ginger/citronelle tea, breads, incredibly creamy avocadoes, the children that despite their poverty smile so brightly and always made my days; The dentists who guided me hand in hand and built me up, singing Haitian songs on the bus with the translators, and most of all the genuine kindness and good nature of the people. Astonishingly, almost every patient, except 2-3 had any sign of distaste, discomfort, or wincing. They were the perfect patients. I know a few months down the line I'll be bogged down with work but I can only hope that I keep in mind that dentistry is so much bigger than what we see and think.

FHI Haiti2012: Fond Parisien

12.28.10

Did my first extractions today! In a small hut in the countryside of Haiti, really felt incredible and I can't wait to do more. Ryan walked me through the procedure on the bus, and on a few patients before helping me out with my own. First we free the gingiva up around the tooth with a periosteal. Next, use the straight elevator to elevate the tooth from the buccal. Usually the mesio-buccal but distobuccal is also all right. Ryan advised against elevating from the lingual because you run the risk of injuring nerves and arteries. Elevation widens the alveolar bone  around the tooth. Once the tooth begins moving we elevate as much as possible before using a forceps. For mandibular molars, the cowhorn forceps lock into the furcation and we rock the tooth facio-lingually while making figure-eight movements. Controlled slow pressure. Once the bone is widened enough the tooth generally comes out easily. After a couple more guided ones Ryan and I manned our own chairs in our small hut. We saw about 15 patients between the two of us, and had some really complex cases, considering there was no electricity. Ryan mentioned that in the US a bunch of these cases would easily be surgical. We worked through lunch and were the last group to finish up. We prescribed the patients amoxicillin, and ibuprofen after their extractions and sent them to the designated pharmacy to pick up the medications. After seeing tons of extractions from shadowing, I was surprised at the strength of the bone and teeth. There really is a good deal of force necessary to take out teeth. Dentists really know how to make it look easy. 

(This was actually a church that was flooded after the earthquake, the small bit peeking from the water is all that's left)

                                                  (Our dental "clinic" was one of these huts)

This site is said to be the poorest, most devastated that we'll see, and the setting lived up to that. Upon arrival I was heartbroken by the sight of small huts covered with USAID tarps, hay rooftops, and children in tattered clothing. I immediately wondered what they ate out here, and it was clear that there wasn't much by the cries for food from the people as we disembarked. 

We spent the day working with a few Haitian medical students. Ryan and I grabbed Mackenzie, who was one of the medical students who knew a good deal of English. During our dental presentation the previous day he also answered all of our questions, and had really great ones of his own. I explained to him how we gave anesthesia, and the nature of the tissues we were targeting. Incredible experience. 

We closed up shop much later than expected and hit the worst traffic I could imagine on the way back. We had run out of water bottles, and there was definitely no stopping for food after dark. The Haitian translator's parents were calling them since generally you do not want to be out later than you need to be in Haiti, especially during the holiday. I spent most of my time talking to the translators and learning some creole. I had a really great conversation with one of the translators about how Haiti is her one and only home. She has been to L.A. and Florida for vocal competitions, but has no interest in leaving unless it is for education. Every day I'm presented with more reasons to admire the Haitian people, and their sense of nationalism really struck a chord in me. 

Once we got back, we had a very late dinner, and a few of us got together to clean off the blood from our dental instruments and pack and run the autoclave. Plugged in my headlight to charge for tomorrow, another day living to serve. 

FHI Haiti 2012: Medical Education

12.27.12 - Day Two

Woke at 5:30AM in my hospital bed to the sound of roosters, dogs, goats, and many other sounds, guarded by my mosquito net. Arrived back at 11:30PM. Incredible day of empowerment in a city right outside Carrefour. Today was about helping educate the Haitian nurses and medical students further on common diseases in Haiti, and on topics which they had specifically requested (like dental!!).  Presentations on Hypertension, Diabetes, Cervical Cancer, dentistry and a few others. Ryan had the poster prepared but since it was in Haitian Creole we reviewed what we wanted to focus on and how the talk would run. Ryan started off the day with his presentation on the oral manifestation of different diseases. Afterwards, we broke into our teams, and the medical and nursing students were divided into smaller groups as well so we could give our presentations.

We covered the cause and mechanism of dental caries, how plaque forms and its relation to gingivitis and periodontitis. We discussed the importance of diet in the etiology of caries and talked about many ways to prevent caries, and concluded with the importance of fluoride treatments, which we provided in the hope that the nurses would continue their use after our departure. We got a handful of questions from each group we presented which was great, but also gave me the impression that many of them had friends or family suffering from dental problems. After our presentation to each group, we called up participants in pairs to present back to us the presentation that we gave to ensure they were learning, and sure enough they were.

What really made the day great besides giving the talks themselves were the connections and relationships that were forming. A couple of the nurses and medical students had asked for Ryan and my contact information to keep in touch. I was especially happy to have gotten to spend a great deal of time with the translators learning about them and hearing their stories. One translator named Dickens especially stood out to me. He's 18, and fluent in Haitian Creole, Spanish, English, French and hopes to learn Dutch, on his own. I was floored. He was the dental  translator for our presentations and did an awesome job getting the information across.

On the way back from the education event we had to stop by a clinic in Carrefour to pick up the medical and dental supplies for our clinic session tomorrow. Our driver parked the bus and Ryan, Moses, Will and I walked down a narrow rocky road to the clinic, which to our surprise was locked since we had been told it would be open. After about 5 minutes of searching from an alternate way in, and calling our primary contact , a boy that was no older than 6 walks up to the door and unlocks it! Even though we got in we still had to struggle in the dark with flashlights to find the supplies we needed, but luckily everything was retrieved.

Once we got back we had dinner, and the night was spent doing medical and dental inventory, and autoclaving instruments. Our autoclave is a rice cooker- looking thing that probably confused people who saw me carrying it.  The power cut out right after our first load, so we had to autoclave our second batch in the morning. Looking forward to tomorrow, according to the team leader Moses, once we get past it, we should be all right for the rest of the trip. We'll be heading out to the countryside in Von Presse.