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!