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.