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.