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.