Wednesday, July 8, 2009

Extension For Prevention

I have found a MAJOR flaw in dental education. Actually, there are plenty - but this one is particularly bad. During the pre-clinical years at this school (and I'm sure everywhere else) we are really hammered on the idea of prevention. Not necessarily cutting the shit out of a tooth with a tiny speck of caries interproximally. Attempting remineralization, PRRs, ect. Back in the day, a gent by the name of G.V. Black came up with an old-school concept called "extension for prevention." The idea is that you extend your preparations well beyond the caries with the idea that you guarantee it won't recur. This thought process was caried out for a LONG time, only recently it seems in education they are teaching the reverse concept "Prevention of extension."

This is what we were taught, conserve structure when you can. Today I finally got my hands dirty with my first DO amalgam (#5). Radiographically, this tooth was a good example of the kind of case I will have to do for my board exam as a D-4. So I start the prep, all is going pretty well. I finally get a real time example of what cutting through tooth and caries feels like. The box was a bit overextended but workable. So how far mesially should I go with the occlusal portion? About half-way is what we are taught unless there is occlusal decay - which there was not. Assuming your walls are convergent, that should be enough retention.

I finish up the prep, and grab my instructor. He proceeds to tell me that I need to, and I quote, "G.V. Black this thing up, extension for prevention." So now I need to cut this healthy tooth all the way to the mesial marginal ridge because I can't exactly argue with the instructor who could easily make my life a living hell for the next two years.

Do you see the problem? What good is the pre-clinical teaching if it is instantly contradicted on live patients? OK, granted there are instructors who are conservative, but nobody seems to realize what we have or have not been taught. It's as if the pre-clinical years are taught at a completely different school.

This sort of confirms my original idea of the clinic - which isn't necessarily all that bad. You will get exposed to many different points of view. It won't take very long to find out whose opinion you actually value and whose you find outdated or downright wrong. This is actually a good thing because it defines you as a professional, you obviously can't agree with everyone on everything.

So the actual fill was quite the bleh, I didn't adapt the matrix band very well and totally stabbed the guy with the wedge which resulted in some unecessary bleeding (good thing he was numb). I put way to much amalgam in initially which took away a lot of carving time. I didn't have my instruments organized very well so I wasted time hunting for various tools and I had to keep grabing the highspeed suction to grab the huge chunks of overfill that were getting dangerously close to aspiration/swallowing territory. I pulled off the matrix and the contact was WAY to tight. I seriously spent about 30 minutes cleaning up the interproximal and reducing the occlusion. My margins were pretty decent, no open margins or excessive excess. Basically I was just too slow and REALLY rusty using all the carvers (I mean it has been about a year since my last amalgam).

The important part is that I didn't have any major errors. I could get the floss through by the end with fairly normal pressure and I got the occlusion down enough so it wasn't bugging him or showing up with the articulating paper. I was actually pretty damn satisfied considering this was my first amalgam on a real person. I need to get faster and remind myself how to use the carvers and burnishers effectively but otherwise, not too shabby.

Now back to dentures tomorrow...sigh.

Monday, July 6, 2009

Warm Fuzzies

Today marked my first truly inpsiring moment in school where I know the crap I do had a true impact on somebody's life. I have a patient in dire need of dental work. She essentially is going to have about 12 teeth extracted (due to extensive perio disease) followed up with partial dentures on both arches. She has no insurance, was laid off last spring, and we are trying our best to spread the extractions out enough so she can pay. We probably will only do the upper arch first. Well this patient has a HUGE gap in the front (#9 missing and #10 has shifted distally). While pretty much all her teeth up top will be yanked minus the canines and premolars, a MAJOR concern for this 40something female is getting that space fixed - especially considering that she is looking for employment and can't stand smiling and looking like Mike Tyson.

So while I know the other anteriors will be extracted eventually, I went ahead and made her what is known around here as a flipper - or interim partial. Basically a removable device that replaces a few teeth - usually used for emergency esthetics.

Now were we ever taught how to make a flipper? You can probably guess the answer to that. So here I am, getting tips from classmates and D-4s, and just really going for it. It took me about 3 hours, but I got the damn thing made. I spent this morning adjusting the wires and removing excess with the patient in the chair.

Was it perfect? No. The thing is not as tight as I would want it in terms of stability and her occlusion is already a bit edge to edge so it is difficult to get that perfect angulation. Her speech is slurred a little with 's' sounds but not too bad (after I trimmed the crap out of it). However, the one part that I knocked out of the ballpark was tooth shade and shape. I added a new #9 and #10 to fill the gap and the color was very close to perfect. The acrylic shade clearly wasn't meant to match african americans, but her smile line is low enough to display zero gum.

The part that makes me happy is knowing that she finally got a job interview for this thursday and I managed to fix the esthetic issue (albeit temporarily). She was happy with the appliance and didn't come back that afternoon which means it didn't break!

So was it the greatest flipper ever made? Hell no. Does it get the job done? Hell yes. Now that my first one is out of the way, I already know what I did wrong and what improvements I can do for the next time. When they say you get out of school what you put into it - this type of experience is exactly what they are talking about.

In other news, I am still chugging along this semester. These next two weeks will be rough. Endo exam (despite having no lecture class), public health final (took today), and OS midterm on friday. Ethics take home final (5-10 pages) and Caries patient portfolio both due next week. Not to mention all the extra lab work I have on the horizon. It kinda sucks having essentially removable cases exclusively. But I can make a custom tray in like 5 mintues now.

First DO amalgam on wednesday coming up. Hope I remember how to use all those carvers!

New D-3 experience post probably up by the end of this semester.

I miss summer vacations.