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 It won't take very long to find out whose opinion you actually value and whose you find outdated or downright wrong.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.